ATI Book Questions - Fundamental Nursing

ATI book questions - Fundamentals 1. A nurse is reviewing hand hygiene techniques with a group of assistive personnel( AP). Which of the following instructions should the nurse include when discussing handwashing? A. Apply 3 to 5 ML of soup to dry hands. B. Wash hands with soap and water C. Rinse hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing. 2. When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client’s bedside. B. Intrust the clients to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of microorganisms into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change. 3. A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body 4. The nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B.The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C.The procedure is delayed 1 hr because the provider receives an emergency call. D.The nurse turns to speak to someone whoenters through the door behind the nurse. E.The client's hand brushes against the outer edge of the sterile field. 5. A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching the sterile technique? (Select all that apply.) A.A bottle containing a sterile solution B.The edge of the sterile drape at the base of the field C.The inner wrapping of an item on the sterile field D.An irrigation syringe appropriately placed on the sterile field One gloved hand with the other E.. One Gloved hand with another gloved hand. Infection Control(53-58) 1. A nurse is reviewing the stages of infection with new nurses. Place the stages in the order in which they occur. A. Prodromal B. Convalescence C. Incubation D. Illness 1. Incubation 2. Prodromal 3. Illness 4. Convalescence 2. A nurse is caring for a client who has an infection Sort the manifestations the nurse would expect to find if the infection is Localized or Systemic. A. Fever. B. Malaise. C. Edema. D. Pain or tenderness. E. increase in pulse and respiratory rate. Localized- C, D Systemic- A, B, E 3. A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse suggest?? (Select all that apply.) A. Place the client in a room that has a negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions. Pertussis. 4. The nurse is reviewing the use of transmission-based isolation precautions with a group of new nurses.Sort the following infectious diseases by the type of precautions required. (Contact, Droplet, Airborne) A. Tuberculosis - Airborne B. SARS-Cov2 (COVID-19) - Airborne C. Influenza Droplet - Droplet D. C. difficile- Contact precautions E. MRSA - Contact precaution The client safety 1. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment. 2. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B.Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession. 3. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? " A.I will place the client on their side."B B."I will go to the nurses' station for assistance." C."I will note the time that the seizure begins." D. "I will prepare to insert an airway." 4. A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A.Extinguish the fire. B.Activate the fire alarm. C.Move clients who are nearby. D.Close all open doors on the unit. Ergonomic principles (71-74) 1. A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) A. "My line of gravity should fall outside my base of support." B. The lower my center of gravity the more stability I have." C." To broaden my base of support, I should spread my feet apart." D."When I lift an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward." 2. A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B.Call for additional staff to assist with the transfer. C.Use a transfer belt and assist the client back into bed. D.Determine the client's ability to help with the transfer. 3. A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) A.Request assistance when repositioning a client. B.Avoid twisting your spine or bending at the waist. C.Keep your knees slightly lower than your hips when sitting for long periods of time. D.Use smooth movements when lifting and moving clients. E.Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles. 4. A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A. Supine B. Semi-Fowler's A. Sumers C. Lateral Semi-prone Recumbent D. Trendelenburg 5. A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath.Which of the following statements should the nurse make? A."Lie on your back with your head and shoulders supported by a pillow. B. "Have your head turned to the side while you lie on your stomach. C."Have a table beside your bed so you can sit on the bedside and rest your arms on the table. D."Lie on your side with your top arm resting on the bed and your weight on your hip." Vitals signs(135-143) 1. A nurse is instructing a newly licensed nurse about choosing a site to measure a client’s temperature. Sort the following clients with the correct temperature site: Oral or Rectal. A. A client who breathes through the mouth.(Rectal) B. A client who has a low platelet count.(Oral) C. client who has facial trauma(Rectal) D.client who has hemorrhoids (Oral) 2.A nurse is caring for client who has an oral temperature of 38.6° C (101.5 heart rate 114/ min, and respiratory rate 22/min. Which of the following interventions should the nurse take? (Select all that apply.) A.Obtain culture specimens before initiating antimicrobials. B.Restrict the client's oral fluid intake. C.Encourage the client to rest and limit activity. D.Allow the client to shiver to dispel excess heat. E.Assist the client with oral hygiene frequently. 4. The nurse determines a client’s radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? 68x84=16 16/mins 5. A nurse is instructing an assistive personnel(AP) how to measure a client's respiratory rate.Which of the following statements should the nurse include? (Select all that apply.) A."Place the client in semi-Fowler's position." B."Have the client rest an arm across the abdomen C.Observe count full respiratory cycle before counting the rate. D. "Count the rate for 30 sec if it is irregular." E."Inform the client you are counting their respiratory rate." 6. A nurse is caring for a client who has a fractured femur and a blood pressure of 140/94 mm Hg. Which of the following actions should the nurse take first? A.Request a prescription for an antihypertensive medication. B.Ask the client if they are having pain. C.Instruct the client about a low-sodium diet. D.Return in 30 min to recheck the client's blood pressure. Hygiene(207-211) 1.A nurse is providing information about age-related physical changes to the family member of an older adult. Which of the following information should the nurse include? A.Older adults have oilier skin than younger persons. B.Dry mouth is common for older adults. C.It is common for older adults to have increased perspiration. D.Hair in the eyebrows decreases. 