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ATI FUNDAMENTALS RN EXAM TESTBANK
QUESTIONS AND ANSWERS WITH
RATIONALES
1. A nurse is planning to collect a stool specimen for ova and parasites from a client
who has diarrhea. Which of the following actions should the nurse take when collecting
the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a bedpan or a container for
stool collection. The toilet water can dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean container using a
tongue depressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen immediately to the
laboratory after labeling the specimen properly to prevent contamination with
microorganisms and keep the specimen from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a biohazard bag with
the client label on the container and the bag for easy identification. This will also
prevent contamination with microorganisms.
2. A nurse is caring for a client who has a tracheostomy and requires suctioning.
Which of the following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for
several minutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases the risk of damage
to the tracheal mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
3. A nurse is providing teaching to a client regarding protein intake. Which of the
following foods should the nurse include as an example of an incomplete
protein?
A. Eggs
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for the synthesis of protein in the body.
B. Soybeans
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for the synthesis of protein in the body.
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Distribution of
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,C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for
the synthesis of protein in the body. Examples of incomplete proteins include lentils,
vegetables, grains, nuts, and seeds.
D. Yogurt
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for the synthesis of protein in the body.
4. A nurse is caring for a client who was admitted to a long-term care facility for
rehabilitation after a total hip arthroplasty. At which of the following times should
the nurse begin discharge planning?
A. One week prior to the client’s discharge
-incorrect: Beginning to plan for the client’s discharge a week prior to the event might not
allow sufficient time for planning. The nurse should begin discharge planning at the time of
admission. B. Upon the client’s admission to the care facility
-The nurse should begin discharge planning at the time that the client is admitted to the
facility.
C. Once the discharge date is identified
-incorrect: Beginning to plan for the client’s discharge once the discharge date is
identified might not allow sufficient time for planning. The nurse should begin discharge
planning at the time of admission.
D. When the client addresses the topic with the nurse
-incorrect: Beginning to plan for the client’s discharge once the discharge date is
identified might not allow sufficient time for planning. The nurse should begin discharge
planning at the time of admission.
5. A nurse is preparing to administer a cleansing enema to a client. Which of
the following actions should the nurse plan to take?
A. Insert the rectal tube 15.2 cm (6 in)
-incorrect: The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in)
B. Wear sterile gloves to insert the tubing
-incorrect: The nurse should wear clean (nonsterile) gloves to prevent contamination.
C. Position the client on his left side
-Positioning is an important aspect of administering an enema. Having the client lie
on his left side facilitates the flow of the enema solution into the sigmoid and
descending colon.
D. Hold the solution bag 91 cm (36 inch) above the client’s rectum
-incorrect: The nurse should hold the solution bag 30 cm (12 in) above the client’s rectum
for a low enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag
too high, the solution might run in too fast, causing discomfort and spasms that make
retaining the enema more difficult.
5. A nurse is caring for a client who has bilateral cats on her hands. Which of
the following actions should the nurse take when assisting the client with
feeding?
A. Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides
the client with the nurse’s full attention during the feeding
, B. Order pureed foods
-incorrect: Without any mouth or throat injuries that make chewing or swallowing
difficult, the client should be served foods of an appropriate variety of textures. Pureed
foods are for clients who cannot chew, have difficulty swallowing, or do not have teeth.
C. Make sure feedings are provided at room temperature
-incorrect: The nurse should ask the client if the food is the correct temperature
D. Offer the client a drink of fluid after every bite
-incorrect: If the client is unable to communicate, the nurse should offer the client
fluids after every 3 or 4 mouthfuls. However, there is no indication that this client is
unable to communicate. Therefore, the client should tell the nurse when she would like
a drink.
6. A nurse is administering an IM injection to a 5-month-old infant. Which of
the following injection sites should the nurse use?
A. Deltoid
-incorrect: The nurse can use the deltoid muscle for injecting small volumes of
medication for children 18 months of age or older, but its proximity to several nerves
and arteries make it a riskier choice.
B. Ventrogluteal
-incorrect: This is a safe site for IM injections for clients older than 7 months.
C. Vastus lateralis
-The nurse should use the vastus lateralis site over the anterior thigh for IM injections for
infants and children.
D. Dorsogluteal
-incorrect: This site is unsafe to use because of its proximity to the sciatic nerve and the
superior gluteal nerve and artery.
7. A nurse is caring for a client who has major fecal incontinence and reports
irritation in the perianal area. Which of the following actions should the nurse take
first?
A. Apply a fecal collection system
-incorrect: The nurse should apply a fecal collection system to divert the feces away
from the area of skin irritation; however, there is another action the nurse should
take first.
B. Apply a barrier cream
-incorrect: The nurse should apply a barrier cream to decrease skin breakdown in the
perianal area from the feces; however, there is another action the nurse should take
first.
C. Cleanse and dry the area
-incorrect: The nurse should cleanse and dry the perianal area to decrease skin
irritation; however, there is another action the nurse should take first.
D. Check the client’s perineum
-The nurse should apply the nursing process priority-setting framework to plan care and
prioritize nursing actions. Each step of the nursing process builds on the previous step,
beginning with an assessment or data collection. Before the nurse can formulate a plan of
action, implement a nursing intervention, or notify a provider of a change in the client’s
status, the nurse must first collect adequate data from the client. Assessing or collecting
additional data will provide the nurse with knowledge to make an appropriate decision.
The priority nursing action is for the nurse to collect more data by assessing the area of
irritation.
