ATI Comprehensive Fundamentals Exam Review - Questions and Answers

ATI Comprehensive Fundamentals Exam Review - Questions and Answers A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique? The nurse washes each part of her hands with 5 strokes. The nurse washes from the elbows down to the hands. The nurse holds her hands higher than her elbows while washing. The nurse uses minimal friction when washing her hands. ️Correct Answer: C. The nurse holds her hands higher than her elbows while washing. The nurse who is performing a surgical handwashing technique should wash while holding her hands higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area. Incorrect Answers:A. Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes. B. An important principle of surgical handwashing is to scrub the hands first and then work toward the elbows. D. Scrubbing is performed with a specially designed and premedicated brush when performing surgical handwashing. The use of mechanical friction is necessary to decontaminate the skin effectively. A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen in order? A. Auscultation B. Light palpation C.Percussion D. Deep palpation ️Correct Answer: A., C., B, D. Auscultation, Percussion, Light palpation, Deep Palpation According to evidence-based practice, the nurse should listen for bowel sounds in all 4 quadrants before palpating the client's abdomen. Palpation and percussion can stimulate the bowel and increase the frequency of bowel sounds, leading to false results. palpate the client's abdomen to identify any areas of tenderness. percuss the abdomen to identify tympany or dullness Incorrect: If you are assessing anything other than the abdomen inspection, palpation, percussion, and auscultation. During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? Confrontation test Symmetry of palpebral fissures Corneal light reflex Accommodation test ️Correct Answer: C. Corneal light reflex. strabismus is cross eyed or wall eyed. The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. This test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, the eyes will not align when the client focuses. Incorrect Answers:A. A confrontation test compares the visual fields of the client with that of the examiner. B. The palpebral fissure is the space between the eyelids, which is unequal in clients who have ptosis (i.e. drooping of one or both of the eyelids). D. The test for accommodation determines whether the client's pupils constrict as they focus on an object the examiner brings closer to the eyes. A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking? Playing in the sand Playing dress-up with old clothes Collecting and trading game cards Describing interpersonal relationships ️Correct Answer: C. Collecting and trading game cards Collecting and trading game cards require seriation of the cards, involving what to collect, what to trade, and what has value. This is a characteristic of Piaget's concrete operational stage for ages 7 to 11 years. Incorrect Answers:A. Playing in the sand is an example of Piaget's sensorimotor stage, which characterizes children from birth to 2 years of age. B. Playing dress-up involves pretending, which reflects Piaget's preoperational thinking stage for ages 2 to 7 years. D. Describing interpersonal relationships requires abstract thought, which is part of Piaget's formal operational reasoning stage for ages 11 years and beyond. nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub ️Correct Answer: D. Pericardial friction rub A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound that is heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems like rheumatic fever. A client who develops pericarditis typically has chest pain that becomes worse with inspiration or coughing and may be relieved by sitting up and leaning forward. Incorrect Answers:A. An audible clicking sound occurs in clients who have undergone prosthetic valve replacement surgery. B. A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. Low- and medium-frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease. C. A third heart sound (S3) is a low-pitched noise after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best heard at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates heart failure. A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? People who practice the Islamic faith pray over the deceased for a period of 5 days before burial. People who practice the Hindu faith bury the deceased with their head facing north. People who practice Judaism stay with the body of the deceased until burial. People who are practicing the Buddhist faith have the female family members prepare the body following death. ️Correct Answer: C. People who practice Judaism stay with the body of the deceased until burial. In the Jewish faith, a family member often stays with the body until burial occurs. Incorrect Answers:A. For those who practice the Islamic faith, the body of the deceased is washed and wrapped during a ritual and then buried as soon as possible following death. B. People who practice the Hindu faith may place the body with the head facing north following death. However, cremation rather than burial is practiced by those of the Hindu faith. D. Male family members prepare the body following death for individuals practicing the Buddhist faith. A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? The client holds the cane on the unaffected side. The client walks by stepping with the unaffected leg before the affected leg. The client holds the cane directly next to the foot The client holds the cane with a straight elbow. ️Correct Answer: A. The client holds the cane on the unaffected side.