ATI FUNDAMENTALS 2 EXAMS VERIFIED QUESTIONS AND CORRECT
ANSWERS
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?
- ANSWERS-Insert 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?
- ANSWERS-Turn 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?
"
- ANSWERS-What 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?
- ANSWERS-Determine 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?
- ANSWERS-face 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?
- ANSWERS-Start 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.
- ANSWERS-Collapse 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?
.
- ANSWERS-Elevate 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?
- ANSWERS-Check 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?
- ANSWERS-"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
ANSWERS
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?
- ANSWERS-Insert 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?
- ANSWERS-Turn 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?
"
- ANSWERS-What 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?
- ANSWERS-Determine 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?
- ANSWERS-face 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?
- ANSWERS-Start 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.
- ANSWERS-Collapse 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?
.
- ANSWERS-Elevate 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?
- ANSWERS-Check 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?
- ANSWERS-"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
