ATIFundamentalsProc
toredExam|
QuestionsandAnswers
CompletewithRational
es
LATEST2023/2024
,1. Anurse is planning to collect a stool specimen for ova and parasites from a client who has
diarrhea.Whichofthefollowingactionsshouldthenursetakewhencollectingthespecimen?
A. Instructtheclient todefecate intothetoiletbowl
-incorrect:Thenurseshouldhavetheclientdefecateintoabedpanoracontainerforstool collection. The
toilet water can dilute and contaminate the liquid specimen.
B. Transferthespecimentoasterile container
-incorrect:Thenurseshouldplacethestoolspecimeninacleancontainerusingatongue depressor.
C. Refrigeratethecollectedspecimen
-incorrect: The nurse should send the collected stool specimen immediately to the laboratory
afterlabelingthespecimenproperlytopreventcontaminationwithmicroorganismsandkeepthe
specimen from getting cold.
D. Placethestoolspecimencollectioncontainerinabiohazardbag
-The nurse should place the specimen collection container in a biohazard bag with the client
labelonthecontainerandthebagforeasyidentification.Thiswillalsopreventcontamination with
microorganisms.
2. Anurseiscaringforaclientwhohasatracheostomyandrequiressuctioning.Whichofthe
following actions should the nurse take?
A. Hyperoxygenatetheclientbeforesuctioning
-Thenurseshoulduseamanualresuscitationbagtohyperoxygenatetheclientforseveral minutes prior
to suctioning.
B. Insertthecatheterduringexhalation
-incorrect:Thenurseshouldinsertthecatheter during inhalation
C. Applysuctionduring insertionofthecatheter
-incorrect:Applyingsuctionwhileinsertingthecatheterincreasestheriskofdamagetothe tracheal
mucosa and removes oxygen from the airways.
D. Applysuctionfornomore than15secs
-incorrect:Thenurseshouldapplysuctionfornomorethan10seconds
3. Anurseisprovidingteachingtoaclientregardingproteinintake.Whichofthefollowing foods
should the nurse include as an example of an incomplete protein?
A. Eggs
-incorrect:thisisacompleteprotein,containsalloftheessentialaminoacidsnecessaryforthe synthesis of
protein in the body.
B. Soybeans
-incorrect:thisisacompleteprotein,containsalloftheessentialaminoacidsnecessaryforthe synthesis of
protein in the body.
,C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for the
synthesisofproteininthebody.Examplesofincompleteproteinsincludelentils,vegetables, grains,
nuts, and seeds.
D. Yogurt
-incorrect:thisisacompleteprotein,containsalloftheessentialaminoacidsnecessaryforthe synthesis of
protein in the body.
4. Anurseiscaringforaclientwhowasadmittedtoalong-termcarefacilityforrehabilitation after a
total hip arthroplasty.At which of the following times should the nurse begin discharge
planning?
A. Oneweekpriortotheclient’s discharge
-incorrect: Beginning to plan for the client’s discharge a weekprior to the event might not allow
sufficienttimeforplanning.Thenurseshouldbegindischargeplanningatthetime ofadmission.
B. Upontheclient’sadmissiontothecarefacility
-Thenurseshouldbegindischargeplanningatthetime thattheclient isadmitted tothefacility.
C. Oncethedischargedateis identified
-incorrect:Beginningtoplanfortheclient’sdischargeoncethedischargedateisidentifiedmight not allow
sufficient time for planning. The nurse should begin discharge planning at the time of admission.
D. Whentheclient addressesthetopicwiththenurse
-incorrect:Beginningtoplanfortheclient’sdischargeoncethedischargedateisidentifiedmight not allow
sufficient time for planning. The nurse should begin discharge planning at the time of admission.
5. Anurseispreparingtoadministeracleansingenematoaclient.Whichofthefollowing actions
should the nurse plan to take?
A. Insertthe rectaltube 15.2cm(6in)
-incorrect:Thenurseshouldinserttherectaltube7to10cm(3to4in)
B. Wearsterileglovestoinsertthetubing
-incorrect:Thenurseshouldwearclean(nonsterile)glovestoprevent contamination.
C. Positiontheclientonhisleftside
-Positioningisanimportantaspectofadministeringanenema.Havingtheclientlieonhisleft side
facilitates the flow of the enema solution into the sigmoid and descending colon.
D. Holdthesolutionbag91cm(36inch)abovetheclient’s rectum
-incorrect:Thenurseshouldholdthesolutionbag30cm(12in)abovetheclient’srectumfora
lowenemaand45cm(18in)forahighenema.Ifthenurseholdsthesolutionbagtoohigh,the solution
might run in too fast, causing discomfort and spasms that make retaining the enema more
difficult.
5. Anurseiscaringforaclient whohasbilateral catsonherhands.Whichofthefollowing actions
should the nurse take when assisting the client with feeding?
