ATI Fundamentals Practice
Exam Solution Update 2023
(A+)
A nurse is talking with the partner of a client who has dementia. The client's partner
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expresses frustration about finding time to manage household responsibilities while
caring for their partner. The nurse should identify that the partner is experiencing which
of the following types of role-performance stress?
A. Role ambiguity
B. Sick role
C. Role overload
D. Role conflict - Correct Answer-C. Role overload
Rationale: The partner's expression of frustration is an example of role overload, which
refers to having more responsibilities within a role than one person can manage
A nurse is performing a skin assessment for a client who expresses cancer about skin
cancer. Which of the following findings should the nurse identify as a potential indication
of a skin malignancy?
A. A lesion with uniform pigmentation
B. New appearance of petechiae
C. A mole with an asymmetrical appearance
D. The presence of a papule - Correct Answer-C. A mole with an asymmetrical
appearance
Rationale: An uneven or asymmetrical shape is a potential indication of a skin
malignancy. This is manifested when part of a lesion or mole looks different from the
other part.
A nurse is assessing a client who reports increased pain following physical therapy.
Which of the following questions should the nurse ask when assessing the quality of the
client's pain?
A. "Is your pain constant or intermittent?"
B. "What would you rate your pain on a scale of 0 to 10?"
C. "Does the pain radiate?"
D. "Is your pain sharp or dull?" - Correct Answer-D. "Is your pain sharp or dull?"
Rationale: Asking the client whether the pain is sharp, dull, crushing, throbbing, aching,
burning, electric-like, or shooting helps determine the quality of the pain.
A nurse is admitting a new client. which of the following actions should the nurse take
while performing medication reconcillation?
A. Verify the client's name on their identification bracelet with the medication
administration record.
B. Call the pharmacy to determine whether the client's medications are available.
C. Compare the client's home medications with the provider's prescriptions.
D. Place the client's home medication bottles in a secure location. - Correct Answer-C.
Compare the client's home medications with the provider's prescriptions.
Rationale: The nurse should compare the client's home medications with the provider's
prescriptions when performing medication reconciliation.
A nurse is auscultating the anterior chest of a client who was newly admitted to a
medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the
stethoscope and identify the type of breath sounds.
A. Crackles
B. Rhonchi
C. Friction rub
D. Normal breath sounds - Correct Answer-C. Compare the client's home medications
with the provider's prescriptions.
Rationale: These are normal bronchovesicular breath sounds, characteristically of
moderate intensity and sounding like blowing as air moves through the larger airways
on inspiration and expiration.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the
following actions should the nurse take?
A. Administer the medication with the needle at a 45 degree angle.
B. Administer the medication into the client's nondominant arm.
C. Pull the client's skin laterally or downward prior to administration.
D. Massage the injection site after administration. - Correct Answer-A. Administer the
medication with the needle at a 45 degree angle.
Rationale: The nurse should insert the needle at a 45 degree to 90 degree angle for a
subcutaneous injection.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary
catheter. Which of the following actions should the nurse take?
A. Place the client in a side-lying position
B. Instill 15mL of irrigation fluid into the catheter with each flush
C. Subtract the amount of irrigant used from the client's urine output.
D. Perform the irrigation using a 20-mL syringe - Correct Answer-C. Subtract the
amount of irrigant used from the client's urine output.
Rationale: The nurse should calculate the fluid used for irrigation and subtract it from
the client's total urinary output.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury.
Which of the following types of dressing should the nurse use?
A. Alginate
B. Gauze
C. Transparent
D. Hydrocolloid - Correct Answer-D. Hydrocolloid
Rationale: Hyrocolloid dressings promote healing in stage 2 pressure injuries by
creating a moist would bed.
A nurse is providing discharge teaching to a client about self-administering heparin.
Which of the following instructions should the nurse include in the teaching?
A. Insert the needle at a 15 degree angle
B. Aspirate for blood return prior to administration
C. Administer the medication into the abdomen
D. Massage the site following the injection. - Correct Answer-C. Administer the
medication into the abdomen
Rationale: The nurse should instruct the client to administer the medication into the
abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread
the skin at the injection site to administer the medication into the subcutaneous tissue.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for
wrist restraints. Which of the following actions should the nurse take?
A. Pad the client's wrist before applying the restraints.
B. Evaluate the client's circulation every 8 hr after application.
C. Remove the restraints every 4 hr to evaluate the client's status.
D. Secure the restraint ties to the bed's side rails. - Correct Answer-A. Pad the client's
wrist before applying the restraints.
Rationale: The use of restraints without padding can abrade the client's skin, resulting in
client injury.
A nurse is initiating a protective environment for a client who has had an allogeneic
stem cell transplant. Which of the following precautions should the nurse plan for this
client?
A. Make sure the client's room has at least six air exchanges per hour
B. Make sure the client wears a mask when outside her room if there is construction in
the area
C. Place the client in a private room with negative-pressure airflow
D. Wear an N95 respirator when giving the client direct care - Correct Answer-B. Make
sure the client wears a mask when outside her room if there is construction in the area
Rationale: An allogeneic stem cell transplant compromises the client's immune system,
greatly increasing the risk for infection. The client will need protection from breathing in
any pathogens in the environment... [Show Less]