ATI Fundamentals 2 Quiz
A nurse is administering a cleansing enema to a client who is scheduled for a
diagnostic procedure. Which of the following actions should the nurse take? - ansInsert
the tip of the tubing 8 cm.
will prevent dislodging of the tubing during the procedure and injury to rectal mucosa
A nurse is applying antiembolitic stockings for a client who has a history of deep vein
thrombosis. Which of the following actions should the nurse take when applying the
stockings? - ansTurn the stockings inside out up to the heel before applying.
Rationale: The nurse should turn the stocking inside out up to the client's heel to make
the application of the stocking easier and cause less constrictive wrinkles.
A nurse is assessing a client who has an onset of severe back pain of unknown origin.
Which of the following questions should the nurse ask to encourage discussion with the
client?
" - ansWhat do you think caused the onset of your pan"
Rationale: The nurse is using an opne-ended question that allows the client to respond
with a wide range of information by using more than one or two words.
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with
both hands and appears frightened. Which of the following actions should the nurse
take first? - ansDetermine whether the client is able to breathe.
before you can notify what is going on with the patient, you have to collect vital data
from the patient
A nurse is caring for a client who has a hearing impairment. Which of the following
interventions should the nurse use when speaking with the client? - ansface the client
when speaking.
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the
room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no
respirations, and is pulseless. Which of the following actions should the nurse take first?
- ansStart chest compressions.
give priority to the factor or situation posing the greatest safety risk.
A nurse is caring for a client who has a mastectomy and has a self-suction drainage
evacuator in place. Which of the following actions should the nurse take to ensure
proper operation of the device. - ansCollapse the device of air after emptying.
, Rationale: The nurse should collapse the device of air after emptying the contents
periodically to create enough suction to pull fluid exudate into the collection area of the
device.
A nurse is caring for a client who has an NG tube for intermittent enteral feedings.
Which of the following actions should the nurse take?
. - ansElevate the client's head of bed 45 degrees before the feeding.
Rationale: the nurse should do this to prevent aspiration
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? - ansCheck
the client's perineum.
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and
asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as
tolerated. Which of the following responses should the nurse make? - ans"I am going to
listen to your abdomen."
a common reason why client's experience nausea and vomiting after a surgery is bc of
delayed gastric emptying time or decreased peristalsis
determine presence of bowel sounds before liquids can be administered
A nurse is caring for a client who postoperative and who has an indwelling urinary
catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of
the following actions should the nurse take first? - ansCheck to determine if the catheter
tubing is kinked.
first apply least invasive framework
A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse,
"Help! My baby is choking on his food." Which of the following findings indicates the
toddler has an airway obstruction? - ansInability of the toddle to cry or speak.
bc no sounds passing through vocal cords
use heimliech maneuver
A nurse is caring for an older adult client who has dysphagia following a
cerebrovascular accident. Which of the following actions should the nurse take when
assisting the client at mealtime? - ansOffer the client tart or sour foods first.
Rationale: , The client who has impaired pharyngeal swallowing should consume tart
and sour foods at the beginning of the meal to stimulate saliva production, which helps
with chewing and swallowing.
A nurse is administering a cleansing enema to a client who is scheduled for a
diagnostic procedure. Which of the following actions should the nurse take? - ansInsert
the tip of the tubing 8 cm.
will prevent dislodging of the tubing during the procedure and injury to rectal mucosa
A nurse is applying antiembolitic stockings for a client who has a history of deep vein
thrombosis. Which of the following actions should the nurse take when applying the
stockings? - ansTurn the stockings inside out up to the heel before applying.
Rationale: The nurse should turn the stocking inside out up to the client's heel to make
the application of the stocking easier and cause less constrictive wrinkles.
A nurse is assessing a client who has an onset of severe back pain of unknown origin.
Which of the following questions should the nurse ask to encourage discussion with the
client?
" - ansWhat do you think caused the onset of your pan"
Rationale: The nurse is using an opne-ended question that allows the client to respond
with a wide range of information by using more than one or two words.
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with
both hands and appears frightened. Which of the following actions should the nurse
take first? - ansDetermine whether the client is able to breathe.
before you can notify what is going on with the patient, you have to collect vital data
from the patient
A nurse is caring for a client who has a hearing impairment. Which of the following
interventions should the nurse use when speaking with the client? - ansface the client
when speaking.
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the
room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no
respirations, and is pulseless. Which of the following actions should the nurse take first?
- ansStart chest compressions.
give priority to the factor or situation posing the greatest safety risk.
A nurse is caring for a client who has a mastectomy and has a self-suction drainage
evacuator in place. Which of the following actions should the nurse take to ensure
proper operation of the device. - ansCollapse the device of air after emptying.
, Rationale: The nurse should collapse the device of air after emptying the contents
periodically to create enough suction to pull fluid exudate into the collection area of the
device.
A nurse is caring for a client who has an NG tube for intermittent enteral feedings.
Which of the following actions should the nurse take?
. - ansElevate the client's head of bed 45 degrees before the feeding.
Rationale: the nurse should do this to prevent aspiration
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? - ansCheck
the client's perineum.
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and
asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as
tolerated. Which of the following responses should the nurse make? - ans"I am going to
listen to your abdomen."
a common reason why client's experience nausea and vomiting after a surgery is bc of
delayed gastric emptying time or decreased peristalsis
determine presence of bowel sounds before liquids can be administered
A nurse is caring for a client who postoperative and who has an indwelling urinary
catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of
the following actions should the nurse take first? - ansCheck to determine if the catheter
tubing is kinked.
first apply least invasive framework
A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse,
"Help! My baby is choking on his food." Which of the following findings indicates the
toddler has an airway obstruction? - ansInability of the toddle to cry or speak.
bc no sounds passing through vocal cords
use heimliech maneuver
A nurse is caring for an older adult client who has dysphagia following a
cerebrovascular accident. Which of the following actions should the nurse take when
assisting the client at mealtime? - ansOffer the client tart or sour foods first.
Rationale: , The client who has impaired pharyngeal swallowing should consume tart
and sour foods at the beginning of the meal to stimulate saliva production, which helps
with chewing and swallowing.
