ATI FUNDAMENTALS FINAL EXAM ACTUAL
EXAM 2024 | ALL QUESTIONS AND
CORRECT ANSWERS WITH RATIONALE
|GRADED A+ | LATEST UPDATE
A nurse is obtaining a clients blood pressure in a client's lower extremity.
Which of the following actions should the nurse take?
a) auscultate the BP at the dorsalis pedis artery
b) measure the clients BP with the client sitting at the side of the bed
c) place the cuff 7.6cm (3in) above the popliteal artery
d) place the bladder of the cuff over the posterior aspect of the thigh -
Correct Answer -d) place the bladder of the cuff over the posterior aspect
of the thigh
This is the correct position for the bladder of the class when the nurse is
measuring a lower extremity blood pressure
- a nurse should auscultate the blood pressure at the popliteal
artery
- the nurse should measure the blood pressure with the client
prone is possible otherwise the client should lie supine with knee
flexed
- the nurse should position the cuff 2.5cm (1 in) above the
popliteal artery
The nurse is performing nasotracheal suctioning. After suctioning the
client's trachea for fifteen seconds, large amounts of thick yellow secretions
return. What action should the nurse implement next?
A. Encourage the client to cough to help loosen secretions.
B. Advise the client to increase the intake of oral fluids.
C. Rotate the suction catheter to obtain any remaining secretions.
D. Re-oxygenate the client before attempting to suction again. - Correct
Answer -D) Re-oxygenate the client before attempting to suction again.
,a nurse is performing an admission assessment for a client who has
asthma and several food allergies. Which of the following actions should
the nurse take first?
a) document the clients food allergies
b) ask the client to identify the specific food allergies
c) monitor the client for signs of anaphylaxis
d) have epinephrine available for administration - Correct Answer -b) ask
the client to identify the specific food allergies
The nurse should apply the nursing process priority-setting
framework in order to plan client care and prioritize nursing
actions. Each step the nursing process builds on the previous
steps beginning with an assessment or data collection, before the
nurse can formulate a plan of action implement a nursing
intervention or notify the provider of a change in the client status.
the nurse must first collect adequate data from the client
assessing or collecting additional data will provide the nurse with
the knowledge to make an appropriate decision. Therefore the
nurse should first assess the client's allergies and identify specific
allergens to ensure the specific foods are not ordered to the client
during meals
The nurse is assessing the nutritional status of several clients. Which client
has the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer. - Correct Answer -B) A
lactating woman nursing her 3-day-old infantA lactating woman (B) has
the greatest need for additional protein intake. (A, C, and D) are
all conditions that require protein, but do not have the increased
metabolic protein demands of lactation
A nurse is assessing a client's thyroid gland. Which of the following
instructions should the nurse give to the client before inspecting and
palpating this gland?
,a) "tilt your head slightly forward"
b) "keep your head straight and look ahead of you"
c) "tilt your head back and swallow"
d) "turn your head to the side against my hand" - Correct Answer -c) "tilt
your head back and swallow"
to examine the thyroid gland the nurse should instruct the client
to extend her head backward into swallow the nurse should be
able to feel the thyroid gland is ascend as the client swallows in
observe any enlargement of the gland
- to palpate the supraclavicular lymph nodes, the nurse should
instruct the client to tilt her head forward and relax their
shoulders
- to palpate the trachea for any deviation to the side, the nurse
should instruct the client to keep her head in an erect neutral
position
- to evaluate the strength of the neck muscles the nurse should
place a hand on the side of the clients head and ask her to turn
her head against the resistance of the hand then there should
then repeat this step on the other side of the client said (ROM)
A nurse is talking with a client whose provider recently informed him of
terminal pancreatic cancer. When the client reports that he understands
the full impact of this diagnosis, the nurse identifies that the client is in
which of the following stages of dying?
a) anger
b) bargaining
c) depression
d) acceptance - Correct Answer -c) depression
during this stage of depression, the client has realized the full
impact of the loss in might express hopelessness and despair
- anger: during the stage of anger the client shows resistance or
blames other people, a higher power, or the situation
- bargaining: stalls awareness of the loss by trying to keep it from
occurring
, - acceptance: integrate the loss (ex. by making final
arrangements)
A nurse is planning care for a young adult client has a terminal illness.
Which of the following concepts for death should nurse considered for this
client?
a) death is unacceptable under any circumstances
b) magical thinking helps avoid thoughts of death
c) death is viewed as an interruption of what might have been
d) that is a natural consequence of the age appearance trading body -
Correct Answer -c) death is viewed as an interruption of what might have
been
young adults tend to see a whole life ahead of them so that is
often seen as an interesting that lies young adults do not typically
welcome death at this time
- a) adolescents tend to reject the end of life especially their own
- b) preschoolers tend to avoid thoughts of death by employing
magical thinking
- d) accepting the deterioration of the body is more likely among
older adults, some of them might consider that relief from a
chronic or terminal illness
a nurse is preparing to assist an older adult client with ambulation
following bed rest for 3 days. Which of the following actions should the
nurse take to decrease the risk of falls?
a) use a gait belt during ambulation
b) ensure the client is wearing socks before ambulating
c) instruct the client to sit on the edge of the bed for 15 secs before
ambulating
c) walk 2 feet behind the client during ambulation - Correct Answer -a) use
a gait belt during ambulation
The nurse should use a gait belt to keep the client center of
gravity midline to decrease the risk of a fall
EXAM 2024 | ALL QUESTIONS AND
CORRECT ANSWERS WITH RATIONALE
|GRADED A+ | LATEST UPDATE
A nurse is obtaining a clients blood pressure in a client's lower extremity.
