ATI PN FUNDAMENTAL PROCTORED NEWEST
2024 TEST BANK 270 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED
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A nurse is assisting with the admission of a client who
has active tuberculosis. Which of the following actions
should the nurse plan to take?
A. Restrict the client's visitors to the immediate family.
B. Assign the client to a negative-pressure airflow
room.
C. Discard personal protective equipment outside the
client's room.
D. Have the client wear a HEPA mask during
transportation throughout the facility. - ...ANSWER...B.
Assign the client to a negative-pressure airflow room.
RATIONALE: The nurse should assign the client to a
negative-pressure airflow room to ensure that the air
from the client's room is not circulated throughout the
facility.
A nurse is assisting with the plan of care for a client
who has a bacterial infection and a persistent oral
temperature of 38.9° C (102° F). Which of the following
interventions should the nurse include in the plan of
care to treat the fever?
A. Administer acetaminophen.
B. Apply ice packs to the client's axillae.
C. Maintain the room temperature at 18.3° C (64.9° F).
D. Assist the client to ambulate four times a day. -
...ANSWER...A. Administer acetaminophen.
RATIONALE: The nurse should administer
acetaminophen or an NSAID such as ibuprofen to the
client to reduce the body's temperature. Acetaminophen
inhibits the synthesis of prostaglandins, resulting in a
reduced fever.
A nurse is contributing to the plan of care for a client
who has a positive throat culture for streptococci.
Which of the following interventions should the nurse
recommend to be included in the plan of care?
A. Place the client in a room with another client who
has pharyngitis.
B. Ensure that the client wears a surgical mask during
transportation throughout the facility.
C. Limit the client's visitors to visitations of 30 min.
D. Provide the client a room with negative-pressure
airflow of six air exchanges per hour. - ...ANSWER...B.
Ensure that the client wears a surgical mask during
transportation throughout the facility.
RATIONALE: Streptococcal pharyngitis requires droplet
precautions. The nurse should instruct the client to
wear a surgical mask when outside of the room to
prevent the spread of infection. Staff should make
every attempt to limit the client's movement outside of
the room.
A nurse is planning care for a client who is disoriented
and at risk for falls. Which of the following
interventions should the nurse include? (Select all that
apply.)
A. Ensure that the client is wearing nonskid slippers.
B. Move the bedside table away from the bedside.
C. Place the client in a room near the nurses' station.
D. Keep the bed's full side rails in the up position.
E. Reinforce teaching about how to use the call bell. -
...ANSWER...A. Ensure that the client is wearing nonskid
slippers.
Nonskid slippers provide better traction and can help
prevent slipping and falling.
C. Place the client in a room near the nurses' station.
Keeping the client close to the nurses' station allows
for more frequent observation to help identify actions
that increase the risk for falls.
E. Reinforce teaching about how to use the call bell.
Even if the client is confused, it is important to reinforce
the use of the call bell for assistance to help prevent
the client from attempting actions that could increase
the risk for falls.
A nurse is contributing to a plan of care for a client who
has a new prescription for a wrist restraint. Which of
the following actions should the nurse include in the
plan?
A. Check that the restraint is tied to a fixed frame of the
bed.
B. Pad bony prominences on the wrist.
C. Remove the restraint every 4 hr to allow movement.
D. Tie the restraint with a knot that will tighten when
pulled. - ...ANSWER...B. Pad bony prominences on the
wrist.
RATIONALE: The nurse should pad bony prominences
on the wrist to prevent skin breakdown caused by the
restraint rubbing against the client's skin.
A nurse is reinforcing teaching with a client who has a
partial hearing loss about how to modify the home
environment. Which of the following is a priority
modification that the nurse should include?
A. Alarm clock that shakes the bed
B. Flashing smoke alarm
C. Low-pitched buzzer doorbell
D. Telephone with an amplified receiver - ...ANSWER...B.
Flashing smoke alarm
RATIONALE: The greatest risk to the client's safety is
injury from a fire. Therefore, the priority modification is
to install flashing smoke alarms because this allows
the client to see when the alarm is activated rather
than having to hear it.
A nurse is caring for four clients who are required to
provide informed consent for treatment. The nurse
should identify that which of the following clients is
able to provide informed consent?
A. A client who is receiving opioid medications via a
PCA pump
B. A client who has moderate Alzheimer's disease
C. An 18-year-old client who has acute appendicitis
D. A 16-year-old client who has a fractured tibia -
...ANSWER...C. An 18-year-old client who has acute
appendicitis
RATIONALE: A competent 18-year-old client who has
acute appendicitis is able to provide informed consent
for treatment.
A nurse is reviewing the medical record of a client who
has heart failure. The nurse should identify which of the
following laboratory results as an indication that the
client has fluid volume excess?
A. Urine specific gravity 1.015
B. Hematocrit 42%
C. Urine pH 6.5
D. BUN 8 mg/dL - ...ANSWER...D. BUN 8 mg/dL
RATIONALE: A BUN of 8 mg/dL is below the expected
reference range of 10 to 20 mg/dL. With fluid volume
excess, the nurse should expect the client's BUN to be
below the expected reference range due to
hemodilution.
