ATI Fundamental Retake #2 Level 2, Corrected QUESTIONS AND ANSWERS LATEST VERSION

ATI Fundamental Retake #2 Level 2, Corrected QUESTIONS AND ANSWERS LATEST VERSION 1) A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take? A) Cotton tip applicator to clean the inside of the cannula B) Soak the outer cannula in warm soapy tap water C) Cleanse the skin around the stoma with normal saline D) Secure the tracheostomy ties to allow one finger to fit snuggly underneath 2) A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? A) Ensure the client is free of metal objects B) Administer 240 ml (8oz) oral contrast before the procedure C) Monitor the client for pain in the suprapubic region D) Assist the client with a bowel cleansing 3) A nurse is testing a client for conduction deafness by performing the Weber’s tests. which of the following actions should the nurse take when performing the test? A) Move a vibrating tuning fork in front of the clients canals one after the other B) Place the base of the vibrating tuning fork on the top of the client’s head C) Place the base of a vibrating tuning fork on the client’s mastoid process D) Count how many seconds a client can hear a tuning fork after it has been struck 4) A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care? A) Prepare the client for a central venous line B) Change the PN infusion bag every 48 hours C) Administer the PN and fat emulsion separately D) Obtain a random blood glucose daily *5) A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching? A) Each element has a range 1 to 5 points B) The higher the score the higher the pressure ulcer risk C) The client’s age is part of the measurement D) The scale measures six elements *6) A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse’s priority? A) Determine the client’s reading ability B) Review the use of an artificial larynx C) With the client schedule a support session D) For the client explain the techniques of esophageal speech 7) A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? A) Eat a light carbohydrate snack before bedtime B) Exercise 1 hour before bedtime C) Drink a cup of hot cocoa before bedtime D) Take a 30 min nap daily 8) A nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first? A) Offer pain medication B) Palpate the abdomen C) Auscultate bowel sounds D) Administer an antiemetic 9) A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the client’s motivation to learn? A) The client’s belief that his needs will be met through education B) The nurse explaining the need for education to the client C) The client seeking family approval by agreeing to a teaching plan D) The nurse’s empathy about the client having to self-inject 10) A nurse is caring for a client who has restraints to each extremity. Which of the following assessment should the nurse perform first? A) Elimination needs B) Comfort level C) Peripheral pulses D) Skin integrity 11) A charge nurse is monitoring the documentation of the medication by a newly licensed nurse. The charge nurse should intervene if the newly licensed nurse uses which of the following abbreviations? A) OJ for orange juice B) SQ for subcutaneous C) SS for sliding scale D) BRP for bathroom privileges 12) A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement? A) Contact B) Droplet C) Airborne D) Protection 13) A nurse is caring for a client receiving continuous enteral feedings through an NG tube. Which of the following is an unexpected finding? A) Diarrhea one time in a 24-hour period B) A weight gain of 0.9 (2lb) in 2 days C) A gastric residual of 300 mL at the end of the shift D) A blood glucose level of 110 14) A nurse is preparing a sterile field to assist with nurturing a client’s laceration. Which of the following actions should the nurse plan to take? A) Pour the sterile solution with the bottle held 20 cm (8 in) above the sterile bowl B) Hold the bottle of sterile solution so that the label is facing the palm of the hand C) Place the lid of the sterile solution bottle face down on the sterile drape D) Apply sterile gloves before opening the bottle of sterile solution 15) A nurse is preparing to administer several medications to a client via NG tube to a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take first? A) Dilute each crushed medication with sterile water B) Mix the medications together in a single syringe C) Combine the medications with the formula D) Flush the NG tube with 5 mL of sterile water prior to administration 16) A nurse is reviewing the medication record of a client who asks about the use of magnet therapy for pain relief. The nurse should identify that which of the following findings is a contraindication for receiving this type of therapy? A) The client who has an implanted defibrillator B) The client who has a prescription for metoprolol C) The client is allergic to penicillin D) The client has a history of alcohol use disorder 17) A nurse is assessing the skin of a client who has worked outdoors for the past 30 years. Which of the following findings is a priority? A) A flat, nonpalpable, discolored area of skin B) A change in the appearance of a mole on the shoulder C) Skin tags in the neck region D) Atrophic wart on the left index finger 18) a nurse is preparing to insert an iv catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating an IV therapy? A) The radial vein on the left wrist B) The cephalic vein in the left distal forearm C) The basilic vein in the right antecubital fossa D) The cephalic vein on the back of the right hand 19) a nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take? A) Tie the restraints to the side rale B) Secure restraints with a square knot C) Remove one restraint at a time D) Remove the restraints every 3 hours 20) Dosage Calculation- Gentamicin 2mg/kg/220 lb.