ATI Fundamentals 2 Quiz
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic
procedure. Which of the following actions should the nurse take? - ANS-Insert the tip of the
tubing 8 cm.
will prevent dislodging of the tubing during the procedure and injury to rectal mucosa
A nurse is applying antiembolitic stockings for a client who has a history of deep vein
thrombosis. Which of the following actions should the nurse take when applying the stockings? -
ANS-Turn the stockings inside out up to the heel before applying.
Rationale: The nurse should turn the stocking inside out up to the client's heel to make the
application of the stocking easier and cause less constrictive wrinkles.
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of
the following questions should the nurse ask to encourage discussion with the client?
" - ANS-What do you think caused the onset of your pan"
Rationale: The nurse is using an opne-ended question that allows the client to respond with a
wide range of information by using more than one or two words.
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both
hands and appears frightened. Which of the following actions should the nurse take first? -
ANS-Determine whether the client is able to breathe.
before you can notify what is going on with the patient, you have to collect vital data from the
patient
A nurse is caring for a client who has a hearing impairment. Which of the following interventions
should the nurse use when speaking with the client? - ANS-face the client when speaking.
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the
nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is
pulseless. Which of the following actions should the nurse take first? - ANS-Start chest
compressions.
give priority to the factor or situation posing the greatest safety risk.
, A nurse is caring for a client who has a mastectomy and has a self-suction drainage evacuator
in place. Which of the following actions should the nurse take to ensure proper operation of the
device. - ANS-Collapse the device of air after emptying.
Rationale: The nurse should collapse the device of air after emptying the contents periodically to
create enough suction to pull fluid exudate into the collection area of the device.
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the
following actions should the nurse take?
. - ANS-Elevate the client's head of bed 45 degrees before the feeding.
Rationale: the nurse should do this to prevent aspiration
A nurse is caring for a client who has major fecal incontinence and reports irritation in the
perianal area. Which of the following actions should the nurse take first? - ANS-Check the
client's perineum.
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for
a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which
of the following responses should the nurse make? - ANS-"I am going to listen to your
abdomen."
a common reason why client's experience nausea and vomiting after a surgery is bc of delayed
gastric emptying time or decreased peristalsis
determine presence of bowel sounds before liquids can be administered
A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to
gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions
should the nurse take first? - ANS-Check to determine if the catheter tubing is kinked.
first apply least invasive framework
A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My
baby is choking on his food." Which of the following findings indicates the toddler has an airway
obstruction? - ANS-Inability of the toddle to cry or speak.
bc no sounds passing through vocal cords
use heimliech maneuver
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular
accident. Which of the following actions should the nurse take when assisting the client at
mealtime? - ANS-Offer the client tart or sour foods first.
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic
procedure. Which of the following actions should the nurse take? - ANS-Insert the tip of the
tubing 8 cm.
will prevent dislodging of the tubing during the procedure and injury to rectal mucosa
A nurse is applying antiembolitic stockings for a client who has a history of deep vein
thrombosis. Which of the following actions should the nurse take when applying the stockings? -
ANS-Turn the stockings inside out up to the heel before applying.
Rationale: The nurse should turn the stocking inside out up to the client's heel to make the
application of the stocking easier and cause less constrictive wrinkles.
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of
the following questions should the nurse ask to encourage discussion with the client?
" - ANS-What do you think caused the onset of your pan"
Rationale: The nurse is using an opne-ended question that allows the client to respond with a
wide range of information by using more than one or two words.
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both
hands and appears frightened. Which of the following actions should the nurse take first? -
ANS-Determine whether the client is able to breathe.
before you can notify what is going on with the patient, you have to collect vital data from the
patient
A nurse is caring for a client who has a hearing impairment. Which of the following interventions
should the nurse use when speaking with the client? - ANS-face the client when speaking.
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the
nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is
pulseless. Which of the following actions should the nurse take first? - ANS-Start chest
compressions.
give priority to the factor or situation posing the greatest safety risk.
, A nurse is caring for a client who has a mastectomy and has a self-suction drainage evacuator
in place. Which of the following actions should the nurse take to ensure proper operation of the
device. - ANS-Collapse the device of air after emptying.
Rationale: The nurse should collapse the device of air after emptying the contents periodically to
create enough suction to pull fluid exudate into the collection area of the device.
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the
following actions should the nurse take?
. - ANS-Elevate the client's head of bed 45 degrees before the feeding.
Rationale: the nurse should do this to prevent aspiration
A nurse is caring for a client who has major fecal incontinence and reports irritation in the
perianal area. Which of the following actions should the nurse take first? - ANS-Check the
client's perineum.
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for
a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which
of the following responses should the nurse make? - ANS-"I am going to listen to your
abdomen."
a common reason why client's experience nausea and vomiting after a surgery is bc of delayed
gastric emptying time or decreased peristalsis
determine presence of bowel sounds before liquids can be administered
A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to
gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions
should the nurse take first? - ANS-Check to determine if the catheter tubing is kinked.
first apply least invasive framework
A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My
baby is choking on his food." Which of the following findings indicates the toddler has an airway
obstruction? - ANS-Inability of the toddle to cry or speak.
bc no sounds passing through vocal cords
use heimliech maneuver
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular
accident. Which of the following actions should the nurse take when assisting the client at
mealtime? - ANS-Offer the client tart or sour foods first.
