ATI Fundamentals Proctored Exam | Questions
and Answers with Rationales | LATEST
1. A nurse is planning to collect a stool specimen for ova and
... [Show More] parasites from a client who has
diarrhea. Which of the following actions should the nurse take when collecting the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a bedpan or a container for stool
collection. The toilet water can dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean container using a tongue
depressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen immediately to the laboratory
after labeling the specimen properly to prevent contamination with microorganisms and keep the
specimen from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a biohazard bag with the client
label on the container and the bag for easy identification. This will also prevent contamination
with microorganisms.
2. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the
following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for several
minutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases the risk of damage to the
tracheal mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
3. A nurse is providing teaching to a client regarding protein intake. Which of the following
foods should the nurse include as an example of an incomplete protein?
A. Eggs
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
B. Soybeans
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for the
synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables,
grains, nuts, and seeds.
D. Yogurt
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
4. A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation
after a total hip arthroplasty. At which of the following times should the nurse begin discharge
planning?
A. One week prior to the client‟s discharge
-incorrect: Beginning to plan for the client‟s discharge a week prior to the event might not allow
sufficient time for planning. The nurse should begin discharge planning at the time of admission.
B. Upon the client‟s admission to the care facility
-The nurse should begin discharge planning at the time that the client is admitted to the facility.
C. Once the discharge date is identified
-incorrect: Beginning to plan for the client‟s discharge once the discharge date is identified might
not allow sufficient time for planning. The nurse should begin discharge planning at the time of
admission.
D. When the client addresses the topic with the nurse
-incorrect: Beginning to plan for the client‟s discharge once the discharge date is identified might
not allow sufficient time for planning. The nurse should begin discharge planning at the time of
admission.
5. A nurse is preparing to administer a cleansing enema to a client. Which of the following
actions should the nurse plan to take?
A. Insert the rectal tube 15.2 cm (6 in)
-incorrect: The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in)
B. Wear sterile gloves to insert the tubing
-incorrect: The nurse should wear clean (nonsterile) gloves to prevent contamination.
C. Position the client on his left side
-Positioning is an important aspect of administering an enema. Having the client lie on his left
side facilitates the flow of the enema solution into the sigmoid and descending colon.
D. Hold the solution bag 91 cm (36 inch) above the client‟s rectum
-incorrect: The nurse should hold the solution bag 30 cm (12 in) above the client‟s rectum for a
low enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag too high, the
solution might run in too fast, causing discomfort and spasms that make retaining the enema
more difficult.
5. A nurse is caring for a client who has bilateral cats on her hands. Which of the following
actions should the nurse take when assisting the client with feeding?
A. Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with
the nurse‟s full attention during the feedingB. Order pureed foods
-incorrect: Without any mouth or throat injuries that make chewing or swallowing difficult, the
client should be served foods of an appropriate variety of textures. Pureed foods are for clients
who cannot chew, have difficulty swallowing, or do not have teeth.
C. Make sure feedings are provided at room temperature
-incorrect: The nurse should ask the client if the food is the correct temperature
D. Offer the client a drink of fluid after every bite
-incorrect: If the client is unable to communicate, the nurse should offer the client fluids after
every 3 or 4 mouthfuls. However, there is no indication that this client is unable to communicate.
Therefore, the client should tell the nurse when she would like a drink.
6. A nurse is administering an IM injection to a 5-month-old infant. Which of the following
injection sites should the nurse use?
A. Deltoid
-incorrect: The nurse can use the deltoid muscle for injecting small volumes of medication for
children 18 months of age or older, but its proximity to several nerves and arteries make it a
riskier choice.
B. Ventrogluteal
-incorrect: This is a safe site for IM injections for clients older than 7 months.
C. Vastus lateralis
-The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants
and children.
D. Dorsogluteal
-incorrect: This site is unsafe to use because of its proximity to the sciatic nerve and the superior
gluteal nerve and artery.
7. 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?
A. Apply a fecal collection system
-incorrect: The nurse should apply a fecal collection system to divert the feces away from the
area of skin irritation; however, there is another action the nurse should take first.
B. Apply a barrier cream
-incorrect: The nurse should apply a barrier cream to decrease skin breakdown in the perianal
area from the feces; however, there is another action the nurse should take first.
C. Cleanse and dry the area
-incorrect: The nurse should cleanse and dry the perianal area to decrease skin irritation;
however, there is another action the nurse should take first.