= 200 21) A nurse is assessing a client who has diabetes prior to performing a blood glucose test. Which of the following findings should indicate to the nurse the client has hyperglycemia? A) Thirst B) Confusion C) Cool Skin D) Shakiness 22) A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first? A) Determine areas of resonance across the abdomen using a systematic approach B) Expose the client’s abdomen to look for changes in appearance C) Perform abdominal palpation by pressing gently with the finger pads D) Use the diaphragm of the stethoscope to listen for bowel sounds 23) a nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take? A) Heat the formula to 105 degrees Fahrenheit B) Flush the tubing with 10 ml of water every 2 hours C) Change the tubing every 72 hours D) Aspirate residual volume every 4 hours 24) A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching? A) I can apply lotion to soften the calluses as long as I don’t put lotion between my toes B) I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly C) I should soak my feet in warm water daily to soften corns and calluses D) I should use an over-the-counter liquid medication to remove corns 25) A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? A) Plain yogurt B) Oatmeal C) Applesauce D) Scrambled eggs 26) A community health nurse is teaching a group of clients about Kegel exercises to prevent urinary incontinence. Which of the following instructions should the nurse Include? A) Contact your pelvic muscle when performing the exercises B) Tighten your button when performing the exercise C) Hold your breath while performing the exercise D) Expect improvement after 2 weeks for performing this exercise 27) A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in the teaching? A) You will receive written information about advance directives prior to signing B) Your partner must be present when you sign the advanced directive C) You are required to sign the advanced directive before surgery D) Your provider must sign the advanced directive 28) A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take? A) Schedule postural drainage after meals B) perform percussion over the lower back C) instruct the client to exhale quickly during vibration D) cover the area of precaution with a towel 29) A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take first? A) Inject air into the short acting insulin vial. B) Draw up the intermediate insulin into the syringe C) Draw the short-acting insulin into the syringe D) Inject air into the intermediate-acting insulin vial 30) A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? SATA A) Oral suction equipment B) Oral airway C) Supplemental oxygen D) Blood glucose monitor E) Limb restraints 31) A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage? A) Dilated pupils B) Bradycardia C) Depression D) Physical exhaustion 32) A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrate correct documentation? A) Client premedicated with MSO4 subq prior to dressing change B) The wound seems clean and does not appear to be infected C) New dressing applied as prescribed, no drainage on old dressing D) No changes noted to the wound from previous nursing notes 33) A nurse is caring for a client who had a stroke and requires assistance with morning ADL’s. Which of the following interprofessional team members should the nurse consult? A) Speech language pathologist B) Registered dietician C) Physical therapist D) Occupational therapist 34) A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching? A) I should limit the time that I spend sitting in a chair B) I will perform leg exercises once every four hours C) I should massage my legs when they hurt D) I will keep my legs crossed while sitting 35) A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan? A) Keep the drainage bag below the level of the bladder B) Tape the catheter to the lower abdomen C) Attach the drainage bad to the side rails of the bed D) Empty the drainage bag when it is ¾ filled 36) A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first? A) Obtain the client’s vital signs B) Report the incident to the unit manager C) Complete an incident report D) Document the fluid infusion in the client’s chart 37) A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take? A) Apply a bath blanket between the client and a cooling blanket B) Give the client a sponge bath using alcohol water solution C) Place ice packs on the client’s neck and behind the knees D) Cover the client with heavy blankets after shivering subsides 38) A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective? A) The client states that he is able to concentrate while eating B) The clients’ vital signs are within the normal range C) The client is laughing at a television show D) The client’s skin on the lower back is intact without redness 39) A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take? A) Place the extremity in a dependent position B) Apply a cool compress for several minutes before insertion C) Place the tourniquet below the proposed insertion site D) Choose the most proximal site on the extremity selected 40) A nurse is delegating client care to assistive personnel. Which of the following tasks should the nurse plan to delegate to the AP. A) Changing IV tubing B) Inserting NG tube C) Evaluating the healing of an incision D) Performing a simple dressing change 41) A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identity? A) Photograph B) Room number C) Bed number D) Age 42) A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching? A) I should gradually increase the time that I wear the hearing aid B) I need to get a new hearing aid every year C) I should leave the battery in the hearing aid when I sleep D) After I insert the hearing aid, I should turn it all the way up 43) A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse use? A) The shallow end of the fracture pan under the client’s buttocks B) Hyperextend the clients back while the fracture pan is still in place C) Encourage the client to defecate for 20 minutes D) Keep the bed flat while the client is on the bed pan 44) A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care? A) Schedule the client as the first surgical procedure of the day B) Cleanse the stoppers with primidone iodine for withdrawing medication C) Remove the stop stocks from iv tubing D)Ensure the gloves in the surgical suite are powdered gloves 45) A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A) Use medical terminology when giving information to the client B) Address all questions to the interpreter C) Have the client nod to indicate understanding D) Recommend an interpreter the same gender as the client 46) A nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first? A) Provide the client with a contact number for a diabetes education specialist B) Make a copy of the medication record of the reconciliation for the client C) Determine whether the client can afford the insulin administration supplies D) Obtain printed information about self-administration 47) A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority? A) Develop a list of goals with the client B) Help the client to find a local support group C) Discuss the clients prior coping mechanisms D) Teach the client to use progressive relaxation techniques 48) A nurse is caring for a client who is postoperative and asks the nurse “When will I get to go home? I’m not sure what happens next.” Which of the following actions should the nurse take next? A) Explain that the client should trust the provider because he has an excellent reputation B) Tell the client that the provider will discharge him when she feels