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FUNDAMENTALS PROCTORED ATI RN
EXAM AND CORRECT ANSWERS
...

A nurse is preparing to instill an enteral feeding to a client who has an NG
tube in place
...
Check how long the feeding container has been opened
B
...
Confirm that the client doesn't have diarrhea
D
...

Which of the following nursing interventions is the highest priority when
the nurse suspects aspiration of the feeding?

A
...
Stop the feeding
C
...
Initiate oxygen therapy - CorreCt Answers -B
...
Which of the following is an appropriate
nursing action prior to administering the tube feeding? Select all
...
Auscultate bowel sounds
...
Assist the client to an upright position
...
Test the pH of gastric aspirate
...
Warm the formula to body temp
...
Discard any residual gastric contents
...
Which of the following actions should the nurse perform
prior to beginning the procedure? Select all
...
Review a signal the client can use if feeling any distress
B
...
Administer oral pain meds
D
...
Have a petroleum-based lubricant available - CorreCt Answers -A, B

An adolescent who has diabetes mellitus is 2 days postop following an
appendectomy
...
He has ambulated
successfully around the unit w/assistance
...
His
incision is approximated & free of redness, w/scant serous drainage on the
dressing
...


A
...
Impaired circulation
C
...
Malnutrition
E
...
surgery
...
Which of the following assessment
findings should the nurse expect? Select all
...
Increase in incisional pain
B
...
Reddened wound edges
D
...
Decrease in thirst - CorreCt Answers -A, B, C

A nursing instructor is reviewing the wound healing process w/a group of
nursing students
...


A
...
Sutured surgical incision
C
...
Laceration sealed w/adhesive
E
...
surgery 24 hr ago reports a pulling sensation & pain
in his surgical incision
...
Which of the following
interventions is appropriate? Select all
...
Cover the area w/saline-soaked sterile dressings
B
...

C
...
Position the client supine w/his hips & knees bent
E
...
Which of the following interventions should the nurse use
to help maintain the integrity of the client's skin? Select all
...
Keep the head of the bed elevated 30 degrees
B
...
Apply cornstarch liberally to the skin after bathing
D
...
Reposition the client at least Q 3 hr while in bed - CorreCt Answers -A, D

not E because it should be at least every 2 hours

102 - CorreCt Answers A nurse on a med-surg unit has received change-of-shift report & will care
for 4 clients
...
Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia

B
...
Reapplying a condom catheter for a client who has urinary incontinence

D
...

Reapplying a condom catheter for a client who has urinary incontinence

Rationale: The application of a condom catheter is a noninvasive, routine
procedure that the nurse may delegate to the AP

A nurse is delegating the ambulation of a client who had knee arthroplasty
5 days ago to an AP
...


A
...

B
...
The client uses a front-wheeled walker when ambulating
D
...
The client is allergic to codeine
F
...
Which of the following assignments should the LPN question?

A
...
Collecting a clean-catch urine specimen from a client who was admitted
on the previous shift
C
...
Replacing the cartridge and tubing on a PCA pump - CorreCt Answers D
...
Which of the
following elements should she identify when presenting the 5 rights of
delegation? Select all
...
Right client
B
...
Right direction/communication
D
...
Right circumstances - CorreCt Answers -B, C, E

A and D are rights of medication administration

A nurse manager of a med-surg unit is assigning care responsibilities for
the oncoming shift
...
To which staff member should the nurse
assign to this client?

A
...
RN
C
...
AP - CorreCt Answers -B
...
RNs are responsible for this, especially if the client is
potentially unstable
...
The AP tells him she will put a diaper on him if he does not use
the urinal more carefully next time
...
Assault
B
...
False imprisonment
D
...
Assault

By threatening the client, the AP is committing assault
...
The nurse believes that this is
not in the client's best interest, so she administers a PRN sedative med that
the client has not requested along w/his usual meds
...
Assault
B
...
Negligence
D
...
False imprisonment

The nurse gave the med as a chemical restraint to keep the client from
leaving the facility against medical advice
...


