ATI Fundamentals NCLEX RN STYLED
A nurse is performing an EYE IRRIGATION for a client who has been exposed to smoke and ash. Which of
the following nursing actions should receive the HIGHEST PRIORITY during the irrigation?
A. Cleansing the eyelids prior to the irrigation
B. Placing the client in an upright position with head tilted backwards
C. Wearing gloves during the procedure
D. Ensuring the irrigant is not warmed to more than 110 degrees Fahrenheit
C. Wearing gloves during the procedure
RATIONALE: the nurse must wear gloves during an eye irrigation to maintain standard precautions. They
protect the nurse from direct contact with body secretions. Wearing gloves also helps protect the
client's eyes from introduction of a foreign body or micro-organisms from the nurse's hands.
It is helpful to remove dust, secretions, and crusts prior to irrigation, but it is not the highest priority
action. The nurse should ask the client to take a position of comfort, such as lying supine or sitting with
her head tilted back or inclined slightly toward the side. However, this is not the highest priority action.
Having the client look upward during irrigation or instillation of eye medications helps reduce blinking. It
is a helpful intervention, but it is not the nurse's highest priority action.
A nurse is caring for a client who is receiving zan IV INFUSION that has INFILTRATED. Which of the
following would be an UNEXPECTED FINDING when the nurse ASSESSES the client's INFUSION LINE and
INSERTION SITE?
A. The infusion slows or stops while the tubing is not kinked
B. The area around the insertion site feels warm when touched
C. Swelling, hardness, or pain located around the needle site
D. Blood fails to return in the tubing when the bottle is lowered
B. The area around the insertion site feels warm when touched
RATIONALE: the area around the insertion site would NOT feel WARM when the IV is INFILTRATED. If the
area around the site feels warm, it may indicate INFECTION or PHLEBITIS.
A sign of infiltration is that the infusion slows or stops despite the fact that the tubing is not kinked.
Another sign of infiltration is swelling, hardness, or pain located around the needle site. In addition,
,blood that fails to return in the tubing when the bottle is lowered indicates infiltration.
TEST-TAKING STRATEGY: since this is a negative-format
stem question, an INAPPROPRIATE finding is CORRECT.
A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that
the provider prescribed TUBE FEEDING because the client
A. Refuses to eat solid foods in the hospital because he does not like them
B. Prefers this feeding method because it is easier
C. Is unable to swallow foods by mouth
D. Has family who requests this method because it is more efficient for their older relative
C. Is unable to swallow foods by mouth
RATIONALE: tube feeding is commonly prescribed for clients who are unable to eat by mouth.
The client or family's preference is not a valid reason for prescribing tube feedings. After consultation
with a dietician, the dietary department may be able to provide more foods the client likes while also
meeting their dietary needs. Consultation with a dietician is important to help the family meet their
older relative's nutritional needs.
In planning care for a client with a SURGICAL WOUND healing by SECONDARY INTENTION, the nurse can
ANTICIPATE that the client will
A. Have well-approximated wound edges
B. Have the wound sutured closed at a later date
C. Require skin grafting for the wound to heal
D. Be at an increased susceptibility for infection
D. Be at an increased susceptibility for infection
RATIONALE: the wound edges are left open and are poorly approximated in a wound healing by
secondary intention. Most wounds left to heal by secondary intention heal within 5-21 days by forming
granulation tissue that fills in the wound edges and is associated with increased scar formation. Open
wounds place the client at an increased risk for wound infection.
Sutured wounds have well approximated edges and heal by PRIMARY INTENTION. Wounds left open to
drain and heal, then later are sutured, heal by TERTIARY INTENTION. Skin grafting is required for deeper
wounds, such as full-thickness burns, and is only rarely required for surgical wounds that do not heal.
, A nurse is caring for a client who is INCONTINENT OF LOOSE STOOL and is reporting a PAINFUL
PERINEUM. Which of the following is the PRIORITY nursing action?
A. Increase the client's fluid intake to prevent dehydration
B. Contact the primary care provider to obtain an order for loose stools
C. Turn the client every 2 hours
D. Check the client's perineum
D. Check the client's perineum
RATIONALE: the first step of the nursing process is assessment. In this situation, the nurse should collect
more data before taking any other action.
Preventing dehydration is important for a client with loose stools, but this is not the priority action.
Contacting the primary care provider may be necessary, but it is not the priority intervention. Turning
the client at least every 2 hours is important for preventing skin breakdown, but it is not the priority
intervention.
TEST-TAKING STRATEGY: "call the provider" is RARELY the correct option. There is almost always an
INDEPENDENT NURSING ACTION (either an important appropriate assessment or immediate
intervention) that the nurse should take PRIOR to "calling the provider."
A client is hospitalized for an INFECTION of a SURGICAL WOUND following abdominal surgery. To
PROMOTE HEALING and FIGHT WOUND INFECTION the nurse plans to arrange to increase the client's
intake of
A. Vitamin C and Zinc
B. B-complex vitamins
C. Vitamin K and Iron
D. Calcium and Vitamin D
A. Vitamin C and Zinc
RATIONALE: the body's need for both vitamin C and zinc increases when fighting a wound infection. The
client should receive a multivitamin plus a mineral supplement of both. In addition, vitamin E
supplements have been shown to aid in skin and wound healing.
