Fundamentals 1 ATI Standardized Quiz Questions and Answers with Rationale (2023/2024)

Fundamentals 1 (25 questions) Questions/Answers/Rationale 1. A nurse is caring for a client who had a terminal illness. The client asks several questions about the nurse’s religious beliefs related to death and dying? Which of the following actions should the nurse take?  Change the topic because the client is trying to divert attention from the illness to the nurse: Changing the subject is a nontherapeutic communication technique that will block development of open communication between the nurse and client.  Encourage the client to express his thoughts about death and dying: (CORRECT) - The nurse should recognize the client’s need to talk about impending death, and encourage the client to discuss his thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Selfdisclosure is a communication skill that can help open lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skills of offering self and listening to the client’s thoughts are appropriate.  Tell the client that religious beliefs are a personal matter: This closed-ended response is a nontherapeutic communication technique that will block the communication with this client.  Offer to contact the client’s minister or the facility’s chaplain: This response places the client’s issue on hold and could cause barriers to communication between the nurse and the client. 2. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?  Open all sterile supplies and solutions: The nurse should open all sterile supplies and solutions prior to providing tracheostomy care. However, there is another action the nurse should take first.  Stabilize the tracheostomy tube: The nurse should stabilize the tracheostomy tube to prevent accidental extubation while providing tracheostomy care. However, there is another action the nurse should take first.  Don sterile gloves: The nurse should don sterile gloves prior to providing tracheostomy care to reduce the transmission of organisms. However, there is another action the nurse should take first.  Perform hand hygiene: (CORRECT) - According to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurse’s hands is a primary source of infection. 3. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?  Measure the pulse using a doppler ultrasound stethoscope: The nurse should use a Doppler ultrasound stethoscope for a pulse that is nonpalpable or very difficult to palpate.  Check the client’s pedal pulses: The nurse should assess pedal pulses to determine circulation in the client’s lower extremities.  Count the apical pulse rate for 1 minutes, and describe the rhythm in the chart: (CORRECT) - If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record.  Take the pulse at each peripheral site and count the rate for 30 seconds: The nurse should assess all peripheral pulses to determine the equality of blood perfusion to the extremities. 4. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?  Identify goals for client care: The nursing process is based on the scientific process. While identifying goals is an appropriate step in the nursing process, it is not the first step.  Obtain client information: (CORRECT) - The nursing process is based on the scientific process. The first step in the scientific process is the collection of data. Therefore, the first step in the nursing process is assessing and obtaining information about the client.  Document nursing care needs: The nursing process is based on the scientific process. While documenting the client’s care needs is an appropriate step in the nursing process, it is not the first step.  Evaluate the effectiveness of care: The nursing process is based on the scientific process. While evaluating the effectiveness of the client’s care is an appropriate step in the nursing process, it is not the first step. 5. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following should the nurse take to transfer the client from the stretcher to the bed?  Lock the wheels on the bed and stretcher: (CORRECT) - Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client.  Instruct the client to raise his arms about his head: The nurse should ask the client to cross his arms across his chest to prevent injuring the arms during the transfer.  Elevate the stretcher 2.5 cm (1 in.) about the height of the bed: The stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed.  Log roll the client: Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery 6. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?  Evaluate pedal pulses: (CORRECT) - For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow’s Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client.  Obtain a medical history: The nurse should obtain the client’s medical history. However, there is another action the nurse should take first.  Measure vital signs: The nurse should obtain baseline vital signs. However, there is another action the nurse should take first.  Assess for leg pain: The nurse should assess the client for pain. However, there is another action the nurse should take first. 7. A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?  Frequent bowel sounds with flatus: Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool.  Absent bowel sounds with distention: (CORRECT) - Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended.  Hyperactive bowel sounds with diarrhea: Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool.  Normal bowel sounds with increased peristalsis: Paralytic ileus is an immobile bowel with decreased peristalsis. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool. 8. A nurse is providing teaching to an older adult who has constipation. Which of the following statements should the nurse include in the teaching?  Drink a minimum of 1,000mL of fluid daily: The nurse should instruct the client to consume a minimum of 1,500 mL of fluid to prevent constipation.  Increase you intake of refined-fiber foods: The nurse should instruct the client to increase consumption of coarse-fiber and whole grains, rather than refined-fiber foods.  Sit on the toilet for 30 minutes after eating a meal: (CORRECT) - Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.  Take a laxative every day to maintain regularity: The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation habits and can cause constipation, rather than cure it. 9. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope position at the left sternal border. Which of the following heart sounds should the nurse document?  Audible click: An audible clicking sound occurs in clients who have prosthetic valve replacement surgery.  Murmur: A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. Low- and medium-frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease.  Third heart sounds: A third heart sound is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best heard at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates heart failure.  