VIRTUAL ATI FUNDAMENTALS UPDATED STUDY
EXAM GUIDE QUESTIONS AND ANSWERS SURE A+
✔✔A client has a new tracheostomy. Which of the following interventions should the
nurse include when performing tracheostomy care?
a. Change tracheostomy ties when soiled.
b. Remove soiled dressing with sterile gloves.
c. Suction the tracheostomy before beginning care.
d. Clean disposable inner cannula with hydrogen peroxide. - ✔✔Change tracheostomy
ties when soiled. CORRECT. Tracheostomy ties should be changed once a day or
when soiled. Secure new ties in place before removing old soiled ones to prevent
accidental decannulation. One or two fingers should be able to be placed between the
tie tape and the neck.
✔✔A nurse is providing discharge education for a female client diagnosed with
Chlamydia. Which statement made by the client would indicate the need for further
instruction?
Select one:
a. "Symptoms of reinfection may include yellow vaginal discharge."
b. "Possible complications to monitor for include pelvic inflammatory disease."
c. "I will refrain from sexual intercourse until completion of antibiotics."
d. "I will return to the clinic in one month for re-screening." - ✔✔I will return to the clinic
in one month for re-screening.
, ✔✔A nurse is caring for a client with a diagnosis of sepsis with a temperature of 40.8 C
(105.5 F). The provider has ordered a cooling blanket. Which intervention is appropriate
to delegate to an Unlicensed Assistive Personnel (UAP)?
Select one:
a. Obtain a fan for the client's use
b. Bathe the client to keep the skin damp
c. Report shivering by the client
d. Assess the client's skin for any reddened - ✔✔Report shivering by the client
✔✔A nurse is caring for an older adult client with delirium. Which intervention will most
effectively reduce the client's risk for falls?
Select one:
a. Hourly rounding by the nurse.
b. Use of a night-light. .
d. Place bedside table in close proximity. - ✔✔Hourly Rounding by the Nurse
✔✔A fire in a first floor operating room is forcing evacuation of clients from a second
floor unit to another building. Which of the following clients would have the highest
priority for the charge nurse to evacuate?
Select one:
a. A client receiving IV antibiotics every six hours for a leg ulcer.
b. A client semi-comatose after a cerebrovascular accident with an indwelling urinary
catheter.
c. A client post left hip replacement of two days ago whose daughter is visiting.
d. A client admitted with pancreatitis with nasogastric tube and PCA pump in place. -
✔✔a. A client receiving IV antibiotics every six hours for a leg ulcer.
✔✔A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1
Liter of IV fluid over 2 hours. Which intervention is the priority?
Select one:
a. Monitor urine output.
b. Fill out an incident report.
c. Report the defective equipment.
d. Document the amount of fluid infused. - ✔✔Fill out an incident report
✔✔A client with pneumonia has an oxygen saturation of 85%, heart rate of 88,
respiratory rate of 22, and blood pressure of 132/88. Which of the following is the
priority nursing intervention?
Select one:
a. Reassess pulse oximetry
EXAM GUIDE QUESTIONS AND ANSWERS SURE A+
✔✔A client has a new tracheostomy. Which of the following interventions should the
nurse include when performing tracheostomy care?
a. Change tracheostomy ties when soiled.
b. Remove soiled dressing with sterile gloves.
c. Suction the tracheostomy before beginning care.
d. Clean disposable inner cannula with hydrogen peroxide. - ✔✔Change tracheostomy
ties when soiled. CORRECT. Tracheostomy ties should be changed once a day or
when soiled. Secure new ties in place before removing old soiled ones to prevent
accidental decannulation. One or two fingers should be able to be placed between the
tie tape and the neck.
✔✔A nurse is providing discharge education for a female client diagnosed with
Chlamydia. Which statement made by the client would indicate the need for further
instruction?
Select one:
a. "Symptoms of reinfection may include yellow vaginal discharge."
b. "Possible complications to monitor for include pelvic inflammatory disease."
c. "I will refrain from sexual intercourse until completion of antibiotics."
d. "I will return to the clinic in one month for re-screening." - ✔✔I will return to the clinic
in one month for re-screening.
, ✔✔A nurse is caring for a client with a diagnosis of sepsis with a temperature of 40.8 C
(105.5 F). The provider has ordered a cooling blanket. Which intervention is appropriate
to delegate to an Unlicensed Assistive Personnel (UAP)?
Select one:
a. Obtain a fan for the client's use
b. Bathe the client to keep the skin damp
c. Report shivering by the client
d. Assess the client's skin for any reddened - ✔✔Report shivering by the client
✔✔A nurse is caring for an older adult client with delirium. Which intervention will most
effectively reduce the client's risk for falls?
Select one:
a. Hourly rounding by the nurse.
b. Use of a night-light. .
d. Place bedside table in close proximity. - ✔✔Hourly Rounding by the Nurse
✔✔A fire in a first floor operating room is forcing evacuation of clients from a second
floor unit to another building. Which of the following clients would have the highest
priority for the charge nurse to evacuate?
Select one:
a. A client receiving IV antibiotics every six hours for a leg ulcer.
b. A client semi-comatose after a cerebrovascular accident with an indwelling urinary
catheter.
c. A client post left hip replacement of two days ago whose daughter is visiting.
d. A client admitted with pancreatitis with nasogastric tube and PCA pump in place. -
✔✔a. A client receiving IV antibiotics every six hours for a leg ulcer.
✔✔A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1
Liter of IV fluid over 2 hours. Which intervention is the priority?
Select one:
a. Monitor urine output.
b. Fill out an incident report.
c. Report the defective equipment.
d. Document the amount of fluid infused. - ✔✔Fill out an incident report
✔✔A client with pneumonia has an oxygen saturation of 85%, heart rate of 88,
respiratory rate of 22, and blood pressure of 132/88. Which of the following is the
priority nursing intervention?
Select one:
a. Reassess pulse oximetry