A client who will undergo neurosurgery the following week tells the nurse
in the surgeon's office that he will prepare his advance directives before he
goes to the hospital
...
"I'd rather have my brother make decisions for me, but I know it has to
be my wife
...
"I know they won't go ahead w/the surgery unless I prepare these
forms
...
"I plan to write that I don't want them to keep me on a breathing
machine
...
"I will get my regular doctor to approve my plan before I hand it in at the
hospital
...

The client has the right to decide and specify which medical procedures he
wants when a life-threatening situation arrives

A client is about to undergo an elective surgical procedure
...


A
...
Witness the client's signature on the consent form
C
...
Describe the consequences of choosing not to have the surgery
E
...
Today,
she found the nurse asleep in a chair in the break room when she was not
on break
...
Remind the nurse that safe client care is a priority on the unit
B
...
Report observations to the nurse manager on the unit
D
...

Any nurse who notices behavior that could possibly jeopardize client care or
indicate a substance abuse problem has a duty to report the situation
immediately to the nurse manager

A nurse is preparing info for a change-of-shift report
...
The client's input & output for the shift
B
...
A bone scan that is scheduled for today
D
...
A bone scan that is scheduled for today

This is important because the nurse might have to modify the client's care
to accommodate them leaving the unit

A nurse enters a client's room & finds him sitting in his chair
...
" How should
the nurse document this in the client's chart?

A
...


B
...
The nurse should not document this info because she did not witness the
fall
D
...

By writing what the client states, the info is subjective data

A nursing instructor is reviewing documentation w/a group of nursing
students
...


A
...
Put the date & time on all entries
C
...
Use as many abbreviations as possible
E
...
The nurse has reapplied it twice during the shift,
but it remains intact only when the client is supine in bed
...

The client sat in a chair during lunch w/an absorbent pad over the fistula
...
The wound care nurse confirmed that
she will see the client later today
...
Which of the following information should the nurse include in
the change-of-shift report? Select all
...
The physical therapist didn't ambulate the client today
B
...
Which of the following
nursing actions are appropriate? Select all
...
Repeat the details of the prescription back to the provider
B
...
Obtain the prescriber's signature on the prescription within 24hrs
D
...
Tell the charge nurse that the provider has prescribed morphine by
telephone - CorreCt Answers -A, B, C

A nurse is caring for an older adult client who lives alone & is to be
discharged in 3 days
...
To which of the following
members of the health care team should the nurse refer him?

A
...
Occupational therapist
C
...
Social worker - CorreCt Answers -D
...
The nurse caring for the client should
initiate a referral w/which of the following members of the
interprofessional care team?

A
...
Certified nursing assistant
C
...
Occupational therapist - CorreCt Answers -D
...

Which of the following members of the interprofessional care team may
assist the client in understanding the medication's effects? Select all
...
Provider
B
...
Pharmacist
D
...
Respiratory therapist - CorreCt Answers -A, C, D

A client who has had a cerebrovascular accident has persistent problems
w/dysphagia
...
Social worker
B
...
Occupational therapist
D
...
When she gives examples of the types of tasks CNAs
may perform, which of the following client activities should she include?
Select all
...
Bathing
B
...
Toileting
D
...
Measuring vital signs - CorreCt Answers -A, B, C, E

Determining pain level requires assessment, which is the job of the licensed
personnel
...
Which of the following findings should the nurse expect?
Select all
...
A concave thoracic spine posteriorly
B
...
A concave lumbar spine posteriorly
D
...
Muscles slightly larger on his dominant side - CorreCt Answers -C, E

A nurse is evaluating a client's neurosensory system
...
A word she whispers 30cm from his ear
B
...
The vibration of a tuning fork she places on his foot
D
...

Stereognosis is tactile recognition

A nurse is assessing a client who reports pain when the nurse evaluates the
internal rotation of her right shoulder
...
Mopping her floors
B
...
Fastening her bra behind her back
D
...

Fastening a bra from behind requires internal rotation of the shoulder, so
this activity will illicit pain

A nurse is preforming a neurosensory examination for a client
...


A
...
Heel-to-toe walk
C
...
Spinal accessory function
E
...


A nurse is collecting data from an older adult client as part of a
neurosensory examination
...