A nurse is moving a client up in bed with the assistance
of a second nurse. Which of the following actions
should the nurse take?
A. Stand facing the center of the bed at the client's side.
B. Place feet apart with the foot nearest the head of the
client's bed in front of the other foot.
C. Keep knees and hips straight while bending at the
waist toward the client.
D. Encourage the client to keep their legs straight and
remain still. - ...ANSWER...B. Place feet apart with the
foot nearest the head of the client's bed in front of the
other foot.
RATIONALE: Placing the feet apart provides a wide base
of support, which improves balance. Additionally, a
forward-backward stance enables the nurse to shift
their weight as the client moves up in bed.
A nurse is reinforcing teaching about the use of
crutches with a client who has a fractured right tibia
and fibula. Which of the following statements by the
client indicates an understanding of the teaching?
A. "I will be sure to keep the crutch tips dry."
B. "I will hold a crutch in each hand when sitting down."
C. "I will place my weight on my underarms."
D. "I will lead with my right leg when going up stairs." -
...ANSWER...A. "I will be sure to keep the crutch tips
dry."
The nurse should instruct the client to inspect the
crutch tips frequently and keep them dry at all times to
decrease the risk for slipping.
A charge nurse smells smoke, enters the visitor
restroom, and sees flames in the trash can. What is the
sequence of actions that the nurse should take? (Move
the steps into the box on the right, placing them in the
selected order of performance. Use all the steps.)
A. Close the fire doors on the unit.
B. Use a fire extinguisher to put out the fire.
C. Evacuate clients from the area.
D. Pull the lever on the fire alarm box. - ...ANSWER...C.
Evacuate clients from the area.
The first action the nurse should take when using the
RACE protocol is to "rescue" or evacuate the clients
from the area to prevent harm.
D. Pull the lever on the fire alarm box.
For the next step, "alarm," the nurse should activate the
facility fire alarm and call to report the fire to the
facility emergency extension.
A. Close the fire doors on the unit.
For the third step, "confine," the nurse should close the
unit fire doors to prevent the fire from spreading.
B. Use a fire extinguisher to put out the fire.
For the final step, "extinguish," the nurse should use a
fire extinguisher to put out the fire by aiming the nozzle
at the base of the fire and using a sweeping motion.
A nurse is calculating the intake and output for a client
over the last 8 hr. The client is receiving a continuous IV
infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of
water. How many mL of fluid should the nurse
document as the client's intake for the last 8 hr? (Round
your answer to the nearest whole number.)
mL - ...ANSWER...1820 mL
A nurse is caring for a client who has a prescription for
a potassium supplement. The client tells the nurse that
the pill is too large to swallow and refuses to take it.
The nurse offers to break the pill into two smaller
pieces. The nurse is demonstrating which of the
following ethical principles?
A. Autonomy
B. Beneficence
C. Justice
D. Nonmaleficence - ...ANSWER...B. Beneficence
The nurse is demonstrating beneficence by acting in the
client's best interest to make it possible for the client to
swallow the medication.
A charge nurse is reinforcing teaching with an assistive
personnel (AP) about performing pulse oximetry. Which
of the following information should the nurse include in
the teaching?
A. Select an alternate site to place the oximetry probe if
the capillary refill is less than 2 seconds.
B. Use an adhesive oximetry probe for a client who has
a latex allergy.
C. Remove polish from the client's fingernail before
applying the oximetry probe.
D. Lubricate the tip of the oximetry probe. -
...ANSWER...C. Remove polish from the client's
fingernail before applying the oximetry probe.
The nurse should instruct the AP to remove the client's
fingernail polish on at least one finger before placing
the probe on that finger because the sensor needs to
detect a pulsating vascular bed to produce a reading.
A nurse is reinforcing dietary teaching with a client who
has chronic kidney disease and requires a lowpotassium diet. Which of the following food choices by
the client demonstrates an understanding of the
teaching?
A. 1 cup of cantaloupe
B. 1 large baked potato
C. 4 oz of banana chips
D. 1 cup of applesauce - ...ANSWER...D. 1 cup of
applesauce
The nurse should determine that applesauce is the best
food choice because 1 cup of applesauce contains 184
mg of potassium per serving. Therefore, the client's
food choice of applesauce demonstrates an
understanding of the teaching.
A nurse is preparing to administer oxygen to a client
who has heart failure and is having severe difficulty
breathing. Which of the following oxygen delivery
equipment should the nurse select to provide the
highest concentration of oxygen to the client?
A. Nasal cannula
B. Simple face mask
C. Venturi mask
D. Nonrebreather mask - ...ANSWER...D. Nonrebreather
mask
A nonrebreather mask provides the highest percentage
of oxygen concentration without intubation and
mechanical ventilation.
A nurse is assisting with a presentation to a group of
older adults at a community center about hypothermia
and hyperthermia. Which of the following information
should the nurse include about age-related changes?
A. Body regulation of heat and cold increases with age.
B. Circulation becomes less efficient with age.
C. Increased metabolic rate occurs with age, increasing
body temperature.
D. Sweat gland activity is increased with age. -
...ANSWER...B. Circulation becomes less efficient with [Show Less]