Although B-complex vitamins, vitamin K, and iron are important for the client's overall health, the
client's need for them is not necessarily increased when fighting a wound infection. If the client is a
A nurse is performing an EYE IRRIGATION for a client who has been exposed to smoke and ash. Which of
the following nursing actions should receive the HIGHEST PRIORITY during the irrigation?
A. Cleansing the eyelids prior to the irrigation
B. Placing the client in an upright position with head tilted backwards
C. Wearing gloves during the procedure
D. Ensuring the irrigant is not warmed to more than 110 degrees Fahrenheit
C. Wearing gloves during the procedure
RATIONALE: the nurse must wear gloves during an eye irrigation to maintain standard precautions. They
protect the nurse from direct contact with body secretions. Wearing gloves also helps protect the
client's eyes from introduction of a foreign body or micro-organisms from the nurse's hands.
It is helpful to remove dust, secretions, and crusts prior to irrigation, but it is not the highest priority
action. The nurse should ask the client to take a position of comfort, such as lying supine or sitting with
her head tilted back or inclined slightly toward the side. However, this is not the highest priority action.
Having the client look upward during irrigation or instillation of eye medications helps reduce blinking. It
is a helpful intervention, but it is not the nurse's highest priority action.
A nurse is caring for a client who is receiving zan IV INFUSION that has INFILTRATED. Which of the
following would be an UNEXPECTED FINDING when the nurse ASSESSES the client's INFUSION LINE and
INSERTION SITE?
A. The infusion slows or stops while the tubing is not kinked
B. The area around the insertion site feels warm when touched
C. Swelling, hardness, or pain located around the needle site
D. Blood fails to return in the tubing when the bottle is lowered
B. The area around the insertion site feels warm when touched
RATIONALE: the area around the insertion site would NOT feel WARM when the IV is INFILTRATED. If the
area around the site feels warm, it may indicate INFECTION or PHLEBITIS.
A sign of infiltration is that the infusion slows or stops despite the fact that the tubing is not kinked.
Another sign of infiltration is swelling, hardness, or pain located around the needle site. In addition,
,blood that fails to return in the tubing when the bottle is lowered indicates infiltration.
TEST-TAKING STRATEGY: since this is a negative-format
stem question, an INAPPROPRIATE finding is CORRECT.
A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that
the provider prescribed TUBE FEEDING because the client
A. Refuses to eat solid foods in the hospital because he does not like them
B. Prefers this feeding method because it is easier
C. Is unable to swallow foods by mouth
D. Has family who requests this method because it is more efficient for their older relative
C. Is unable to swallow foods by mouth
RATIONALE: tube feeding is commonly prescribed for clients who are unable to eat by mouth.
The client or family's preference is not a valid reason for prescribing tube feedings. After consultation
with a dietician, the dietary department may be able to provide more foods the client likes while also
meeting their dietary needs. Consultation with a dietician is important to help the family meet their
older relative's nutritional needs.
In planning care for a client with a SURGICAL WOUND healing by SECONDARY INTENTION, the nurse can
ANTICIPATE that the client will
A. Have well-approximated wound edges
B. Have the wound sutured closed at a later date
C. Require skin grafting for the wound to heal
D. Be at an increased susceptibility for infection
D. Be at an increased susceptibility for infection
RATIONALE: the wound edges are left open and are poorly approximated in a wound healing by
secondary intention. Most wounds left to heal by secondary intention heal within 5-21 days by forming
granulation tissue that fills in the wound edges and is associated with increased scar formation. Open
wounds place the client at an increased risk for wound infection.
Sutured wounds have well approximated edges and heal by PRIMARY INTENTION. Wounds left open to
drain and heal, then later are sutured, heal by TERTIARY INTENTION. Skin grafting is required for deeper
wounds, such as full-thickness burns, and is only rarely required for surgical wounds that do not heal.
, A nurse is caring for a client who is INCONTINENT OF LOOSE STOOL and is reporting a PAINFUL
PERINEUM. Which of the following is the PRIORITY nursing action?
A. Increase the client's fluid intake to prevent dehydration
B. Contact the primary care provider to obtain an order for loose stools
C. Turn the client every 2 hours
D. Check the client's perineum
D. Check the client's perineum
RATIONALE: the first step of the nursing process is assessment. In this situation, the nurse should collect
more data before taking any other action.
Preventing dehydration is important for a client with loose stools, but this is not the priority action.
Contacting the primary care provider may be necessary, but it is not the priority intervention. Turning
the client at least every 2 hours is important for preventing skin breakdown, but it is not the priority
intervention.
TEST-TAKING STRATEGY: "call the provider" is RARELY the correct option. There is almost always an
INDEPENDENT NURSING ACTION (either an important appropriate assessment or immediate
intervention) that the nurse should take PRIOR to "calling the provider."
A client is hospitalized for an INFECTION of a SURGICAL WOUND following abdominal surgery. To
PROMOTE HEALING and FIGHT WOUND INFECTION the nurse plans to arrange to increase the client's
intake of
A. Vitamin C and Zinc
B. B-complex vitamins
C. Vitamin K and Iron
D. Calcium and Vitamin D
A. Vitamin C and Zinc
RATIONALE: the body's need for both vitamin C and zinc increases when fighting a wound infection. The
client should receive a multivitamin plus a mineral supplement of both. In addition, vitamin E
supplements have been shown to aid in skin and wound healing.
Although B-complex vitamins, vitamin K, and iron are important for the client's overall health, the
client's need for them is not necessarily increased when fighting a wound infection. If the client is a