D. Check the client‟s perineum
-The nurse should apply the nursing process priority-setting framework to plan care and
prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning
with an assessment or data collection. Before the nurse can formulate a plan of action, implement
a nursing intervention, or notify a provider of a change in the client‟s status, the nurse must first
collect adequate data from the client. Assessing or collecting additional data will provide the
nurse with knowledge to make an appropriate decision. The priority nursing action is for the
nurse to collect more data by assessing the area of irritation.9. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse
should identify that which of the following findings is an indication of infiltration?
A. Redness at the infusion site
-incorrect: Redness at the infusion site is an indication of phlebitis or infection.
B. Edema at the infusion site
-Edema due to fluid entering subcutaneous tissue is an indication of infiltration.
C. Warmth at the infusion site
-incorrect: Warmth at the infusion site is an indication of phlebitis or infection.
D. Oozing of blood at the infusion site
-incorrect: Oozing of blood at the infusion site is an indication that the IV system is not intact.
10. A nurse is caring for a client who reports not sleeping at night, which interferes with her
ability to function during the day. Which of the following interventions should the nurse suggest
to this client?
A. Avoid beverages that contain caffeine
-Caffeine is a stimulant. The nurse should suggest that the client avoid caffeinated beverages.
B. Take a sleep medication regularly at bedtime
-incorrect: Sleep-promoting medication is a last resort. The nurse should not suggest this type of
medication for the client before recommending other nonpharmacological interventions.
C. Watch television for 30 minutes in bed to relax prior to falling asleep
-incorrect: Clients should associate going to bed with sleep. Therefore, the client should not get
into bed until she is sleepy.
D. Advise the client to take several naps during the day
-incorrect: Napping in the daytime can prevent sound sleep at night
11. A nurse is conducting an admission interview with a client. Which of the following pieces of
assessment information should the nurse collect during the introductory phase of the interview?
A. Clients level of comfort and ability to participate in the interview
-The nurse should assess the client‟s level of comfort and establish a rapport during the
introductory or orientation phase. The nurse should engage in active listening and present a
relaxed attitude to place the client at ease and encourage client participation. This will assist the
nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes.
B. Previous illnesses and surgeries
-incorrect: The nurse should assess the client‟s health history, including previous illnesses and
surgeries, during the working phase of the interview.
C. Events surrounding the client‟s recent illness
-incorrect: The nurse should assess the client‟s health history, including events surrounding the
recent or current illness, during the working phase of the interview.
D. Sociocultural history
-incorrect: The nurse should assess the client‟s sociocultural history during the working phase of
the interview.
12. A nurse is performing an abdominal assessment of a client. Which of the following positions
should the nurse tell the client to assume for this examination?
A. Lithotomy
-incorrect: The lithotomy position is useful for gynecological examinations.B. Lateral
-incorrect: The lateral recumbent, or side-lying position, limits access to the abdomen. This
position is useful when auscultating the heart to detect murmurs.
C. Supine
-The nurse should tell the client to assume the supine position to promote relaxation of the
abdominal muscles. Having the client bend the knees enhances relaxation of the stomach
muscles.
D. Sims
-incorrect: The Sims‟ position limits access to the abdomen. This position is useful for rectal and
vaginal examinations.390. A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional
deficiencies. A laboratory results within the expected reference range for which of the following
substances indicates adequate protein uptake and synthesis?
A. Albumin
-The nurse should identify that an albumin level within the expected reference range is an
indication that the client has adequate protein uptake and synthesis. Albumin levels measure
protein status. They are useful for identifying long-term protein depletion rather than short-term
or acute changes in nutritional status.
B. Calcium
-incorrect: Calcium levels do not reflect protein status. Calcium levels reflect the adequacy of
bone and tooth formation, blood clotting, nerve impulse transmission, muscle contraction and
relaxation, and various other essential processes.
C. Sodium
-incorrect: Sodium levels do not reflect protein status. Sodium levels indicate fluid balance,
nerve impulse transmission, acid-base balance, and various other cellular activities.
D. Potassium
-incorrect: Potassium levels do not reflect protein status. Potassium levels reflect the status of
many metabolic activities, including nerve impulse transmission, cardiac conduction, and
skeletal and smooth muscle contraction.
391. A nurse is caring for a client who has a stage II pressure ulcer. Which of the following
wound dressings should the nurse apply to the ulcer?
A. Hydrocolloid
-The nurse should apply a hydrocolloid dressing to a stage II pressure ulcer. This type of
dressing is applied to absorb exudate and to produce a moist environment that will facilitate
healing while preventing maceration of surrounding skin.B. Collagen
-incorrect: The nurse should apply collagen to a clean, moist wound to stop bleeding, bring cells
into the wound, and stimulate their proliferation to facilitate healing.