A
...
Some vision & hearing decline
C
...
Some short-term memory decline

E
...
Which of the following
should the nurse teach the client about using oxygen safely in his home?
Select all
...
Family members who smoke must be at least 10 ft from the client when
the oxygen is in use
B
...
A "No smoking" sign should be placed on the front door
D
...
A fire extinguisher should be readily available in the home - CorreCt
Answers -B, C, E

Family members that smoke should do so outside, and wool creates static
electricity so it should be avoided
...
Which of
the following statements made by a participant indicates a need for further
clarification & instruction?

A
...
"
B
...
"
C
...
"

D
...
" - CorreCt Answers -B
Although the baby can hold his head above the water by sitting up, this does
not make the baby safe in the tub
...


A home health nurse is discussing the dangers of carbon monoxide
poisoning w/a client
...
Carbon monoxide has a distinct odor
B
...
The lungs are damaged from carbon monoxide inhalation
D
...

Carbon monoxide is a very dangerous gas because it binds w/hemoglobin &
ultimately reduces the oxygen supplied to the tissues in the body
...

The water heaters, gas-burning furnances, and appliances should be
inspected annually
The lungs are not damaged in the process of inhalation

A nurse educator is presenting a module on basic first aid for newly
licensed home health nurses
...
Hypotension

B
...
Clammy skin
D
...
Hypotension
Tachycardia, hot dry skin, and tachypnea are other manifestations of heat
stroke

A home health nurse is discussing the dangers of food poisoning w/a client
...


A
...
Immunocompromised individuals are at risk for complications from food
poisoning
C
...
Healthy individuals usually recover from the illness in a few weeks
E
...
coli
...


A nurse is caring for a client diagnosed w/severe acute respiratory
syndrome (SARS)
...
Which of the
following illustrate the rationale for reporting? Select all
...
Planning & evaluating control & prevention strategies
B
...
Ensuring proper medical treatment
D
...
Monitoring for common-source outbreaks - CorreCt Answers -A, B, C, E

Not D because endemic disease is already prevalent within a population, so
reporting is not necessary

A nurse is contributing to the plan of care for a client who is being admitted
to the facility w/a suspected diagnosis of pertussis
...


A
...
Wear a mask when providing care within 3 ft of the client
C
...
Use sterile gloves when handling soiled linens
E
...

The nurse should wear a gown when contamination from body fluids might
happen

A nurse is caring for a client who presents w/linear clusters of fluidcontaining vesicles w/some crustings
...
Allergic reaction
B
...
Systemic lupus erythematosus
D
...
Herpes zoster

pink body rash=allergic reaction
red circles w/white centers=ringworm
red cheek rash bilaterally=lupus

A nurse is caring for a client who reports severe sore throat, pain when
swallowing, & swollen lymph nodes
...
Prodromal
B
...
Convalescence
D
...
Illness
specific s/s present is the illness stage

A nurse educator is reviewing w/a newly hired nurse the difference in
clinical manifestations of a localized vs
...
The nurse
indicates understanding when she states that which of the following are
clinical manifestations of a systemic infection? Select all
...
Fever
B
...
Edema
D
...
Increase in pulse & respiratory rate - CorreCt Answers -A, B, E

Edema and pain and tenderness is localized

A nurse is teaching a young adult client about health promotion & illness
prevention
...
"I already had my immunizations as a child, so I'm protected in that
area
...
"It is important to schedule routine health care visits even if I'm feeling
well
...
"If I'm having any discomfort, I'll just got to an urgent care center
...
"If I am felling stressed, I will remind myself that this is something I
should expect
...

routine health screenings are important at any age

A nursing instructor is explaining the various stages of the lifespan to a
group of nursing students
...
Becoming actively involved in providing guidance to the next generation
B
...
Devoting a great deal of time to establishing an occupation
D
...

Exploring and establishing career options & establishing oneself is
important developmental task in a young adult

A nurse is counseling a young adult who describes having difficulty dealing
w/several issues
...
"I have my own apartment now, but it's not easy living away from my
parents
...
"It's been so stressful for me to even think about having my own family
...
"I don't even know who I am yet, & now I'm supposed to know what to
do
...
"My girlfriend is pregnant, & I don't think I have what it takes to be a
good father
...