Pericardial friction rub: (CORRECT) - A pericardial friction rub has a highpitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward. 10. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?  The client asks the nurse to repeat the instructions before attempting the exercises: Asking the nurse to repeat the instructions demonstrates that, while the client might not totally understand the mechanics of performing the exercises, he does have a readiness to learn the activity.  The client reports severe pain: (CORRECT) - A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity.  The client asks the nurse how often deep breathing should be done after surgery: Asking about the frequency of the activity indicates a readiness to learn. The client is motivated to perform the activity and wants to know how often to do it.  The client tells the nurse that this exercise will probably be painful after surgery: The client's statement indicates to the nurse that the client has a readiness to learn because he is able to think about the possible effects of the exercise following surgery. 11. A nurse is teaching a group of older adults about expected changed of aging. Which of the following statements by a group member indicates that the teaching has been effective?  I should expect my heart rate to take longer to return to normal after exercise as I get older: (CORRECT) - Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.  Urinary incontinence is something I will have to live with as I grow older: Although bladder capacity decreases in older adults, urinary incontinence is not an expected finding and older adults should report incontinence so that it can be investigated and treated.  I expect to have less ear wax as I get older: Older adults have an increased buildup of cerumen in the ears, which may increase expected incidence problems with hearing loss.  My stomach will empty more quickly after meals as I grow older: Decreased gastric emptying is an expected finding in older adults. 12. A nurse is caring for a client who had type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?  Tell me what I can do to help you overcome your fear of giving yourself injections: (CORRECT) - This response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections.  I am sure your provider will not be pleased that you refuse to give yourself insulin injections: This response illustrates the nontherapeutic communication technique of challenging the client and ignores the client's concern.  It’s okay. I’m sure your partner will be able to learn how to give you the insulin injections: This response illustrates the nontherapeutic communication technique of unwarranted reassurance and does not address the client's fears.  You won’t be able to go home unless you learn to give yourself insulin injections: This response illustrates the nontherapeutic communication technique of threatening the client. This response will not help the client overcome his fears. 13. A nurse is providing preoperative teaching to a client who is schedules for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?  Ask your provider to prescribe epoetin before the surgery: Epoetin is a hematopoietic growth factor used for the treatment of anemia. While taking epoetin prior to surgery can boost the client’s hematocrit levels, it is inappropriate if the client already has an adequate hematocrit level. Furthermore, this action might not eliminate the need for a blood transfusion and its related risks.  You should ask your provider about taking iron supplements prior to the surgery: While taking an iron supplement prior to surgery can boost the client’s hemoglobin levels, it is inappropriate if the client already has an adequate hemoglobin level and intake of iron from dietary sources. Furthermore, this action might not eliminate the need for a blood transfusion and its related risks.  Request a family member to donate blood for you: A blood donation from a family member does not eliminate the risk of acquiring an infection.  Donate autologous blood before the surgery: Autologous blood transfusion is the collection and reinfusion of the client’s blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client’s own blood eliminates exposure to transfusion-transmitted infection. 14. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?  Obtaining hydrogen peroxide for the tracheostomy care: Half-strength peroxide solution is used to clean the inner cannula.  Obtaining cotton balls for the tracheostomy care: (CORRECT) - Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.  Obtaining sterile gloves for the tracheostomy care: Tracheostomy care is a sterile procedure requiring the use of sterile gloves.  Obtaining a sterile brush for the tracheostomy care: Pipe cleaners, or a small sterile brush, can be used to remove thick or crusty secretions from the inner cannula. 15. A nurse observes an AP preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?  The reading will be inaudible if the cuff is too small for the client: Although the blood pressure reading for a client who is obese may be difficult to hear with any cuff, a cuff that is too small for the client will not yield an inaudible reading.  The width of the cuff bladder should be 75% of the circumference of the client’s arm: The width of the cuff bladder should be 40% of the circumference of the client’s arm.  As long as the cuff will circle the arm the reading will be accurate: A cuff that is an incorrect size for the client will not yield an accurate reading.  Using a cuff that is too small will result in an inaccurately high reading: (CORRECT) - Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client. 16. A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress:  My parents are retired, and they have come help me out with our children: Clients who have social and emotional support systems tend to experience less psychological distress.  I am going to ask my husband to go to counseling with me: Open communication is an important method to improve relationships that might be strained. Seeking counseling is a positive strategy.  I keep having nightmares about my upcoming surgery: (CORRECT) - Nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate that the client is at risk for experiencing psychological distress.  My girlfriends bought me a nice wig: Clients who have social and emotional support systems tend to experience less psychological distress. 17. A nurse is caring for a client who requires a CXR. Prior to the client being transported forthe procedure, which of the following actions should the nurse take first?  Explain the x-ray procedure to the client: The nurse should explain the x-ray procedure to the client. However, there is another action the nurse should take first.  Help the client into a wheelchair before the transporter arrives: The nurse should have the client ready for the procedure. However, there is another action the nurse should take first.  Ask if the client has any questions: The nurse should inquire if the client has any questions about the procedure. However, there is another action the nurse should take first.  