2. A nurse is providing a client with a complete bed bath. When providing the care, the nurse must recognize the order in which areas of the body will be bathed. Place the options in the correct order. Face Trunk Legs Feet 3. A nurse is providing instructions about foot care to who has diabetes mellitus. which of the following actions should the nurse include? (Select all that apply.) A. Wear wool socks. B. Apply lotion between the toes. C. Wash the feet daily, using warm water. D. Warm the feet using a heating pad. E.Smooth the edges of the toenail with an emery board. 4. A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side. B. Place two fingers in the client's mouth to open it. C.Brush the client's teeth once per day. D.Inject a mouth rinse into the center of the client's mouth. 5. A nurse is providing denture care for a client. Which of the following actions should the nurse take? A.Using a gauze pad to grasp and pull forward and downward to remove the upper denture. B. Storing the dentures overnight in a labeled denture cup filled with a solution of water and mouthwash. C. After brushing the dentures, rinsing them in hot water. D. Donning sterile gloves prior to performing denture care. Airway management(315-323) 1. A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) A. Restlessness B. Tachypnea C.Bradycardia D.Confusion E. Hypertension 2. A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A.Apply petroleum jelly around and inside the nares. B.Remove the nasal cannula during mealtimes. C.Check the position of the cannula frequently. D.Report any nausea or difficulty breathing. E.Post "No Smoking" signs in prominent locations. 3. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B.Assist the client to Fowler's position. C.Promote removal of pulmonary secretions. D.Obtain a specimen for arterial blood gases. 4. A nurse is preparing to perform endotracheal suctioning for a client. Place the following actions in the proper order. A. Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds. B.Assist the client to high-Fowler's or Fowler's position for suctioning if possible. C.Don the required personal protective equipment. D. Encourage the client to breathe deeply and cough in an attempt to clear the secretions without artificial suction. E. Obtain baseline breath sounds and vital signs, including SaO by pulse oximeter so we Can monitor SaOz continually during the procedure. F.Pull the catheter back 1 cm (0.4 in) prior to applying suction. G.Reattach the BVM or ventilator and administer 100% oxygen. H.Rinse catheter and suction tubing with sterile saline until clear. I.Remove the bag or ventilator from the tracheostomy or endotracheal tube and insert the catheter into the lumen of the airway. Advance the catheter until resistance is met. The catheter should reach the level of the carina (location of bifurcation into the mainstem bronchi). C,B,D,E,I,F,A,G,H 5. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A.Apply the oxygen source loosely if the SpOz decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C.Clean the outer cannula surfaces in a circular motion from the stoma site outward. D.Replace the tracheostomy ties with new ties. E.Cut a slit in gauze squares to place beneath the tube holder. Immobility to mobility (ROM) ( 221-225) 1. A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B.Muscle atrophy C.Pressure injury D.Fecal impaction 2. A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) A, Instruct the client not to perform the Valsalva maneuver. B.Apply elastic stockings. C. Review laboratory values for total protein level.. F.Place pillows under the client's knees and lower extremities. E. Assist the client to change positions often. 3. A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) A.Hold the cane on the right side. B.Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane. 4. A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A.Encourage the client to perform - To Redul antiembolic exercises every 2 hr. B.Instruct the client to cough and deep breathe every 4 hr. C.Restrict the client's fluid intake. D.Reposition the client every 4 hr Case study exercises 1. Claire is preparing to apply the sequential compression sleeves to Mr. Tuttle's legs. Which technique should Claire use to determine the correct size of the stocking? A.Measuring the length of the leg from the groin to the heel B. Measuring the thickest part of the calf C.Measuring the distance between the top of the thigh to the bottom of the knee D.Measuring around the largest part of the thigh 2. Claire is evaluating Mr. Tuttle's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? A."This device will keep me from getting sores on my skin." B."This device will keep the blood pumping through my legs." C."With this device on, my leg muscles won't get weak." D."This device is going to keep my joints in good shape." Nutrition and oral hydration. 1. A nurse is preparing a presentation about basic nutrients for a group of high school athletes. The nurse should include that which of the following provides the body with the most energy? A.Fat B.Protein C.Glycogen D.Carbohydrates 2. A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults. B.The recommended intake of daily fiber decreases in older adults. C. Many older adults need calcium supplementation. D.Older adults need more calories than they did when they were younger. E.Older adults should consume a diet low in carbohydrates. 3. . A nurse is caring for a client who weighs 80 kg (176 |b) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index - (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese. 1.6x1.6=2.56// 80/26=21.25 4. A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Giving the client thin liquids B.Instructing the client to tuck their chin when swallowing. C. Having the client use a straw Avoid Straws. D.Encouraging the client to lie down and rest after meal. 5. A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A.Cooked barley B.Pureed broccoli C.Vanilla custard D. Lentil soup