1|Page
CMS ATI FUNDAMENTALS NEWEST 2024
ACTUAL EXAM TEST BANK 470 QUESTIONS
AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED
A+||BRAND NEW!!
A nurse is preparing to administer a bolus feeding to a client through an
NG tube and observes that the exit mark on the tube has moved since the
last feeding. Which of the following actions should the nurse plan to
take?
A. Auscultate over the client's stomach while injecting air
B. Request an X-ray of the client's abdomen
C. Place the head of the client's bed in a flat position
D. Administer the feeding if the pH of the aspirated contents is greater
than 6 - ANSWER- B. Request an X-ray of the client's abdomen
A nurse is caring for a client who requires the insertion of a nasogastric
tube. Which of the following actions should the nurse take when
preparing to insert the tube?
A. Wear sterile gloves for the insertion procedure
B. Assist the client into a side-lying position
C. Measure the distance from the nose to the earlobe to the xiphoid
D. Lubricate the tip of the tube with petroleum jelly - ANSWER- C.
Measure the distance from the nose to the earlobe to the xiphoid
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A nurse is collecting data on a client. The nurse should recognize that
which of the following findings places the patient at risk for impaired
skin integrity?
A. 3+ Achilles reflex
B. Faint pedal pulses
C. Feet warm to the touch bilaterally
D. Capillary refill less than 2 sec - ANSWER- B. Faint pedal pulses
A charge nurse is observing a newly licensed nurse perform
tracheostomy care for a client. Which of the following actions by the
newly licensed nurse requires intervention?
A. Obtaining hydrogen peroxide for the tracheostomy care
B. Obtaining cotton balls for the tracheostomy care
C. Obtaining sterile gloves for the tracheostomy care
D. Obtaining a sterile brush for the tracheostomy care - ANSWER- B.
Obtaining cotton balls for the tracheostomy care
A nurse is collecting data about a client's incision and observes the
drainage to be blood-tinged. Which of the following terms should the
nurse use to document this finding?
A. Sanguineous
B. Purulent
C. Serous
D. Hyperemia - ANSWER- A. Sanguineous
,3|Page
A nurse is caring for a client who begins having a tonic-clonic seizure
while sitting in a chair at the bedside. Which of the following actions
should the nurse take first?
A. Provide oxygen
B. Turn the client onto his side
C. Provide privacy
D. Lower the client to the floor - ANSWER- D. Lower the client to the
floor
A nurse is initiating the use of a sequential compression device for a
client who is postoperative following knee surgery. Which of the
following actions should the nurse take?
A. Set the ankle pressure at 70 mmHg
B. Have the client turn onto a side
C. Place a sleeve on top of each leg with the opening at the knee
D. Make sure 2 fingers can fit under the sleeves - ANSWER- D. Make
sure 2 fingers can fit under the sleeves
A nurse is collecting data from a client who reports nausea and vomiting
for 2 days. Which of the following findings should indicate to the nurse
that the client is experiencing fluid volume deficit?
A. Decreased urine specific gravity
B. Increased heart rate
C. Decreased hematocrit
, 4|Page
D. Increased skin turgor - ANSWER- B. Increased heart rate
As a nurse is preparing to administer liquid medication from a bottle to a
client. Which of the following actions should the nurse take?
A. Hold the medication bottle with the label against the palm of the hand
when pouring
B. Place the cap with the inside facing down on a hard surface
C. Fill the cup until the medication is even with the edge of the dosage
scale
D. Pour any excess liquid back into the bottle when measuring -
ANSWER- A. Hold the medication bottle with the label against the palm
of the hand when pouring
A nurse is preparing to insert an indwelling urinary catheter. Which of
the following instructions should the nurse give the client to ease the
passage of the catheter through the urinary meatus?
A. "Bear down."
B. "Perform Kegel exercises."
C. "Hold your breath."
D. "Raise your head off of the pillow." - ANSWER- A. "Bear down."
A nurse is caring for a client who has a stage Il pressure ulcer. Which of
the following wound dressings should the nurse apply to the ulcer?