he is ready to leave C) Assure the client that the provider will come to talk to him when she gets the chance D) Inform the provider that the client is requesting information about his treatment plan 49) A nurse is caring for a client who has colon cancer and is scheduled for a colon resection with a possible colostomy. Before the procedure, the client tells the nurse, I’m worried about the bag. Which of the following is an appropriate response by the nurse? A) You are worried about having to wear a colostomy bag? B) Let’s wait until after the surgery to discuss your concerns C) Have you ever known someone who has a colostomy D) The surgeon will only place the colostomy if it is necessary 50) A nurse working on a medical surgical unit is making client assignments for an upcoming shift. Which of the following tasks should the nurse assign to assistive personnel? A) Assisting with ambulation for a client who has a pulmonary infection. B) Showing a client how to use an incentive spirometer C) Inserting a glycerin suppository D) Irrigating a clients infected surgical wound 51) A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the injection? A) Discard the needle in a puncture proof container B) Place the needle on the bedside table C) Recap the needle before disposal D) Remove the needle from the syringe 52) A charge nurse in a long-term care facility is preparing an educational program about Delerium for newly hired nurses. Which of the following statements should the nurse plan to include? A. Delirium has an abrupt onset B. Delirium does not affect the client's perception of her environment C. Delirium has a slow progression D. Delirium does not affect a client's sleep cycle 53) A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take? A. Place the wasted portion of the controlled substance in the sharp container B. Verify the count total of the controlled substance after removing the amount needed. C. Report any discrepancy in the count total of the controlled substance after administration D. Ask a second nurse to record her signature when wasting any unused portion of the controlled substance 54) A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect? A) Heightened sense of pain B) Nighttime urinary incontinence C) Decreased sense of balance D) Increased nighttime sleeping 55) A nurse is caring for a client that refuses to follow the providers prescription for strict bed rest. The nurse overhears assistive personnel tell the client “If you do not remain in bed, I will place you in restraints.” A) False imprisonment B) Defamation of character C) Battery D) Assault 56) A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? A) Unplug the pump B) Label with a defective equipment sticker C) Obtain a replacement pump D) Notify the biomedical department to fix the pump 57) A nurse is caring for an infant who is to undergo surgery. The nurse should identify which of the following individuals should sign the consent form? A) The infants 17-year-old mother B) The infant’s grandparents C) The infant’s provider D) The mothers 21-year-old sibling 58) A nurse is reviewing the medical record for a newly admitted client. Which of the following laboratory values should the nurse report to the provider? A) Sodium 140 B) Potassium 5.8 C) Calcium 9.6 D) Magnesium 1.9 59) A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage? A) Present information about the benefits of quitting smoking B) Develop a plan for the client to integrate the change C) Recommend small changes for the client to make D) Assist the client in setting goals to make the change 60) A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Place them in order of performance. Use all steps) 1. Provide adequate lighting to inspect the abdomen 2. Listen to the abdomen arteries using the bell of a stethoscope 3. Percuss all four quadrants of the abdomen to measure sound quality 4 Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm ( 1 to 3 in) into the abdomen 5. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen 61) A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse? A. The test will indicate if you are at risk for developing blood clots B. This test will determine if your heart is performing properly C. This test is used to check how your kidneys are working D. The test will provide information about the function of your liver 62) A. nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. I will place the client in a private room B. I will tell the clients visitors to wear a mask when they are within three feet of the client C. I will remove my gown before my gloves after providing client care D. I will wear an N95 respirator mask when caring for the client 63) A nurse is receiving a client's intake and output and notes the following 0.9% sodium chloride 600 mL IV infusion, Cefazolin 250 mg in dextrose 5% water 100 ml intermittent IV bolus, 200 mL emesis, 40ml voided urine, and 20 ml urine from straight to the reservation. The nurse should record the client's net fluid intake oz how many ml? Round the answer to the nearest whole number. Use a leading zero if it applies. 440 64) A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, I trust my doctor. But I don't understand what is meant by resecting my intestines. Which of the following actions should the nurse take? A. Describe the surgery to the client B. Provide brochures about the procedure C. Notify the provider D. Complete an incident report 65) A nurse receives a new prescription over the telephone from a client’s provider. Which of the following actions should the nurse take first? A. Ensure the provider signs the prescription B. Read back the prescription to the provider C. Document the prescription as a telephone prescription in the medical record D. Write down the complete prescription 66) A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (SATA) I need to check my medications for expiration dates I will use the grab bars when getting in and out of the bathtub I need to have a fire escape plan with my family I will apply tape over frayed areas of electrical cords I need to set my hot water heater to 140 degrees 67) A nurse is caring for a male client who has a prescription for intermittent urinary catherization with a coude’ catheter. Which images shows the type of catheter should the nurse use? 68) A nurse is preparing a medication from a vial for a subcutaneous injection for a client. Which of the following actions should the nurse take first? A) Hold the vial with the top facing upward while injection air into the cial B) Hold the syringe at a 45 angle to verify dosage C) Hold the syringe so that bubbles collect at the level of the plunger D) Inject air into the vial with the eye of the needle immersed in the fluid