A. Sitatthebedsidewhenfeedingtheclient
-Thenurseshouldavoidappearingtobeinahurry.Sittingatthebedsideprovidestheclientwith the nurse’s
full attention during the feeding
, B. Orderpureed foods
-incorrect:Withoutanymouthorthroatinjuriesthatmakechewingorswallowingdifficult,the client
should be served foods of an appropriate variety of textures. Pureedfoods arefor clients who
cannot chew, have difficulty swallowing, or do not have teeth.
C. Makesurefeedingsare providedatroom temperature
-incorrect:Thenurseshouldasktheclientifthe foodisthecorrect temperature
D. Offertheclientadrinkoffluid after everybite
-incorrect: If the client is unable to communicate, the nurse should offer the client fluids after
every3or4mouthfuls.However,thereisnoindicationthatthisclientisunabletocommunicate.
Therefore, the client should tell the nurse when she would like a drink.
6. AnurseisadministeringanIMinjectiontoa5-month-oldinfant.Whichofthefollowing
injection sites should the nurse use?
A. Deltoid
-incorrect:Thenursecanusethedeltoidmuscleforinjectingsmallvolumesofmedicationfor children
18 months of age or older, but its proximity to several nerves and arteries make it a riskier
choice.
B. Ventrogluteal
-incorrect: ThisisasafesiteforIMinjectionsforclients older than7 months.
C. Vastuslateralis
-ThenurseshouldusethevastuslateralissiteovertheanteriorthighforIMinjectionsforinfants and
children.
D. Dorsogluteal
-incorrect:Thissiteisunsafetousebecauseofitsproximitytothesciaticnerveandthesuperior gluteal
nerve and artery.
7. Anurseiscaringforaclientwhohasmajorfecalincontinenceandreportsirritationinthe perianal
area. Which of the following actions should the nurse take first?
A. Applyafecalcollection system
-incorrect:Thenurseshouldapplyafecalcollectionsystemtodivertthefecesawayfromthe area of
skin irritation; however, there is another action the nurse should take first.
B. Applyabarrier cream
-incorrect:Thenurseshouldapplyabarriercreamtodecreaseskinbreakdownintheperianal area from
the feces; however, there is another action the nurse should take first.
C. Cleanseanddrythe area
-incorrect:Thenurseshouldcleanseanddrytheperianalareatodecreaseskinirritation; however, there
is another action the nurse should take first.
D. Checktheclient’sperineum
-The nurse should apply the nursing process priority-setting framework to plan care andprioritize
nursingactions.Eachstepofthenursingprocessbuildsonthepreviousstep,beginning
withanassessmentordatacollection.Beforethenursecanformulateaplanofaction,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.
toredExam|
QuestionsandAnswers
CompletewithRational
es
LATEST2023/2024
,1. Anurse is planning to collect a stool specimen for ova and parasites from a client who has
diarrhea.Whichofthefollowingactionsshouldthenursetakewhencollectingthespecimen?
A. Instructtheclient todefecate intothetoiletbowl
-incorrect:Thenurseshouldhavetheclientdefecateintoabedpanoracontainerforstool collection. The
toilet water can dilute and contaminate the liquid specimen.
B. Transferthespecimentoasterile container
-incorrect:Thenurseshouldplacethestoolspecimeninacleancontainerusingatongue depressor.
C. Refrigeratethecollectedspecimen
-incorrect: The nurse should send the collected stool specimen immediately to the laboratory
afterlabelingthespecimenproperlytopreventcontaminationwithmicroorganismsandkeepthe
specimen from getting cold.
D. Placethestoolspecimencollectioncontainerinabiohazardbag
-The nurse should place the specimen collection container in a biohazard bag with the client
labelonthecontainerandthebagforeasyidentification.Thiswillalsopreventcontamination with
microorganisms.
2. Anurseiscaringforaclientwhohasatracheostomyandrequiressuctioning.Whichofthe
following actions should the nurse take?
A. Hyperoxygenatetheclientbeforesuctioning
-Thenurseshoulduseamanualresuscitationbagtohyperoxygenatetheclientforseveral minutes prior
to suctioning.
B. Insertthecatheterduringexhalation
-incorrect:Thenurseshouldinsertthecatheter during inhalation
C. Applysuctionduring insertionofthecatheter
-incorrect:Applyingsuctionwhileinsertingthecatheterincreasestheriskofdamagetothe tracheal
mucosa and removes oxygen from the airways.
D. Applysuctionfornomore than15secs
-incorrect:Thenurseshouldapplysuctionfornomorethan10seconds
3. Anurseisprovidingteachingtoaclientregardingproteinintake.Whichofthefollowing foods
should the nurse include as an example of an incomplete protein?
A. Eggs
-incorrect:thisisacompleteprotein,containsalloftheessentialaminoacidsnecessaryforthe synthesis of
protein in the body.
B. Soybeans
-incorrect:thisisacompleteprotein,containsalloftheessentialaminoacidsnecessaryforthe synthesis of
protein in the body.
,C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for the
synthesisofproteininthebody.Examplesofincompleteproteinsincludelentils,vegetables, grains,
nuts, and seeds.