A. Hydrocolloid
B. Collagen
CMS ATI FUNDAMENTALS NEWEST 2024
ACTUAL EXAM TEST BANK 470 QUESTIONS
AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED
A+||BRAND NEW!!
A nurse is preparing to administer a bolus feeding to a client through an
NG tube and observes that the exit mark on the tube has moved since the
last feeding. Which of the following actions should the nurse plan to
take?
A. Auscultate over the client's stomach while injecting air
B. Request an X-ray of the client's abdomen
C. Place the head of the client's bed in a flat position
D. Administer the feeding if the pH of the aspirated contents is greater
than 6 - ANSWER- B. Request an X-ray of the client's abdomen
A nurse is caring for a client who requires the insertion of a nasogastric
tube. Which of the following actions should the nurse take when
preparing to insert the tube?
A. Wear sterile gloves for the insertion procedure
B. Assist the client into a side-lying position
C. Measure the distance from the nose to the earlobe to the xiphoid
D. Lubricate the tip of the tube with petroleum jelly - ANSWER- C.
Measure the distance from the nose to the earlobe to the xiphoid
,2|Page
A nurse is collecting data on a client. The nurse should recognize that
which of the following findings places the patient at risk for impaired
skin integrity?
A. 3+ Achilles reflex
B. Faint pedal pulses
C. Feet warm to the touch bilaterally
D. Capillary refill less than 2 sec - ANSWER- B. Faint pedal pulses
A charge nurse is observing a newly licensed nurse perform
tracheostomy care for a client. Which of the following actions by the
newly licensed nurse requires intervention?
A. Obtaining hydrogen peroxide for the tracheostomy care
B. Obtaining cotton balls for the tracheostomy care
C. Obtaining sterile gloves for the tracheostomy care
D. Obtaining a sterile brush for the tracheostomy care - ANSWER- B.
Obtaining cotton balls for the tracheostomy care
A nurse is collecting data about a client's incision and observes the
drainage to be blood-tinged. Which of the following terms should the
nurse use to document this finding?
A. Sanguineous
B. Purulent
C. Serous
D. Hyperemia - ANSWER- A. Sanguineous
,3|Page
A nurse is caring for a client who begins having a tonic-clonic seizure
while sitting in a chair at the bedside. Which of the following actions
should the nurse take first?
A. Provide oxygen
B. Turn the client onto his side
C. Provide privacy
D. Lower the client to the floor - ANSWER- D. Lower the client to the
floor
A nurse is initiating the use of a sequential compression device for a
client who is postoperative following knee surgery. Which of the
following actions should the nurse take?
A. Set the ankle pressure at 70 mmHg
B. Have the client turn onto a side
C. Place a sleeve on top of each leg with the opening at the knee
D. Make sure 2 fingers can fit under the sleeves - ANSWER- D. Make
sure 2 fingers can fit under the sleeves
A nurse is collecting data from a client who reports nausea and vomiting
for 2 days. Which of the following findings should indicate to the nurse
that the client is experiencing fluid volume deficit?
A. Decreased urine specific gravity
B. Increased heart rate
C. Decreased hematocrit
, 4|Page
D. Increased skin turgor - ANSWER- B. Increased heart rate
As a nurse is preparing to administer liquid medication from a bottle to a
client. Which of the following actions should the nurse take?
A. Hold the medication bottle with the label against the palm of the hand
when pouring
B. Place the cap with the inside facing down on a hard surface
C. Fill the cup until the medication is even with the edge of the dosage
scale
D. Pour any excess liquid back into the bottle when measuring -
ANSWER- A. Hold the medication bottle with the label against the palm
of the hand when pouring
A nurse is preparing to insert an indwelling urinary catheter. Which of
the following instructions should the nurse give the client to ease the
passage of the catheter through the urinary meatus?
A. "Bear down."
B. "Perform Kegel exercises."
C. "Hold your breath."
D. "Raise your head off of the pillow." - ANSWER- A. "Bear down."
A nurse is caring for a client who has a stage Il pressure ulcer. Which of
the following wound dressings should the nurse apply to the ulcer?
A. Hydrocolloid
B. Collagen