Applying Erikson stages of development, knowing oneself is done in
adolescence, and this requires the most urgent help

A nurse is reviewing safety precautions w/a group of young adults at a
community health fair
...


A
...
Wear a helmet while skiing
C
...
Secure firearms in a safe location
E
...
Which of the following recommendations should the nurse
include in this discussion? Select all
...
Human papillomavirus
B
...
Varicella
D
...
Polio - CorreCt Answers -A, B, C

D is not for after 18 months of age and polio is also given as a child and not
usually beyond 18 yrs old

A nurse is caring for an 82-yr-old client in the ER who has an oral body
temp of 38
...
He is
restless & his skin is warm
...


A
...
Restrict the client's oral fluid intake
C
...
Allow the client to shiver to dispel excess heat
E
...


Why E-Oral hygiene helps prevent cracking of dry mucous membranes of
the mouth & lips
...
Which of the following is the nurse's priority
instruction for measuring vital signs for this client?

A
...
"
B
...
"
C
...
"
D
...
" - CorreCt
Answers -A
...
"

The greatest risk to a client w/a low platelet count is injury that results in
bleeding, obtaining a temp this way increases the risk for bleeding
...
Which of the following guidelines should the nurse include? Select all
...
Place the client in semi-Fowler's position
B
...
Observe 1 full respiratory cycle before counting the rate
D
...
Count & report any signs the client demonstrates - CorreCt Answers -A,
B, C

For D, this is if the rate is irregular after initial count, for E, sighs are
expected & don't need to be reported

A nurse who is admitting a client who has a fractured femur obtains a BP
reading of 140/94 mmHg
...
Which of
the following actions should the nurse take next?

A
...
Ask the client if she is having pain
C
...
Return in 30min to recheck the client's BP - CorreCt Answers -B
Perform a pain assessment would be the appropriate action to take next

A nurse is performing an admission assessment on a client
...
What is the client's pulse
deficit? - CorreCt Answers -16/min

the pulse deficit is the difference between the apical & radial pulse rates
...
Which of the following info should the nurse include when
explaining the procedure to the client?

A
...
One stool specimen is sufficient for testing
C
...
The specimen cannot be contaminated - CorreCt Answers -D
...
When the nurse
discusses dietary changes that can help prevent constipation, which of the
following foods should the nurse recommend?

A
...
Fresh fruit & whole wheat toast
C
...
Roast chicken & white rice - CorreCt Answers -B
...

When assessing the client, the nurse should expect which of the following
findings? Select all
...
Bradycardia

B
...
Fever
D
...
Peripheral edema - CorreCt Answers -B, C, D

fever=caused by dehydration
tachycardia not brady
hypotension because of decreased BP from dehydration
fluid overload=peripheral edema

A nurse is preparing to administer a cleansing enema to an adult client in
preparation for a diagnostic procedure
...


A
...
Position the client on the left side w/the right leg flexed forward
C
...
Slowly insert the rectal tube about 2 inches
E
...

-24 inches is too high & will cause it to run to fast & possible painful
distention of the colon, 18 inches is the recommended height

While a nurse is administering a cleansing enema, the client reports
abdominal cramping
...
Have the client hold his breath briefly
B
...
Remind the client that cramping is common at this time
D
...

This will slow the rate of instillation & relieve some discomfort

A nurse is caring for a client who has been sitting in a chair for 3 hrs
...
Stasis of secretions
B
...
Pressure ulcer
D
...
Which of the following
interventions should the nurse implement to maintain the patency of the
client's airway?