C. Calcium alginate
-incorrect: The nurse should apply calcium alginate to a stage IV pressure ulcer. This type of
dressing is used for wounds with significant exudate and must be covered with a secondary
dressing.
D. Proteolytic enzyme
-incorrect: The nurse should apply a proteolytic enzyme to an unstageable pressure ulcer. This
type of dressing is applied to facilitate debridement and to soften eschar.
392. A nurse on a medical-surgical unit observes smoke billowing from a client‟s room. Which
of the following actions should the nurse take first?
A. Close the door to the client‟s room
-incorrect: The nurse should close the doors and windows in the immediate vicinity to help
contain the fire; however, this is not the first action the nurse should take.
B. Evacuate the client from the room
-The acronym RACE can help nurses remember the order of the actions to take in the event of a
fire. The components of RACE are rescue, activate, confine, and extinguish. The first priority is
rescuing or removing the client from immediate danger. The second action is activation of the
fire alarm system. The third action is confining the fire by closing doors and windows. The final
action is extinguishing the fire, if possible, using an available fire extinguisher. If attempts to
extinguish a fire could compromise the safety of clients or staff members, the nurse should await
the arrival of emergency fire personnel.
C. Sound the fire alarm
-incorrect: The nurse should sound the fire alarm to summon fire professionals to put out the fire
and ensure safety in the facility; however, this is not the first action the nurse should take.
D. Activate the fire extinguisher
-incorrect: The nurse should attempt to extinguish the fire safely if possible; however, this is not
the first action the nurse should take.
393. A. nurse is teaching a client who is recovering from gallbladder surgery how to use an
incentive spirometer. Which of the following pieces of information should the nurse include in
the teaching?
A. Exhale slowly to reach the goal volume
-incorrect: The nurse should instruct the client to inhale slowly to reach the goal volume and to
decrease the collapse of alveoli in the client‟s lungs.
B. Hold the breath for 5 sec after goal volume is reached
-The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximal
inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of
atelectasis and pneumonia.
C. Continue to breathe deeply between each cycle
-incorrect: The nurse should instruct the client to breathe normally for short periods of time
between each cycle of breaths to reduce hyperventilation and fatigue.
D. Limit the repeat pattern of breathing to 5 breaths-incorrect: The nurse should instruct the client to repeat the patterns for 10 to 20 breathes every
hour while awake to prevent atelectasis and pneumonia.
394. A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the
following abdominal assessments should the nurse expect?
A. Frequent bowel sounds with flatus
B. Absent bowel sounds with distention
-Paralytic ileus is an immobile bowel. In this disorder, bowel sounds are absent, and the
abdomen is distended.
C. Hyperactive bowel sounds with diarrhea
D. Normal bowel sounds with increased peristalsis
-incorrect A/C/D: With paralytic ileus, bowel sounds are absent, the abdomen is distended and
there is no flatus or stool.
395. A nurse is caring for a client who has a fecal impaction. Before the digital removal of the
mass, which of the following types of enemas should the nurse plan to administer to soften the
feces?
A. Carminative
-incorrect: The nurse should administer a carminative enema to assist a client to expel flatus.
B. Hypertonic
-incorrect: The nurse should administer a hypertonic fluid solution to cleanse the client‟s bowels
(ex: in preparation for surgery).
C. Oil retention
-The nurse should administer an oil retention enema prior to the removal of a fecal impaction to
soften the stool. This makes the procedure less painful for the client.
D. Sodium polystyrene sulfate
-incorrect: The nurse should administer a sodium polystyrene sulfate enema to a client who has a
high potassium level.
396. A nurse is teaching a client about how to remove a soiled dressing. Which of the following
statements by the client indicates an understanding of the teaching?
A. „I‟ll wear nonsterile gloves.”
-Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the
client‟s hands. The gloves the client uses can be clean and do not need to be sterile unless the
provider specifically prescribes sterile gloves for dressing changes.
B. “I‟ll use adhesive remover each time.”
-incorrect: The client should use adhesive remover only if tape removal or residual adhesive
creates significant problems on especially sensitive skin.
C. “I‟ll take my pain pill after I change the dressing.”
-incorrect: If the client expects the dressing removal to hurt, the client should take an analgesic
long enough before the dressing change for the medication to take effect.
