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ATI RN FUNDAMENTALS 2019 EXAM PROCTORED

1. A nurse is performing a skin assessment for a client who expresses concern 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

Variations in pigmentation are a possible indication of a skin malignancy. A lesion

with uniform pigmentation is not an expected indication of a skin malignancy.

b. New appearance of petechiae

Petechiae are capillaries that have burst under the skin and appear as small spots on

the skin. Although they can be indications of other conditions, petechiae are not an

expected indication of a skin malignancy.

c. A mole with asymmetrical appearance

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

d. The presence of a papule

Papules are solid elevations that are palpable in the skin and are less than 1 cm (0.39

in) in size. They are not an expected indication of a skin malignancy.

2. A nurse is assessing a client who reports pain following physical therapy. Which of

the following questions should the nurse as when assessing the quality of the

client’s pain?

a. “Is your pain constant or intermittent?”

Asking the client whether the pain is constant or intermittent determines the onset,

duration, and pattern of the pain.

b. “What would you rate your pain on a scale of 0 to 10?”

Asking the client to rate the pain using the pain scale determines the intensity of the

pain.

c. “Does the pain radiate?”

Asking the client whether the pain radiates determines the pain’s location.

d. “Is your pain sharp or dull?”

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Asking the client whether the pain is sharp or dull, crushing, throbbing, aching,

burning, electric- like, or shooting helps determine the quality of the pain.

3. A nurse is admitting a new client. Which of the following actions should the nurse

take while performing medication reconciliation?

a. Verify the client’s name on their identification bracelet with the

medication administration record.

The nurse should verify the client’s name on their identification bracelet when

administering medication; however, this action is not a part of performing medication

reconciliation.

b. Call the pharmacy to determine whether the client’s medications are

available. The nurse should call the pharmacy if the client’s medications are not

available to administer at the appropriate time; however this action is not a part of

performing medication reconciliation

c. Compare the client’s home medications with the provider’s

prescriptions. The nurse should compare the client’s home medications with the

provider’s prescriptions when performing medication reconciliation.

d. Place the client’s home medication bottles in a secure location.

The nurse should place the client's home medications in a secure location to ensure

safe handling of prescribed medications; however, this action is not a part of

performing medication reconciliation.

4. A nurse is auscultating the anterior chest of a client who was admitted to a medicalsurgical unit. Listen to the audio clip of what the nurse auscultates through the

stethoscope and identify the type of breath sounds. (Click on the audio button to

listen to the clip.)

a. Crackles

Unlike these breath sounds, crackles (also called rales) are discontinuous sounds

heard primarily during inhalation and resulting from air bubbling through fluid or

mucus in the airways.

b. Rhonchi

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Rhonchi are dry, low-pitched, snore-like noises produced in the throat or bronchial

tube due to a partial obstruction, such as by secretions.

c. Friction rub

Friction rub is a scratching sound that persists throughout the respiratory cycle.

d. Normal breath sounds

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.

5. 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 45o

angle.

The nurse should insert the needle at 45o to 90omangle for a subcutaneous injection.

b. Administer the medication into the client’s nondominant arm.

The nurse should administer enoxaparin into the abdomen, at least 5cm (2 inches)

from the umbilicus.

c. Pull the client’s skin laterally or downward prior to administration.

The Z-track technique involves displacing the skin laterally or downward prior to

administration of an IM injection.

d. Massage the injection site after the administration.

The nurse should not massage the injection following the injection of an

anticoagulant due to the risk for bruising.

6. 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 15 mL 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.

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7. A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury.

Which of the following types of dressing should the nurse use?

a. Alginate

Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage.

Alginate forms a soft gel when it comes in contact with drainage.

b. Gauze

Moistened gauze promotes healing in stage 4 or unstageable injuries by causing

debridement and allowing granulation of the wound bed.

c. Transparent

Transparent dressings promote healing in stage 1 pressure injuries by preventing

further friction and sharing.

d. Hydrocolloid

Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a

moist wound bed.

8. 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 15o

angle

The nurse should instruct the client to insert the needle at a 45o

to 90o

angle to

administer into the subcutaneous tissue.

b. Aspirate for blood return prior to administration

The nurse should instruct the client not to aspirate for blood return because this can

cause tissue damage and bruising.

c. Administer the medication into the abdomen

The nurse should instruct the client to administer the medication into the abdomen at

least 5.08cm (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.

d. Massage the site following the injection

The nurse should instruct the client not to massage the site because this can cause

tissue damage and bruising.

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