A
...
Suction Q8 hr
C
...
Promote incentive spirometer use - CorreCt Answers -Answer: D
...
Which of the following nursing
interventions reduce the risk of thrombus development? Select all
...
Instruct the client not to use the Valsalva maneuver
B
...
Review lab values for total protein level
D
...
Assist the client to change position often - CorreCt Answers -B, E

A nurse is instructing a postop client about the sequential compression
device the provider has prescribed
...
"This device will keep me from getting sores on my skin
...
"This thing will keep the blood pumping through my leg
...
"With this thing on, my leg muscles won't get weak
...
"This device is going to keep my joints in good shape
...

sequential pressure devices promote venous return in the deep veins of the
legs & thus help prevent thrombus formation

To promote the safe use of a cane for a client who is recovering from a
minor musculoskeletal injury of the left lower extremity, which of the
following instructions should the nurse provide? Select all
...
Hold the cane on the right side
B
...
Place the cane 15in in front of the feet before advancing
D
...
Advance the stronger leg so that it aligns evenly w/the cane - CorreCt
Answers -A, B, D

C-the client should place the cane 6-10 inches in front before advancing not
15
E-the client should advance the stronger leg past the cane not aligned w/it

A nurse is assessing the pain level of a client who has come to the ER
reporting severe abd
...
The nurse asks the client whether he has nausea
& has been vomiting
...
Presence of associated symptoms
B
...
Pain quality
D
...

this is a common symptom people have when experiencing pain

A nurse is assessing a client who is reporting severe pain despite analgesia
...
asking what precipitates the pain
B
...
offering the client a pain scale to measure his pain
D
...

pain scale can measure the amount and intensity of the pain

A nurse is obtaining hx from a client who has pain
...
some clients exaggerate their level of pain
B
...

C
...
pain is whatever the client says it is - CorreCt Answers -D
the client is the best source of information in their pain, it is a subjective
experience

A nurse is caring for a client who is receiving morphine via a PCA infusion
device after abd
...
Which of the following statements indicates that
the client knows how to use the device?

A
...
"
B
...
"
C
...
"
D
...
" CorreCt Answers -C
...
Which of the following effects should the nurse
anticipate? Select all
...
Urinary incontinence
B
...
Bradypnea
D
...
Nausea - CorreCt Answers -C, D, E

Urinary retention, not incontinence is an adv effect of these meds as well as
constipation, not diarrhea
...
Which of the following findings should the nurse document
as extrapyramidal symptoms (EPS)? Select all
...
Orthostatic hypotension
B
...
Acute dystonias
D
...
Uncontrollable restlessness - CorreCt Answers -B, C, E

A and D are adverse effects, but not EPS

A nurse is providing teaching about managing anticholinergic effects for a
client who has a new prescription for oxybutunin (Ditropan XL)
...


A
...
Wear sunglasses when exposed to sunlight
C
...
Take the medication w/an antacid
E
...
The meds include cimetidine (Tagamet) & imipramine
hydrochloride (Tofranil)
...
Decreased therapeutic effects of cimetidine
B
...
Decreased risk of adv effects of cimetidine
D
...

A med that decreases the metabolism of a 2nd med increases the serum
level of the 2nd med, increasing risk for toxicity

A nurse in an outpatient clinic is caring for a client who states she is trying
to get pregnant
...
Which of the following statements by the nurse
is appropriate?

A
...
"
B
...
"
C
...
"
D
...
" - CorreCt Answers -A
...


A nurse in an outpatient surgical center is admitting a client for a
laproscopic procedure
...
Prior to administering the med, which of the following
actions is the highest priority?

A
...
Administering the med to the client at the prescribed time
C
...
Documenting the client's anxiety level - CorreCt Answers -C
...
The amount available is 40 mg/mL
...
3 mL

A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over
15min
...
9% sodium chloride (0
...
The drop factor of the manual IV tubing is 10
gtt/mL
...
Which of the
following is an appropriate nursing intervention?

A
...

B
...

C
...

D
...
- CorreCt Answers B
...


A nurse is preparing a presentation about basic nutrients for a group of
high school athletes
...
Fat
B
...
Glycogen
D
...

carbs provide glucose

A nurse is caring for a client who is on a low-residue diet
...
Cooked barley
B
...
Vanilla custard
D
...


low-residue diets are low in fiber and easy to digest: dairy products
especially

A nurse is caring for a client who weighs 80 kg (176 lb) and is 1
...
Calculate her BMI & determine whether this client is obese based
on her BMI
...


A nurse in a senior center is counseling a group of older adults about their
nutritional needs & considerations
...