D. “I‟ll fold the dressing with the soiled surface facing outward.”
-incorrect: The client should remove the dressing by folding the soiled surfaces inward to prevent
the transfer of microorganisms to the client‟s hands and other surfaces.397. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
A. Encourage the child to cough frequently to clear congestion from anesthesia
-incorrect: The child should be discouraged from coughing or clearing the throat following a
tonsillectomy because these actions can contribute to bleeding.
B. Place a heating pad on the client‟s neck for comfort
-incorrect: The nurse should offer an ice collar, not a heating pad, to ease the child‟s pain.
C. Administer analgesics to the child on a routine schedule throughout the day and night
-To soothe the client‟s throat following a tonsillectomy, the nurse should administer pain
medication routinely. The nurse can provide the medication rectally or intravenously to avoid the
oral route.
D. Provide the child with ice cream when oral intake is initiated
-incorrect: Milk products, such as ice cream and pudding, are usually avoided because they coat
the mouth and throat, causing the child to clear the throat and potentially leading to bleeding. Ice
chips and ice pops are usually the first items offered following a tonsillectomy.
398. A nurse is collecting a urine specimen for culture and sensitivity for a client who has a
urinary tract infection. The client has an indwelling urinary catheter in place. Which of the
following actions should the nurse take?
A. Withdraw the specimen from the drainage bag
-incorrect: The nurse should use a fresh specimen obtained near the indwelling urinary catheter
to prevent contamination.
B. Cleanse the collection port with soap and water
-incorrect: The nurse should cleanse the collection port with an antimicrobial swab to prevent
contamination.
C. Place the specimen in a clean specimen cup
-incorrect: The nurse should place the specimen in a sterile specimen cup to prevent
contamination.
D. Clamp the tubing below the collection port
-The nurse should clamp the tubing below the collection port to allow fresh, uncontaminated
urine to collect before withdrawing the specimen through the port and placing it in a sterile cup.
399. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank
pain, and the nurse notes reddish-brown urine in the client‟s urinary catheter bag. The nurse
recognizes these manifestations as which of the following types of transfusion reactions?
A. Hemolytic
-A hemolytic reaction occurs when the client‟s blood is incompatible with the donor‟s blood.
Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion
reaction.
B. Febrile
-incorrect: A febrile reaction occurs when the client‟s blood is sensitive to the WBCs and
platelets in the donor‟s blood. Fevers, chills, headaches, and flushing are indications of a febrile
reaction.
C. Circulatory overload-incorrect: Circulatory overload occurs when blood is administered too quickly for the client‟s
circulatory system to handle. Dyspnea, coughing, headaches, and hypertension are indications of
circulatory overload.
D. Sepsis
-incorrect: Sepsis occurs when the blood is contaminated with bacteria. High fevers, vomiting,
and diarrhea are indications of sepsis.
400. A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The
parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How
many teaspoons should the nurse instruct the parent to give the child? (Nearest whole number).
-2 teaspoons
401. A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the
following actions should the nurse take?
A. Apply a cold pack to the edematous area
-incorrect: The nurse should avoid applying a cold pack to an area that displays edema because it
can further decrease adequate circulation and prevent absorption of the edema.
B. Check capillary refill before applying an ice pack to the affected area
-The nurse should check the affected area for adequate circulation by assessing pulses and
capillary refill because a cold pack applied to an area of impaired circulation can further decrease
the blood supply to the area.
C. Half-fill an ice pack with crushed ice
-incorrect: The nurse should fill an ice pack two-thirds full of crushed ice to mold around the
affected area.
D. Apply an ice pack for 60 min intervals
-incorrect: The nurse should apply an ice pack for 30-minute intervals to anesthetize and prevent
further swelling of the affected area.
402. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client
who is scheduled for emergency surgery for appendicitis. Which of the following statements
indicates a lack of readiness to learn by the client?
A. The client asks the nurse to repeat the instructions before attempting the exercises
-incorrect: By asking the nurse to repeat the instructions, the client is demonstrating a readiness
to learn the activity, even though he might not understand the mechanics of performing the
exercises.
B. The client reports severe pain
-A client who is experiencing severe pain is not able to concentrate and is not ready to learn a
new activity.
C. The client asks the nurse how often deep breathing should be done after surgery
-incorrect: Asking about the frequency of the activity indicates a readiness to learn, as the client
is motivated to perform the exercises and wants to know how often to do them.
D. The client tells the nurse that this exercise will probably be painful after surgery
-incorrect: This indicates a readiness to learn because the client is able to think about the possible
effects of the exercise following surgery [Show Less]