VIRTUAL ATI - FUNDAMENTALS EXAMS VERIFIED QUESTIONS AND CORRECT
ANSWERS
A client has a new tracheostomy. Which of the following interventions should the nurse include when
performing tracheostomy care?
a. Change tracheostomy ties when soiled.
b. Remove soiled dressing with sterile gloves.
c. Suction the tracheostomy before beginning care.
d. Clean disposable inner cannula with hydrogen peroxide.
- ANSWERS-Change tracheostomy ties when soiled. CORRECT. Tracheostomy ties should be changed once
a day or when soiled. Secure new ties in place before removing old soiled ones to prevent accidental
decannulation. One or two fingers should be able to be placed between the tie tape and the neck.
A client with pneumonia has an oxygen saturation of 85%, heart rate of 88, respiratory rate of 22, and
blood pressure of 132/88. Which of the following is the priority nursing intervention?
Select one:
a. Reassess pulse oximetry
b. Administer albuterol inhaler
c. Immediately notify the provider
d. Place the client on 2 Liters oxygen
- ANSWERS-Reassess pulse oximetry
A fire in a first floor operating room is forcing evacuation of clients from a second floor unit to another
building. Which of the following clients would have the highest priority for the charge nurse to evacuate?
Select one:
a. A client receiving IV antibiotics every six hours for a leg ulcer.
b. A client semi-comatose after a cerebrovascular accident with an indwelling urinary catheter.
c. A client post left hip replacement of two days ago whose daughter is visiting.
d. A client admitted with pancreatitis with nasogastric tube and PCA pump in place.
- ANSWERS-a. A client receiving IV antibiotics every six hours for a leg ulcer.
,A nurse caring for client who is recovering from a colon resection is changing the dressing over the client's
incision. Which of the following is an appropriate action by the nurse?
A. Use sterile gloves to remove the old dressing
B. Place old dressing in the client's trash can
C. Open sterile dressings before putting on sterile gloves
D. Put date and time on dressing using a marker
- ANSWERS-C
A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-
month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate
medical attention?
Select one:
a. The baby has an axillary temperature of 100.4 F. (38 C)
b. The baby develops swelling or redness at the injection site
c. The baby develops a localized or generalized rash
d. The baby is crying inconsolably for more than three hours
- ANSWERS-d. The baby is crying inconsolably for more than three hours
A nurse in a long-term care facility is assisting with an educational program regarding common sites of
health care associated infections for a group of newly hired assistive personnel. Which of the following
sites should be included in the teaching (STTA)
Urinary Tract
Surgical Wound
Musculoskeletal System
Respiratory Tract
Blood Stream
- ANSWERS-Urinary Tract, Surgical Wound, Respiratory Tract, Blood Stream
A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following
findings indicates the client could be experiencing an anastomotic leak?
Lethargy
Neuralgia
, Bradycardia
Oliguria
- ANSWERS-Oliguria
When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by
surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or
intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death.
A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes,
the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After
calling for assistance and notifying the provider, which of following is the priority action by the nurse?
Wrap the cord in a towel saturated with 0.9% sodium chloride
Apply oxygen via face mask
Place client in knee-chest position
Increase IV fluid rate
- ANSWERS-place client in knee-chest position
Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the
fetus off the cord.
A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1 Liter of IV fluid over 2
hours. Which intervention is the priority?
Select one:
a. Monitor urine output.
b. Fill out an incident report.
c. Report the defective equipment.
d. Document the amount of fluid infused.
- ANSWERS-Fill out an incident report
A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have
active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis?
- ANSWERS-Sputum culture for acid-fast bacillus
A nurse is caring for a client who is from a culture different than his own. Which action by the nurse is most
important in the provision of culturally competent care?
Include the family in the client's care
ANSWERS
A client has a new tracheostomy. Which of the following interventions should the nurse include when
performing tracheostomy care?
a. Change tracheostomy ties when soiled.
b. Remove soiled dressing with sterile gloves.
c. Suction the tracheostomy before beginning care.
d. Clean disposable inner cannula with hydrogen peroxide.
- ANSWERS-Change tracheostomy ties when soiled. CORRECT. Tracheostomy ties should be changed once
a day or when soiled. Secure new ties in place before removing old soiled ones to prevent accidental
decannulation. One or two fingers should be able to be placed between the tie tape and the neck.
A client with pneumonia has an oxygen saturation of 85%, heart rate of 88, respiratory rate of 22, and
blood pressure of 132/88. Which of the following is the priority nursing intervention?
Select one:
a. Reassess pulse oximetry
b. Administer albuterol inhaler
c. Immediately notify the provider
d. Place the client on 2 Liters oxygen
- ANSWERS-Reassess pulse oximetry
A fire in a first floor operating room is forcing evacuation of clients from a second floor unit to another
building. Which of the following clients would have the highest priority for the charge nurse to evacuate?
Select one:
a. A client receiving IV antibiotics every six hours for a leg ulcer.
b. A client semi-comatose after a cerebrovascular accident with an indwelling urinary catheter.
c. A client post left hip replacement of two days ago whose daughter is visiting.
d. A client admitted with pancreatitis with nasogastric tube and PCA pump in place.
- ANSWERS-a. A client receiving IV antibiotics every six hours for a leg ulcer.
,A nurse caring for client who is recovering from a colon resection is changing the dressing over the client's
incision. Which of the following is an appropriate action by the nurse?
A. Use sterile gloves to remove the old dressing
B. Place old dressing in the client's trash can
C. Open sterile dressings before putting on sterile gloves
D. Put date and time on dressing using a marker
- ANSWERS-C
A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-
month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate
medical attention?
Select one:
a. The baby has an axillary temperature of 100.4 F. (38 C)
b. The baby develops swelling or redness at the injection site
c. The baby develops a localized or generalized rash
d. The baby is crying inconsolably for more than three hours
- ANSWERS-d. The baby is crying inconsolably for more than three hours
A nurse in a long-term care facility is assisting with an educational program regarding common sites of
health care associated infections for a group of newly hired assistive personnel. Which of the following
sites should be included in the teaching (STTA)
Urinary Tract
Surgical Wound
Musculoskeletal System
Respiratory Tract
Blood Stream
- ANSWERS-Urinary Tract, Surgical Wound, Respiratory Tract, Blood Stream
A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following
findings indicates the client could be experiencing an anastomotic leak?
Lethargy
Neuralgia
, Bradycardia
Oliguria
- ANSWERS-Oliguria
When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by
surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or
intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death.
A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes,
the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After
calling for assistance and notifying the provider, which of following is the priority action by the nurse?
Wrap the cord in a towel saturated with 0.9% sodium chloride
Apply oxygen via face mask
Place client in knee-chest position
Increase IV fluid rate
- ANSWERS-place client in knee-chest position
Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the
fetus off the cord.
A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1 Liter of IV fluid over 2
hours. Which intervention is the priority?
Select one:
a. Monitor urine output.
b. Fill out an incident report.
c. Report the defective equipment.
d. Document the amount of fluid infused.
- ANSWERS-Fill out an incident report
A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have
active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis?
- ANSWERS-Sputum culture for acid-fast bacillus
A nurse is caring for a client who is from a culture different than his own. Which action by the nurse is most
important in the provision of culturally competent care?
Include the family in the client's care
