ATI PN Fundamentals Exam Form B | Questions and Answers with Rationales | Latest 2020 / 2021

1.      A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box in order of performance)

A.    -Place a towel under the client's head with an emesis basin under their chin.

B.     -Assess the client's gag reflex.

C.     -Cleanse the client's mouth using a toothbrush.

D.    -Separate the client's upper and lower teeth with an oral airway device.

E.     -Position the client on their side with their head turned to the side. 

ANS: B,E,A,D,C

 Rationale:

1- Assess the client's gag reflex. (The nurse should first assess the client's gag reflex to determine risk for aspiration)

2- Position the client on their side with their head turned to the side. (Turning the client on their side allows secretions to drain from the mouth).

3- -Place a towel under the client's head with an emesis basin under their chin.(Using a towel and emesis basin helps protect bed linens).

4- Separate the client's upper and lower teeth with an oral airway device. (An oral airway device allows safe access to the client's mouth).

5- Cleanse the client's mouth using a toothbrush (Finally, the client's mouth can be cleansed with a toothbrush or swabs).

2.      A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

A.    Measure the client's gastric residual before each feeding.

B.     Change the bag and tubing every 24 hours.

C.     Document intake and output.

D.    Flush the tubing with 30 mL of water after each feeding.    

Rationale: When using the nursing process, the first action the nurse should take is assessment. Therefore, obtaining gastric residual volume is the priority action for the nurse to take).

3.      A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

A.    Sit beside the client.

B.     Speak slowly and loudly.

C.     Dim the lights in the client's room.

D.    Choose a private room for the interview.

Rationale: The nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying).

4.      A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which the following entities?

A.    An insurance agency offering a life insurance policy.

B.     A family member who requests the client's diagnosis.

C.     A physical therapist who is involved in the client's care.

D.     An employer completing a pre-employment screening.

Rationale: According to HIPPA guidelines, a nurse is allowed to disclose personal health information to members of the health care team involved in the client's care).

5.      A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent film dressing should the nurse include?

A.    "This dressing keeps the wound bed dry."

B.     "This dressing allows the wound bed to breathe."

C.     "This dressing requires a secondary dressing."

D.    This dressing requires paper tape to secure." 

Rationale: A transparent dressing is applied to allow oxygen to pass through the dressing. This is referred to as "breathing" and promotes healing of the wound.)

6.      A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

A.    Fluid Overload

B.     Diarrhea

C.    Headache

D.    Difficulty voiding      

Rationale: The nurse should identify that a headache can be an adverse effect following a lumbar puncture. To minimize the client's discomfort, the nurse should administer analgesics, other fluids, and maintain the client in a dorsal recumbent position for the length of time prescribed by the provider).

7.      A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?

A.    Four-point

B.     Three-point

C.     Two-point

D.    Swing-through           

Rationale: The nurse should identify that the client needs to be able to bear weight on the unaffected leg; therefore, a three-point gait provides at least two points of support at all times.

8.      A nurse assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

A.    Heart rate 89/min.

B.     Pink mucous membranes.

C.    Pallor with scaly skin.

D.    Body mass index 23.  

Rationale: The nurse should identify that pallor along with scaly skin can indicate malnutrition. The skin should be smooth and have the same hue as other areas of sun-exposed skin in clients who are well-nourished).

9.      A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy.

A.    Eggs.

B.     Latex.

C.     Seafood.

D.    Bee stings.      

Rationale: Nurses use products containing latex, including gloves, tourniquets, and IV tubing to deliver IV therapy. Clients who have an allergic reaction to latex can have a wide range of manifestations, such as itching and hives or a more serious reaction, such as dyspnea or laryngospasm).

10.  A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

A.    Clean the perineal area at least once a day.

B.     Empty the drainage bag when it is three-fourths full.

C.     Flush the catheter with sterile water daily.

D.    Disconnect the drainage bag when emptying and measuring urine. 

Rationale: The nurse should clean the perineal area at least once a day to reduce the risk for infection).

11.  A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following?

A.    Complicated grief.

B.     Maturational loss.

C.     Disenfranchised grief.

D.     Actual loss.

Rationale: The nurse should identify that the client's comments indicate an actual loss, which is a loss that occurs when the person can no longer feel, see, hear or know an object, another person, or a part of themselves, such as the loss of a body part).

12.  A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 ib. How many kilograms does the child weigh? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)           

Answer: 13.6 kg.

Rationale: (This is because 1kg converts to 2.2 ibs. you take

1kg/2.2ibs * 30 ibs/1

or just 30/2.2 and you get 13.6 kg)

13.  A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

A.    "It must be difficult facing this type of surgery."

B.     "Other clients who have had this surgery have done just fine."

C.     "This facility is known for providing excellent care for people who need this type of surgery."

D.    "I can request a sleeping pill, if you think that will help."    

Rationale: Stating that it must be difficult to be in this position is an open-ended and non-judgmental statement that allows the client to talk about their fears).

14.  A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

A.    Client is itching from medication.

B.     Client states, "I started to itch after taking that medication."

C.     It appears that the client has a rash from the medication.

D.    Rash from medication noted.

Rationale: The nurse should document information using an objective description, putting the client's exact words in quotation marks).