ATI Fundamentals Nursing- Ch. 12, 13, 14, 15

Question 1

12-1. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.)

A. Place a belt restraint on the client when they are sitting on the bedside commode.
B. Keep the bed in its lowest position with all side rails up.
C. Make sure that the client’s call light is within reach.
D. Provide the client with nonskid footwear.
E. Complete a fall-risk assessment.

Answer 1

C. Make sure that the client’s call light is within reach.
D. Provide the client with nonskid footwear.
E. Complete a fall-risk assessment.

Question 2

12-2. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority?

A. Complete a fall-risk assessment.
B. Educate the client and family about fall risks.
C. Eliminate safety hazards from the client’s environment.
D. Make sure the client uses assistive aids in their possession.

Answer 2

A. Complete a fall-risk assessment.

Question 3

12-3. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?

A. “I will place the client on their side.”
B. “I will go to the nurses’ station for assistance.”
C. “I will note the time that the seizure begins.”
D. “I will prepare to insert an airway.”

Answer 3

B. “I will go to the nurses’ station for assistance.”

Question 4

12-4. A nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurse’s priority?

A. Extinguish the fire.
B. Activate the fire alarm.
C. Move clients who are nearby.
D. Close all open doors on the unit.

Answer 4

C. Move clients who are nearby.

Question 5

13-1. A nurse is providing information about how to reduce the risk of poisoning in infants and toddlers to a group of guardians. What information should the nurse include?

Question 6

13-2. A nurse educator is providing education on infant safety to a group of guardians. Which of the following statements by a guardian indicates an understanding of the teaching?
A. “I should line the crib with bumper pads.”
B. “I will make sure the crib slats are no more than 3 inches apart.”
C. “I should place the baby on their back when sleeping.”
D. “I should place the baby in a vehicle safety seat facing forward in the back seat of the car.”

Answer 6

C. “I should place the baby on their back when sleeping.”

Question 7

13-3. A home health nurse is educating a new home health aide about home safety for the older adult.
What information should the nurse include?

Question 8

13-4. A nurse is performing a primary survey for a client who has a lite-threating condition. In which order should the nurse perform the assessment?
A. Check the client’s level of consciousness
B. Check the client’s airway
C. Check the client’s exposure to adverse elements.
D. Check the client’s ventilation
E. Check the client’s circulation

Answer 8

B. Check the client’s airway
D. Check the client’s ventilation
E. Check the client’s circulation
A. Check the client’s level of consciousness
C. Check the client’s exposure to adverse elements.

Question 9

13-5. A home health nurse is assessing a client who experienced extreme exposure to heat and has a body temperature of 40°C (104°F). The nurse should anticipate that the client will display which of the following manifestations?

A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea

Answer 9

A. Hypotension

Question 10

14-1. A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.)

A. “My line of gravity should fall outside my base of support.”
B. “The lower my center of gravity, the more stability I have.”
C. “To broaden my base of support, l should spread my feet apart.”
D. “When I lift an object, I should hold it as close to my body as possible.”
E. “When pulling an object, I should move my front foot forward.”

Answer 10

B. “The lower my center of gravity, the more stability I have.”
C. “To broaden my base of support, l should spread my feet apart.”
D. “When I lift an object, I should hold it as close to my body as possible.”

Question 11

14-2. A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse’s priority at this time?

A. Obtain a walker for the client to use to transfer back to bed.
B. Call for additional staff to assist with the transfer.
C. Use a transfer belt and assist the client back into bed.
D. Determine the client’s ability to help with the transfer.

Answer 11

D. Determine the client’s ability to help with the transfer.

Question 12

14-3. A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.)

A. Request assistance when repositioning a client.
B. Avoid twisting your spine or bending at the waist.
C. Keep your knees slightly lower than your hips when sitting for long periods of time.
D. Use smooth movements when lifting and moving clients.
E. Take a break from repetitive movements every 2 to 3-hr to flex and stretch your joints and muscles.

Answer 12

A. Request assistance when repositioning a client.
B. Avoid twisting your spine or bending at the waist.
D. Use smooth movements when lifting and moving clients.

Question 13

14-4. A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client?

A. Supine
B. Semi-Fowler’s
C. Lateral Semi-prone Recumbent
D. Trendelenburg

Answer 13

B. Semi-Fowler’s

Question 14

14-5. A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath.
Which of the following statements should the nurse make?

A. “Lie on your back with your head and shoulders supported by a pillow.”
B. “Have your head turned to the side while you lie on your stomach.”
C. “Have a table beside your bed so you can sit on the bedside and rest your arms on the table.”
D. “Lie on your side with your top arm resting on the bed and your weight on your hip.”

Answer 14

C. “Have a table beside your bed so you can sit on the bedside and rest your arms on the table.”

Question 15

15-1. A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse’s priority?

A. A client who has partial-thickness and full-thickness burns to the face, neck and chest.
B. A client who received crush injuries to the chest and abdomen and is expected to die
C. A client who has a 4-inch laceration to the head
D. A client who has a fractured fibula and tibia

Answer 15

A. A client who has partial-thickness and full-thickness burns to the face, neck and chest.

Question 16

15-2. A nurse notes a fire in a trash can in a client’s room. In what order should the nurse take action?

A. Pull the fire alarm.
B. Use the fire extinguisher.
C. Help the client and others leave the area.
D. Close doors.

Answer 16

C. Help the client and others leave the area.
A. Pull the fire alarm.
D. Close doors.
B. Use the fire extinguisher.

Question 17

15-3. A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (Select all that apply.)

A. Open doors to client rooms.
B. Place blankets over clients who are confined to beds.
C. Move beds away from windows.
D. Draw shades and close drapes.
E. Instruct ambulatory clients in the hallways to return to their rooms.

Answer 17

B. Place blankets over clients who are confined to beds.
C. Move beds away from windows.
D. Draw shades and close drapes.

Question 18

15-4. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?

A. Irrigate the affected area with running water.
B. Wash the affected area with antibacterial soap.
C. Brush the chemical off the skin and clothing.
D. Leave the clothing in place until emergency personnel arrive.

Answer 18

C. Brush the chemical off the skin and clothing.

Question 19

15-5. A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.)

A. A client who is dehydrated and receiving IV fluid and electrolytes
B. A client who has a nasogastric tube to treat a small bowel obstruction
C. A client who is scheduled for elective surgery
D. A client who has chronic hypertension and blood pressure 135/85 mm Hg
E. A client who has acute appendicitis and is scheduled for an appendectomy

Answer 19

C. A client who is scheduled for elective surgery
D. A client who has chronic hypertension and blood pressure 135/85 mm Hg

Question 20

15-6. A nurse educator is reviewing actions to take in the event of a bomb threat by phone to a group of new nurses. Which of the following statements by a nurse indicates understanding?

A. “I will get the caller off the phone as soon as possible so I can alert the staff.”
B. “I will begin evacuating clients using the elevators.”
C. “I will not ask any questions and just let the caller talk.”
D. “I will listen for background noises.”

Answer 20

D. “I will listen for background noises.”