Which of the following actions should the nurse take?
a) auscultate the BP at the dorsalis pedis artery
b) measure the clients BP with the client sitting at the side of the bed
c) place the cuff 7.6cm (3in) above the popliteal artery
d) place the bladder of the cuff over the posterior aspect of the thigh -
Correct Answer -d) place the bladder of the cuff over the posterior aspect
of the thigh
This is the correct position for the bladder of the class when the nurse is
measuring a lower extremity blood pressure
- a nurse should auscultate the blood pressure at the popliteal
artery
- the nurse should measure the blood pressure with the client
prone is possible otherwise the client should lie supine with knee
flexed
- the nurse should position the cuff 2.5cm (1 in) above the
popliteal artery
The nurse is performing nasotracheal suctioning. After suctioning the
client's trachea for fifteen seconds, large amounts of thick yellow secretions
return. What action should the nurse implement next?
A. Encourage the client to cough to help loosen secretions.
B. Advise the client to increase the intake of oral fluids.
C. Rotate the suction catheter to obtain any remaining secretions.
D. Re-oxygenate the client before attempting to suction again. - Correct
Answer -D) Re-oxygenate the client before attempting to suction again.
,a nurse is performing an admission assessment for a client who has
asthma and several food allergies. Which of the following actions should
the nurse take first?
a) document the clients food allergies
b) ask the client to identify the specific food allergies
c) monitor the client for signs of anaphylaxis
d) have epinephrine available for administration - Correct Answer -b) ask
the client to identify the specific food allergies
The nurse should apply the nursing process priority-setting
framework in order to plan client care and prioritize nursing
actions. Each step the nursing process builds on the previous
steps beginning with an assessment or data collection, before the
nurse can formulate a plan of action implement a nursing
intervention or notify the provider of a change in the client status.
the nurse must first collect adequate data from the client
assessing or collecting additional data will provide the nurse with
the knowledge to make an appropriate decision. Therefore the
nurse should first assess the client's allergies and identify specific
allergens to ensure the specific foods are not ordered to the client
during meals
The nurse is assessing the nutritional status of several clients. Which client
has the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer. - Correct Answer -B) A
lactating woman nursing her 3-day-old infantA lactating woman (B) has
the greatest need for additional protein intake. (A, C, and D) are
all conditions that require protein, but do not have the increased
metabolic protein demands of lactation
A nurse is assessing a client's thyroid gland. Which of the following
instructions should the nurse give to the client before inspecting and
palpating this gland?
,a) "tilt your head slightly forward"
b) "keep your head straight and look ahead of you"
c) "tilt your head back and swallow"
d) "turn your head to the side against my hand" - Correct Answer -c) "tilt
your head back and swallow"
to examine the thyroid gland the nurse should instruct the client
to extend her head backward into swallow the nurse should be
able to feel the thyroid gland is ascend as the client swallows in
observe any enlargement of the gland
- to palpate the supraclavicular lymph nodes, the nurse should
instruct the client to tilt her head forward and relax their
shoulders
- to palpate the trachea for any deviation to the side, the nurse
should instruct the client to keep her head in an erect neutral
position
- to evaluate the strength of the neck muscles the nurse should
place a hand on the side of the clients head and ask her to turn
her head against the resistance of the hand then there should
then repeat this step on the other side of the client said (ROM)
A nurse is talking with a client whose provider recently informed him of
terminal pancreatic cancer. When the client reports that he understands
the full impact of this diagnosis, the nurse identifies that the client is in
which of the following stages of dying?
a) anger
b) bargaining
c) depression
d) acceptance - Correct Answer -c) depression
during this stage of depression, the client has realized the full
impact of the loss in might express hopelessness and despair
- anger: during the stage of anger the client shows resistance or
blames other people, a higher power, or the situation
- bargaining: stalls awareness of the loss by trying to keep it from
occurring
, - acceptance: integrate the loss (ex. by making final
arrangements)
A nurse is planning care for a young adult client has a terminal illness.
Which of the following concepts for death should nurse considered for this
client?
a) death is unacceptable under any circumstances
b) magical thinking helps avoid thoughts of death
c) death is viewed as an interruption of what might have been
d) that is a natural consequence of the age appearance trading body -
Correct Answer -c) death is viewed as an interruption of what might have
been
young adults tend to see a whole life ahead of them so that is
often seen as an interesting that lies young adults do not typically
welcome death at this time
- a) adolescents tend to reject the end of life especially their own
- b) preschoolers tend to avoid thoughts of death by employing
magical thinking
- d) accepting the deterioration of the body is more likely among
older adults, some of them might consider that relief from a
chronic or terminal illness
a nurse is preparing to assist an older adult client with ambulation
following bed rest for 3 days. Which of the following actions should the
nurse take to decrease the risk of falls?
a) use a gait belt during ambulation
b) ensure the client is wearing socks before ambulating
c) instruct the client to sit on the edge of the bed for 15 secs before
ambulating
c) walk 2 feet behind the client during ambulation - Correct Answer -a) use
a gait belt during ambulation
The nurse should use a gait belt to keep the client center of
gravity midline to decrease the risk of a fall