Identify the client using two identifiers: (CORRECT) - The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow’s Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Once the client’s identity is determined, the nurse can then proceed with the other options. This action is the priority action because it provides for the safety of the client. It is a nursing responsibility to be certain that each client receives only what has been prescribed. The nurse must assure that the correct client is being transported for a chest x-ray. 18. A nurse is teaching an AP about proper hand hygiene. Which of the following statements by the AP indicated an understanding of the teaching?  There are times I should use soap and water rather than alcohol-based hand rub to clean my hands: (CORRECT) - While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.  I will use cold water when I was my hands to protect my skin from becoming too dry: Hand hygiene should be performed with warm water. Warm water preserves the protective oil of the skin better than hot water.  I will apply friction for at least 10 seconds while washing my hands: Friction is required to loosen and remove dirt and pathogens from the hands. To be effective, friction should be applied for at least 15 to 20 seconds.  After washing my hands I will dry them from the elbows down: Drying should be performed from the cleanest area (fingertips) to the least clean area (forearms) to prevent contamination of the newly cleaned hands 19. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?  Holding a community clinic to administer influenza immunizations: Administering influenza immunizations is an example of primary prevention for people who are healthy but in danger of becoming ill.  Screening groups of older adults in a nursing care facility for early influenza manifestations: (CORRECT) - Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.  Educating parents of young children about dangers of influenza: Educating clients about the dangers of influenza is an example of primary prevention for people who are healthy but in danger of becoming ill.  Finding rehabilitation programs for older adults who have complications from influenza: This is an example of tertiary prevention, which tries to prevent complications and help people recover from an existing illness. 20. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques?  Nurse washes each part of the her hands with 5 strokes: Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes.  Nurse washes from the elbows down to the hands: An important principle of surgical handwashing is to scrub the hands first, then work toward the elbows.  Nurse washes from the with her hands held higher than her elbows: (CORRECT) - The nurse who is performing a surgical hand-washing technique should wash with her hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.  Nurse uses minimal friction when washing her hands: Scrubbing is performed with a specially designed and premedicated brush when performing surgical hand-washing. The use of mechanical friction is necessary to decontaminate the skin effectively. 21. A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes a client crying?  Contact the family and ask them to stay with the client: With this action, the nurse does not respond to the client’s immediate needs and shifts the responsibility of helping the client to others.  Offer to call the client’s minister: This response by the nurse uses the nontherapeutic communication block of putting the client’s needs on hold and shifts the responsibility of helping the client to someone else.  Sit and hold the client’s hand: (CORRECT) - With this action, the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client.  Leave the room and allow the client to cry privately: This is not an appropriate nursing action because it fails to acknowledge the client’s distress. 22. A nurse in an ED is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client’s skin turgor?  Push on a fingernail bed until it blanches, release it and observe how long it takes the skin to become pink: The nurse uses this technique for assessing capillary refill.  Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back: (CORRECT) - The nurse should use this technique for assessing skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; with dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skin fold on the back of the forearm.  Press the skin about the ankle for 5 seconds, release it, and note the depth of the impression: The nurse uses this technique for determining how much pitting edema a client has.  Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers: The nurse uses this technique for determining a client’s body fat percentage. 23. A nurse is obtaining the BP in a client’s lower extremity. Which of the following actions should the nurse take?  Auscultate for the BP at the dorsalis pedis artery: The nurse should auscultate for the blood pressure at the popliteal artery.  Measure the BP with the client sitting on the side of the bed: The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed.  Place the cuff 7.6 cm (3in.) above the popliteal artery: The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.  Place the bladder of the cuff over the posterior aspect of the thigh: (CORRECT) - This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure. 24. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of thefollowing actions should the nurse take?  Encourage the child to cough frequently to clear the congestion from anesthesia: The child should be discouraged from coughing or clearing the throat following a tonsillectomy because these actions can contribute to bleeding.  Place a heating pad at the child’s neck for comfort: The nurse should offer an ice collar, not a heating pad, to ease the child’s pain.  Administer analgesics to the child on a routine schedule throughout the day and night: (CORRECT) - To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route.  Provide a child while ice cream when oral intake is initiated: Milk products, such as ice cream and pudding, are usually avoided because they coat the mouth and throat, causing the child to clear the throat. Clearing the throat can lead to bleeding. Ice chips and ice pops are usually the first items offered following a tonsillectomy. 25. A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?  Tie the restraints to the side rails: The nurse should not tie the restraints to the side rails because this can injure the client if the rails are lowered.  Perform ROM exercises to the wrist every 3 hours: The nurse should ensure that the restraints are removed and range-of-motion exercises are performed every 2 hr.  Remove the restraints one at a time: (CORRECT) - The nurse should remove one restraint at a time for a client who is violent or noncompliant.  Obtain a PRN prescription for the restraints: Restraint prescriptions can only be written for a 24-hr period and cannot be a PRN prescription.