ATI Fundamental RN 2016A

 Qwivy | Qwivy.com | www.qwivy.com

1. A nurse in a clinic is caring for a middle adult client who states, "The doctor says that,

since I am at an average risk for colon cancer, I should have a routine screening. What

does that involve?" Which of the following responses should the nurse make?

A. "I'll get a blood sample from you and send it for a screening test."

B. "Beginning at age 600, you should have a colonoscopy."

C. "You should have a fecal occult blood test every year."

D. "The recommendation is to have a sigmoidoscopy every 10 years."

Blood tests do not detect colorectal cancer.

Colorectal cancer screening for clients at average risk begins at age 50. One option for

screening is a colonoscopy every 10 years. Another option for screening is a flexible

sigmoidoscopy every 5 years.

2. A nurse is caring for a client who is having difficulty breathing. The client is lying in

bed with a nasal cannula delivering oxygen. Which of the following interventions

should the nurse take first?

A. Suction the client's airway

B. Administer a bronchodilator

C. Increase the humidity in the client's room

D. Assist the client to an upright position

 Qwivy | Qwivy.com | www.qwivy.com

R: When providing client care, the nurse should first use the least invasive

intervention. Therefore, the nurse should elevate the head of the client's bed to the

semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting

upright improves gas exchange and prevents pressure on the diaphragm from

abdominal organs.

Increase the humidity in the client's room. 

R: The nurse might have to increase the humidity in the client's room to thin secretions

that can limit airflow; however, the nurse should use a less invasive intervention first.

Administer a bronchodilator.

R: The nurse might have to administer a bronchodilator to open the client's airway and

facilitate breathing; however, the nurse should use a less invasive intervention first.

Suction the client's airway.

R: The nurse might have to remove pulmonary secretions to ease the client's

breathing; however, the nurse should use a less invasive intervention first.

3. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a

client. Which of the following actions should the nurse take?

A. Gently shake the container of medication prior to administration

B. Transfer the medication to a medicine cup

C. Place the client in a semi-Fowler's position prior to medication administration

D. Verify the dosage by measuring the liquid before administration

R: The nurse should gently shake the liquid medication to ensure the medication is

mixed.

 Qwivy | Qwivy.com | www.qwivy.com

Transfer the medication to a medicine cup.

R: The nurse should not transfer prepackaged liquid medication to a medicine cup to

reduce the risk of altering the premeasured dose.

Place the client in a semi-Fowler's position prior to medication administration.

R: The nurse should place the client in a high-Fowler's position when administering an

oral liquid medication to reduce the risk of aspiration.

Verify the dosage by measuring the liquid before administering it.

R: The nurse should not transfer prepackaged liquid medication to a measuring device

to reduce the risk of altering the premeasured dose. 

4. A nurse is planning care to improve self-feeding for a client who has vision loss.

Which of the following interventions should the nurse include in the plan of care?

A. Tell the client which food should eat first.

B. Provide small-handle utensils for the client.

C. Thicken liquids on the client's tray

D. Use a clock pattern to describe food on the client's plate

R: Describing the location of the food on the plate by using a clock pattern allows the

client to have greater independence during meals.

Thicken liquids on the client's tray.

R: Clients who have dysphagia, not vision loss, require thickening of liquids to facilitate

swallowing without choking.

Provide small-handle utensils for the client.

R: Large-handle adaptive utensils are easier for the client to grip and allow for greater

independence during meals for clients who have vision loss.

Tell the client which food she should eat first.

R: The nurse should allow the client to decide for herself the order in which she

consumes food.

 Qwivy | Qwivy.com | www.qwivy.com

5. A nurse is teaching an older adult client who is at risk for osteoporosis about

beginning a program of regular physical activity. Which of the following types of

activity should the nurse recommend?

A. Walking briskly

B. Riding a bicycle

C. Performing isometric exercises

D. Engaging in high-impact aerobics

R: Weight-bearing exercises are essential for maintaining bone mass, which helps to

prevent osteoporosis. Walking engages older adult clients in this preventive and

therapeutic strategy. 

Riding a bicycle.

R. Cycling has no weight-bearing advantages; therefore, it does not help prevent

osteoporosis.

Performing isometric exercises

R. Isometric exercises have no weight-bearing advantages; therefore, they do not help

prevent osteoporosis.

Engaging in high-impact aerobics.

 Qwivy | Qwivy.com | www.qwivy.com

R. High-impact aerobics can injure bones that have lost density; therefore, the nurse

should not recommend these exercises for the client who is at risk for developing

osteoporosis.

6. A nurse is assessing a client's readiness to learn about insulin administration. Which

of the following statements should the nurse identify as an indication that the client is

ready to learn?

A. "I can concentrate best in the morning."

B. "It is difficult to read the instructions because my glasses are at home."

C. "I'm wondering why I need to learn this."

D. "You will have to talk to my wife about this."

R. The client's statement indicates a readiness to learn because he is verbalizing the

best time for him to learn.

"It is difficult to read the instructions because my glasses are at home."

R. The client's statement indicates the client is not ready to learn. He has to have the

tools he needs to learn and comprehend the information.

"I'm wondering why I need to learn this."

 Qwivy | Qwivy.com | www.qwivy.com

R. The client's statement indicates a reluctance to learn information he thinks he might

not need to know.

"You will have to talk to my wife about this."

R. With this statement, the client is redirecting the nurse's attempt to teach toward

someone else, indicating that he is not ready to learn. 

7. A nurse is giving discharge instructions to a client who will require oxygen therapy at

home. Which of the following statements should the nurse identify as an indication

that the client understands how to manage this therapy at home?

A. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from

my oxygen.

B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen.

C. "I'll check the wires and cables on my TV to make sure they are in good

working order.

D. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they

don't knock it over.

R. Oxygen is a highly flammable gas. The client should make sure any electrical

equipment in the room where she is using supplemental oxygen is functioning properly

so it does not create any electrical sparks.

 Qwivy | Qwivy.com | www.qwivy.com

"I'll make sure that, when my friend comes by, she smokes at least 6 feet away from

my oxygen tank."

R. Oxygen is a highly flammable gas. The client's visitors should smoke outside the

house.

"I'll use a woolen blanket if I get chilly while I'm using my oxygen."

R. Oxygen is a highly flammable gas. Woolen and synthetic materials can create

sparks, so the client should use a cotton blanket during supplemental oxygen therapy.

"I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't

knock it over."

R. The client should keep her oxygen tank upright and secure in its holder at all times.

8. A nurse is caring for a client who is reporting difficulty falling asleep. Which of the

following measures should the nurse recommend?

A. Drink a cup of hot cocoa before bedtime

B. Exercise 1 hr before going to bed

C. Use progressive relaxation techniques at bedtime

D. Reflect on the day's activities before going to bed

 Qwivy | Qwivy.com | www.qwivy.com