ATI FUNDAMENTALS RN EXAM TESTBANK
QUESTIONS AND ANSWERS WITH
RATIONALES
1. A nurse is planning to collect a stool specimen for ova and parasites from a client
who has diarrhea. Which of the following actions should the nurse take when collecting
the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a bedpan or a container for
stool collection. The toilet water can dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean container using a
tongue depressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen immediately to the
laboratory after labeling the specimen properly to prevent contamination with
microorganisms and keep the specimen from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a biohazard bag with
the client label on the container and the bag for easy identification. This will also
prevent contamination with microorganisms.
2. A nurse is caring for a client who has a tracheostomy and requires suctioning.
Which of the following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for
several minutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases the risk of damage
to the tracheal mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
3. A nurse is providing teaching to a client regarding protein intake. Which of the
following foods should the nurse include as an example of an incomplete
protein?
A. Eggs
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for the synthesis of protein in the body.
B. Soybeans
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for the synthesis of protein in the body.
,Downloaded by: franklinalvarez16 | f
Distribution of
this document is illegal
,C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for
the synthesis of protein in the body. Examples of incomplete proteins include lentils,
vegetables, grains, nuts, and seeds.
D. Yogurt
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for the synthesis of protein in the body.
4. A nurse is caring for a client who was admitted to a long-term care facility for
rehabilitation after a total hip arthroplasty. At which of the following times should
the nurse begin discharge planning?
A. One week prior to the client’s discharge
-incorrect: Beginning to plan for the client’s discharge a week prior to the event might not
allow sufficient time for planning. The nurse should begin discharge planning at the time of
admission. B. Upon the client’s admission to the care facility
-The nurse should begin discharge planning at the time that the client is admitted to the
facility.
C. Once the discharge date is identified
-incorrect: Beginning to plan for the client’s discharge once the discharge date is
identified might not allow sufficient time for planning. The nurse should begin discharge
planning at the time of admission.
D. When the client addresses the topic with the nurse
-incorrect: Beginning to plan for the client’s discharge once the discharge date is
identified might not allow sufficient time for planning. The nurse should begin discharge
planning at the time of admission.
5. A nurse is preparing to administer a cleansing enema to a client. Which of
the following actions should the nurse plan to take?
A. Insert the rectal tube 15.2 cm (6 in)
-incorrect: The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in)
B. Wear sterile gloves to insert the tubing
-incorrect: The nurse should wear clean (nonsterile) gloves to prevent contamination.
C. Position the client on his left side
-Positioning is an important aspect of administering an enema. Having the client lie
on his left side facilitates the flow of the enema solution into the sigmoid and
descending colon.
D. Hold the solution bag 91 cm (36 inch) above the client’s rectum
-incorrect: The nurse should hold the solution bag 30 cm (12 in) above the client’s rectum
for a low enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag
too high, the solution might run in too fast, causing discomfort and spasms that make
retaining the enema more difficult.
5. A nurse is caring for a client who has bilateral cats on her hands. Which of
the following actions should the nurse take when assisting the client with
feeding?
A. Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides
the client with the nurse’s full attention during the feeding
, B. Order pureed foods
-incorrect: Without any mouth or throat injuries that make chewing or swallowing
difficult, the client should be served foods of an appropriate variety of textures. Pureed
foods are for clients who cannot chew, have difficulty swallowing, or do not have teeth.
C. Make sure feedings are provided at room temperature
-incorrect: The nurse should ask the client if the food is the correct temperature
D. Offer the client a drink of fluid after every bite
-incorrect: If the client is unable to communicate, the nurse should offer the client
fluids after every 3 or 4 mouthfuls. However, there is no indication that this client is
unable to communicate. Therefore, the client should tell the nurse when she would like
a drink.
6. A nurse is administering an IM injection to a 5-month-old infant. Which of
the following injection sites should the nurse use?
A. Deltoid
-incorrect: The nurse can use the deltoid muscle for injecting small volumes of
medication for children 18 months of age or older, but its proximity to several nerves
and arteries make it a riskier choice.
B. Ventrogluteal
-incorrect: This is a safe site for IM injections for clients older than 7 months.
C. Vastus lateralis
-The nurse should use the vastus lateralis site over the anterior thigh for IM injections for
infants and children.
D. Dorsogluteal
-incorrect: This site is unsafe to use because of its proximity to the sciatic nerve and the
superior gluteal nerve and artery.
7. A nurse is caring for a client who has major fecal incontinence and reports
irritation in the perianal area. Which of the following actions should the nurse take
first?
A. Apply a fecal collection system
-incorrect: The nurse should apply a fecal collection system to divert the feces away
from the area of skin irritation; however, there is another action the nurse should
take first.
B. Apply a barrier cream
-incorrect: The nurse should apply a barrier cream to decrease skin breakdown in the
perianal area from the feces; however, there is another action the nurse should take
first.
C. Cleanse and dry the area
-incorrect: The nurse should cleanse and dry the perianal area to decrease skin
irritation; however, there is another action the nurse should take first.
D. Check the client’s perineum
-The nurse should apply the nursing process priority-setting framework to plan care and
prioritize nursing actions. Each step of the nursing process builds on the previous step,
beginning with an assessment or data collection. Before the nurse can formulate a plan of
action, implement a nursing intervention, or notify a provider of a change in the client’s
status, the nurse must first collect adequate data from the client. Assessing or collecting
additional data will provide the nurse with knowledge to make an appropriate decision.
The priority nursing action is for the nurse to collect more data by assessing the area of
irritation.