A
...
Older adults need the same amount of most vitamins & minerals as
younger adults do
C
...
Older adults need more calories than they did when they were younger
E
...
The client states his pain level is a 10 on a scale of 0-10
...
Meperidine (Demerol) 75 mg IM
B
...
Morphine 2 mg IV
D
...

IV morphine is the best because the onset is rapid and absorption to the
blood is immediate, which is adequate for a client with a 10 pain severity

A nurse is teaching a client about taking multiple oral meds at home to
include time-release capsules, liquid meds, enteric-coated pills, & narcotics
...
"I can open the capsule w/the beads in it & sprinkle them on my
oatmeal
...
"If I am having difficulty swallowing, I will add the liquid meds to a batch
of pudding
...
"The pills w/the coating on them can be crushed
...
"I will eat 2 crackers w/the pain pills
...

this will prevent N&V from the narcotic

A nurse is teaching a client how to administer medication through a
jejunostomy tube
...
"Flush the tube before & after each med
...
"Administer your meds w/your enteral feeding
...
"Administer tablets through the tube slowly
...
"Mix all the crushed meds prior to dissolving in water
...
Which of the following statements by a newly
licensed nurse indicates an understanding of the 1st-pass effecct?

A
...
"
B
...
"
C
...
"
D
...
" - CorreCt Answers -B
...
Which of
the following statements by the client indicates understanding of the proper
technique?

A
...
"
B
...
"

C
...
"
D
...
" - CorreCt Answers -B
...


A nurse prepares to administer an injection of morphine (Duramorph) to a
client who reports pain
...
She asks a 2nd nurse
to give the injection
...
Offer to assist the client needing the bedpan
...
Administer the injection prepared by the other nurse
C
...
Tell the client needing the bedpan she will have to wait for her nurse CorreCt Answers -A
...
The med was
scheduled for administration at 0900
...


A
...
0825
C
...
0840

E
...
Which of the following actions by the newly hired nurse indicates an
understanding of med error prevention?

A
...
Checking w/the provider when a single dose requires administration of
multiple tablets
C
...
Relying on another nurse to clarify a med prescription - CorreCt
Answers -B
this could indicate a possible error so it should be checked w/the provider

A nurse educator is teaching a module on safe med administration to newly
hired nurses
...


A
...
"
B
...
"
C
...
"
D
...
"

E
...
" - CorreCt Answers -A,
B, E

A nurse is preparing to administer digoxin (Lanoxin) to a client who states,
"I don't want to take that med
...
" Which of the
following responses by the nurse is appropriate in this situation?

A
...
"
B
...
"
C
...
"
D
...
" - CorreCt Answers -D
...
infection that puts her
at risk for hypoxemia
...


A
...
Tachypnea
C
...
Confusion
E
...


A nurse is caring for a client who is having difficulty breathing
...
Which
of the following interventions is the nurse's priority?

A
...
Assist the client to Fowler's position
C
...
Obtain a specimen for arterial blood gases - CorreCt Answers -B
Fowler's facilitates better breathing

A nurse is preparing to preform endotracheal suctioning for a client
...


A
...
Perform suctioning on a routine basis, Q2-3 hours
C
...
Use a new catheter for each suctioning attempt
E
...

C-endotracheal suctioning requires surgical asepsis

A nurse is caring for a client who has a tracheostomy
...


A
...
Use surgical asepsis to remove & clean the inner cannula
C
...
Replace the tracheostomy ties w/new ties
E
...
- CorreCt
Answers -A, B, C

D-only replace ties if soiled or wet
E-use a commercially prepared gauze w/slit not one nurse makes

A provider is discharging a client with a prescription from home oxygen
therapy via nasal cannula
...


A
...
Remove the nasal cannula during mealtimes
C
...
Report any nasal stuffiness, nausea, or fatigue
E
...
When the nurse pours water into the
syringe after the formula drains from the syringe, the client asks the nurse

why the water is necessary
...
"Water helps clear the tube so it doesn't get clogged
...
"Flushing helps make sure the tube stays in place
...
"This will help you get enough fluids
...
"Adding water makes the formula less concentrated

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