ATI FUNDAMENTALS 2 EXAM
QUESTIONS AND VERIFIED ANSWERS|
100% CORRECT
A nurse is changing the bed linens for a client who is on bed rest. Which of the
following actions should the nurse plan to take?
A. Place the soiled linens on the chair while making the bed.
B. Hold the linens away from the body and clothing.
C. Place the linens on the floor until able to pace it in a linen bag.
D. Shake the clean linens to unfold.
B. Hold the linens away from the body and clothing.
The nurse should hold the linens away from the body and clothing to prevent soiling or the
transfer of microorganisms. The microorganisms present on the nurse's clothing can
expose other clients to microorganisms.
Other Rationales:
The nurse should place the soiled linens in a linen bag immediately after removing the linen from
the bed to prevent the spread of microorganisms on surfaces within the client's room and
exposure to personnel.
Soiled linen is contaminated with microorganisms and will further contaminate the floor and
attract any microorganisms present on the floor, which places the nurse and the client at
risk for infection.
Opening linens by shaking them causes movement of air. Air currents can carry dust and spread
microorganisms throughout the room, which places the client and the nurse at risk for
infection.
,A nurse is changing the dressings for a client who is 3 days postoperative following a
cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The
nurse should document this finding as which of the following types of drainage?
A. Sanguineous exudate
B. Serous exudate
C. Serosanguineous exudate
D. Purulent exudate
D. Purulent exudate
Purulent exudate drainage on the client's dressings is thick yellow, green and brown
drainage and usually indicates wound sloughing or infection.
Other Rationales:
Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs
from the plasma that appears bright red on the dressings.
Serous exudate drainage on the client's dressings indicates plasma from the blood and
appears clear to light yellow, and is watery.
Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light
bloody drainage, which is typically pale yellow to blood-tinged and watery drainage.
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?
A. Encourage the client to drink fluids before swallowing food.
B. Offer the client tart or sour foods first.
C. Tilt the client's head backward when swalling.
D. Turn on the television.
B. Offer the client tart or sour foods first.
, 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.
Other Rationales:
The client who has impaired pharyngeal swallowing is at risk for choking when liquids
(especially thin liquids) are offered while eating solid foods. It is preferable to suggest
"dry swallows" to clear the mouth between bites of food.
The client who has impaired pharyngeal swallowing should tilt the head forward to
promote swallowing.
The client who has impaired pharyngeal swallowing should minimize distractions at
mealtimes to concentrate on chewing thoroughly and swallowing.
A nurse is changing the dressings for a client who has two Penrose drains near an abdominal
incision. Which of the following adhering devices is the best choice for the nurse to use to
decrease skin irritation?
A. Abdominal binder
B. Montgomery straps
C. Hypoallergenic tape
D. Plastic tape
B. Montgomery Straps
The nurse should apply the least restrictive priority-setting framework. This framework assigns
QUESTIONS AND VERIFIED ANSWERS|
100% CORRECT
A nurse is changing the bed linens for a client who is on bed rest. Which of the
following actions should the nurse plan to take?
A. Place the soiled linens on the chair while making the bed.
B. Hold the linens away from the body and clothing.
C. Place the linens on the floor until able to pace it in a linen bag.
D. Shake the clean linens to unfold.
B. Hold the linens away from the body and clothing.
The nurse should hold the linens away from the body and clothing to prevent soiling or the
transfer of microorganisms. The microorganisms present on the nurse's clothing can
expose other clients to microorganisms.
Other Rationales:
The nurse should place the soiled linens in a linen bag immediately after removing the linen from
the bed to prevent the spread of microorganisms on surfaces within the client's room and
exposure to personnel.
Soiled linen is contaminated with microorganisms and will further contaminate the floor and
attract any microorganisms present on the floor, which places the nurse and the client at
risk for infection.
Opening linens by shaking them causes movement of air. Air currents can carry dust and spread
microorganisms throughout the room, which places the client and the nurse at risk for
infection.
,A nurse is changing the dressings for a client who is 3 days postoperative following a
cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The
nurse should document this finding as which of the following types of drainage?
A. Sanguineous exudate
B. Serous exudate
C. Serosanguineous exudate
D. Purulent exudate
D. Purulent exudate
Purulent exudate drainage on the client's dressings is thick yellow, green and brown
drainage and usually indicates wound sloughing or infection.
Other Rationales:
Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs
from the plasma that appears bright red on the dressings.
Serous exudate drainage on the client's dressings indicates plasma from the blood and
appears clear to light yellow, and is watery.
Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light
bloody drainage, which is typically pale yellow to blood-tinged and watery drainage.
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?
A. Encourage the client to drink fluids before swallowing food.
B. Offer the client tart or sour foods first.
C. Tilt the client's head backward when swalling.
D. Turn on the television.
B. Offer the client tart or sour foods first.
, 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.
Other Rationales:
The client who has impaired pharyngeal swallowing is at risk for choking when liquids
(especially thin liquids) are offered while eating solid foods. It is preferable to suggest
"dry swallows" to clear the mouth between bites of food.
The client who has impaired pharyngeal swallowing should tilt the head forward to
promote swallowing.
The client who has impaired pharyngeal swallowing should minimize distractions at
mealtimes to concentrate on chewing thoroughly and swallowing.
A nurse is changing the dressings for a client who has two Penrose drains near an abdominal
incision. Which of the following adhering devices is the best choice for the nurse to use to
decrease skin irritation?
A. Abdominal binder
B. Montgomery straps
C. Hypoallergenic tape
D. Plastic tape
B. Montgomery Straps
The nurse should apply the least restrictive priority-setting framework. This framework assigns