D. Yogurt
-incorrect:thisisacompleteprotein,containsalloftheessentialaminoacidsnecessaryforthe synthesis of
protein in the body.
4. Anurseiscaringforaclientwhowasadmittedtoalong-termcarefacilityforrehabilitation after a
total hip arthroplasty.At which of the following times should the nurse begin discharge
planning?
A. Oneweekpriortotheclient’s discharge
-incorrect: Beginning to plan for the client’s discharge a weekprior to the event might not allow
sufficienttimeforplanning.Thenurseshouldbegindischargeplanningatthetime ofadmission.
B. Upontheclient’sadmissiontothecarefacility
-Thenurseshouldbegindischargeplanningatthetime thattheclient isadmitted tothefacility.
C. Oncethedischargedateis identified
-incorrect:Beginningtoplanfortheclient’sdischargeoncethedischargedateisidentifiedmight not allow
sufficient time for planning. The nurse should begin discharge planning at the time of admission.
D. Whentheclient addressesthetopicwiththenurse
-incorrect:Beginningtoplanfortheclient’sdischargeoncethedischargedateisidentifiedmight not allow
sufficient time for planning. The nurse should begin discharge planning at the time of admission.
5. Anurseispreparingtoadministeracleansingenematoaclient.Whichofthefollowing actions
should the nurse plan to take?
A. Insertthe rectaltube 15.2cm(6in)
-incorrect:Thenurseshouldinserttherectaltube7to10cm(3to4in)
B. Wearsterileglovestoinsertthetubing
-incorrect:Thenurseshouldwearclean(nonsterile)glovestoprevent contamination.
C. Positiontheclientonhisleftside
-Positioningisanimportantaspectofadministeringanenema.Havingtheclientlieonhisleft side
facilitates the flow of the enema solution into the sigmoid and descending colon.
D. Holdthesolutionbag91cm(36inch)abovetheclient’s rectum
-incorrect:Thenurseshouldholdthesolutionbag30cm(12in)abovetheclient’srectumfora
lowenemaand45cm(18in)forahighenema.Ifthenurseholdsthesolutionbagtoohigh,the solution
might run in too fast, causing discomfort and spasms that make retaining the enema more
difficult.
5. Anurseiscaringforaclient whohasbilateral catsonherhands.Whichofthefollowing actions
should the nurse take when assisting the client with feeding?
A. Sitatthebedsidewhenfeedingtheclient
-Thenurseshouldavoidappearingtobeinahurry.Sittingatthebedsideprovidestheclientwith the nurse’s
full attention during the feeding
, B. Orderpureed foods
-incorrect:Withoutanymouthorthroatinjuriesthatmakechewingorswallowingdifficult,the client
should be served foods of an appropriate variety of textures. Pureedfoods arefor clients who
cannot chew, have difficulty swallowing, or do not have teeth.
C. Makesurefeedingsare providedatroom temperature
-incorrect:Thenurseshouldasktheclientifthe foodisthecorrect temperature
D. Offertheclientadrinkoffluid after everybite
-incorrect: If the client is unable to communicate, the nurse should offer the client fluids after
every3or4mouthfuls.However,thereisnoindicationthatthisclientisunabletocommunicate.
Therefore, the client should tell the nurse when she would like a drink.
6. AnurseisadministeringanIMinjectiontoa5-month-oldinfant.Whichofthefollowing
injection sites should the nurse use?
A. Deltoid
-incorrect:Thenursecanusethedeltoidmuscleforinjectingsmallvolumesofmedicationfor children
18 months of age or older, but its proximity to several nerves and arteries make it a riskier
choice.
B. Ventrogluteal
-incorrect: ThisisasafesiteforIMinjectionsforclients older than7 months.
C. Vastuslateralis
-ThenurseshouldusethevastuslateralissiteovertheanteriorthighforIMinjectionsforinfants and
children.
D. Dorsogluteal
-incorrect:Thissiteisunsafetousebecauseofitsproximitytothesciaticnerveandthesuperior gluteal
nerve and artery.
7. Anurseiscaringforaclientwhohasmajorfecalincontinenceandreportsirritationinthe perianal
area. Which of the following actions should the nurse take first?
A. Applyafecalcollection system
-incorrect:Thenurseshouldapplyafecalcollectionsystemtodivertthefecesawayfromthe area of
skin irritation; however, there is another action the nurse should take first.
B. Applyabarrier cream
-incorrect:Thenurseshouldapplyabarriercreamtodecreaseskinbreakdownintheperianal area from
the feces; however, there is another action the nurse should take first.
C. Cleanseanddrythe area
-incorrect:Thenurseshouldcleanseanddrytheperianalareatodecreaseskinirritation; however, there
is another action the nurse should take first.
D. Checktheclient’sperineum
-The nurse should apply the nursing process priority-setting framework to plan care andprioritize
nursingactions.Eachstepofthenursingprocessbuildsonthepreviousstep,beginning
withanassessmentordatacollection.Beforethenursecanformulateaplanofaction,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.
