ATI FUNDAMENTALS EXAM PRACTICE
QUESTIONS AND VERIFIED ANSWERS|
100% CORRECT
A nurse is caring for an older adult client with delirium. Which intervention will most
effectively reduce the client's risk for falls? A. Use of a night-light. B. Demonstrate how to
use the call light. C. Place bedside table in close proximity. D. Hourly rounding by the nurse.
D. Hourly rounding by the nurse.Rationale: In the health care environment, hourly rounding
by the nurse significantly reduces the occurrence of client falls as well as reducing call light
usage and increasing client satisfaction.
A nurse is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of
the following pH values provides a good indication of correct tube placement? A. 2 B. 5 C. 7
D. 9
A. 2
Rationale: A good indication of appropriate placement is obtaining gastric contents with a pH
between 0 and 4.
A client is receiving home oxygen. What teaching points should the nurse provide the
client and the caregiver regarding home oxygen safety?
Since oxygen is combustible, the following nursing actions are important for the nurse to
implement:Post ""No Smoking"" or ""Oxygen in Use"" signs to alert others of the fire hazard.
Know where to find the closest fire extinguisher. Educate about the fire hazard of smoking
with oxygen use. Have clients wear a cotton gown because synthetic or wool fabrics can
generate static electricity. Ensure that all electric devices (razors, hearing aids, radios) are
working well. Make sure all electric machinery (monitors, suction machines) is grounded. Do
not use volatile, flammable materials (alcohol, acetone) near clients receiving oxygen.
List three (3) actions the nurse should take during the assessment and data collection steps.
, Recognize patterns or trends.
Compare the data with expected standards or reference ranges.
Arrive at conclusions to guide nursing care.
What points would the nurse discuss when teaching cane walking to a client for the
first time?
-Maintain two points of support on the ground at all times.
-Keep the cane on the stronger side of the body.· Support body weight on both legs.
-Move the cane forward 15 cm (6-10 inches).
-Then move the weaker leg forward toward the cane.
-Next advance the stronger leg past the cane.
A nurse is teaching a community course in home safety and providing first aid.
What instructions should the nurse include for a client that is bleeding?
Identify any sources of external bleeding and apply direct pressure to the wound site. DO
NOT remove impaling objects. Instead, stabilize the object. Internal bleeding can require
intravascular volume replacement with fluids and/or blood products, or surgical intervention.
A client with hypovolemia has been prescribed intravenous fluid at 125mL/hr. The IV site
to provide hydration has infiltrated. What steps will the nurse take to treat the infiltrated
IV site? And what will the nurse do to address the client's hydration needs?
Treatment with an infiltration to an IV site includes: stop infusion, remove peripheral catheter,
apply cold compress, and elevate the extremity. The nurse needs to also address the hydration
issue with this client, diagnosed with hypovolemia. The nurse needs to insert a new peripheral
catheter in the opposite extremity or in an appropriate extremity with good blood supply above
the site of the infiltration.
Infiltration vs. Phlebitis
Infiltration: site swollen and cool
Phlebitis: site swollen, warm, and red (think -itis)
QUESTIONS AND VERIFIED ANSWERS|
100% CORRECT
A nurse is caring for an older adult client with delirium. Which intervention will most
effectively reduce the client's risk for falls? A. Use of a night-light. B. Demonstrate how to
use the call light. C. Place bedside table in close proximity. D. Hourly rounding by the nurse.
D. Hourly rounding by the nurse.Rationale: In the health care environment, hourly rounding
by the nurse significantly reduces the occurrence of client falls as well as reducing call light
usage and increasing client satisfaction.
A nurse is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of
the following pH values provides a good indication of correct tube placement? A. 2 B. 5 C. 7
D. 9
A. 2
Rationale: A good indication of appropriate placement is obtaining gastric contents with a pH
between 0 and 4.
A client is receiving home oxygen. What teaching points should the nurse provide the
client and the caregiver regarding home oxygen safety?
Since oxygen is combustible, the following nursing actions are important for the nurse to
implement:Post ""No Smoking"" or ""Oxygen in Use"" signs to alert others of the fire hazard.
Know where to find the closest fire extinguisher. Educate about the fire hazard of smoking
with oxygen use. Have clients wear a cotton gown because synthetic or wool fabrics can
generate static electricity. Ensure that all electric devices (razors, hearing aids, radios) are
working well. Make sure all electric machinery (monitors, suction machines) is grounded. Do
not use volatile, flammable materials (alcohol, acetone) near clients receiving oxygen.
List three (3) actions the nurse should take during the assessment and data collection steps.
, Recognize patterns or trends.
Compare the data with expected standards or reference ranges.
Arrive at conclusions to guide nursing care.
What points would the nurse discuss when teaching cane walking to a client for the
first time?
-Maintain two points of support on the ground at all times.
-Keep the cane on the stronger side of the body.· Support body weight on both legs.
-Move the cane forward 15 cm (6-10 inches).
-Then move the weaker leg forward toward the cane.
-Next advance the stronger leg past the cane.
A nurse is teaching a community course in home safety and providing first aid.
What instructions should the nurse include for a client that is bleeding?
Identify any sources of external bleeding and apply direct pressure to the wound site. DO
NOT remove impaling objects. Instead, stabilize the object. Internal bleeding can require
intravascular volume replacement with fluids and/or blood products, or surgical intervention.
A client with hypovolemia has been prescribed intravenous fluid at 125mL/hr. The IV site
to provide hydration has infiltrated. What steps will the nurse take to treat the infiltrated
IV site? And what will the nurse do to address the client's hydration needs?
Treatment with an infiltration to an IV site includes: stop infusion, remove peripheral catheter,
apply cold compress, and elevate the extremity. The nurse needs to also address the hydration
issue with this client, diagnosed with hypovolemia. The nurse needs to insert a new peripheral
catheter in the opposite extremity or in an appropriate extremity with good blood supply above
the site of the infiltration.
Infiltration vs. Phlebitis
Infiltration: site swollen and cool
Phlebitis: site swollen, warm, and red (think -itis)
