ATI Practice Test - Learning System Fundamentals 2

Question 1

ATI Practice Test - Learning System Fundamentals 2

A client’s provider has ordered that a sputum specimen be collected for culture and sensitivity. The nurse plans to collect his specimen

A. after the client has taken an expectorant.
B. in the evening, after forcing fluids all day.
C. after antibiotics have been started.
D. in the morning, on arising.

Answer 1

D. in the morning, on arising.

Question 2

ATI Practice Test - Learning System Fundamentals 2

A nurse is informed during change-of-shift report that a client who is postoperative has not voided for 8 hr. The appropriate initial nursing action is to

A. assist the client to the bathroom.
B. place a bedpan under the client and pour warm water over the perineum.
C. palpate and percuss the client’s bladder.
D. catherize the client.

Answer 2

C. palpate and percuss the client’s bladder.

Rationale:
Remember the various stages of the nursing process (data collection, intervention, evaluation). Rely on the nursing process to determine what to do. Data collection comes first followed by planning, intervention, and evaluation.

Question 3

ATI Practice Test - Learning System Fundamentals 2

When assisting an older adult client with dysphagia at mealtime, the nurse should

A. encourage the client to drink plenty of fluids.
B. offer the client tart and sour foods.
C. have the client tilt head back when swallowing.
D. turn on the television at mealtimes.

Answer 3

B. offer the client tart and sour foods.

Rationale:
Tart and sour foods stimulate saliva production, which helps with chewing and swallowing.

Question 4

ATI Practice Test - Learning System Fundamentals 2

A client admitted for evaluation and control of hypertension. Several hours after the client’s admission, the nurse discovers teh client supine on the floor, unresponsive to verbal or painful stimuli. The nurse’s first action at this time should be to

A. establish an airway
B. collect neurological data from the client.
C. administer oxygen.
D. elevate the client’s head to 45º.

Answer 4

A. establish an airway

Question 5

ATI Practice Test - Learning System Fundamentals 2

A client has just been transferred from the postanesthesia care unit following abdominal surgery. To prevent atelectasis, which measure does the nurse plan to include in the client’s care?

A. Administer 40% oxygen via humidified face mask.
B. Have the client use the incentive spirometer q1 to 2 hr while awake.
C. Restrict fluids while the intravenous line remains in place.
D. Maintain patency of the nasogastric tube until bowel sounds return.

Answer 5

B. Have the client use the incentive spirometer q1 to 2 hr while awake.

Question 6

ATI Practice Test - Learning System Fundamentals 2

A client is admitted to the hospital for evaluation of inadequate circulation to the lower extremities. The provider prescribes a tub bath at the client’s request. While assisting the client with the bath, the nurse would put the client at risk with which of the following actions?

A. Filling the tub about one third full
B. Asking if the water is the right temperature when the client steps into the tub
C. Closing the door to the tub room and telling the client to use the call light for assistance when needed.
D. Checking the skin for signs of breakdown either before or after the client bathes.

Answer 6

B. Asking if the water is the right temperature when the client steps into the tub

Question 7

ATI Practice Test - Learning System Fundamentals 2

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as

A. purulent.
B. serous.
C. serosanguineous.
D. sanguineous.

Answer 7

A. purulent.

Question 8

ATI Practice Test - Learning System Fundamentals 2

A client who reports shortness of breath requests the nurse’s help in changing position. In addition to repositioning the client, the nurse should give highest priority

A. giving the client a back rub to help her relax.
B. notifying the charge nurse that the client is short of breath.
C. putting the client on 15-min checks.
D. observing the rate, depth, and character of the client’s respirations.

Answer 8

D. observing the rate, depth, and character of the client’s respirations.

Question 9

ATI Practice Test - Learning System Fundamentals 2

A nurse is caring for a client who is 2 postoperative following had abdominal surgery. The nurse is concerned about which of the following findings?

A. Shallow respirations 20/min
B. A urinary drainage bag with 100 mL of straw-colored urine
C. A blood pressure reading of 98/66
D. A wound dressing with thick, light green drainage

Answer 9

D. A wound dressing with thick, light green drainage

Question 10

ATI Practice Test - Learning System Fundamentals 2

A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse

A. refrigerates the collects specimen.
B. transfers the specimen to a sterile container.
C. instructs the client to defecate into a bedpan.
D. sends only the bloody and mucoid portions of the stool.

Answer 10

A. refrigerates the collects specimen.

Question 11

ATI Practice Test - Learning System Fundamentals 2

A client is in the bathroom. The nurse hears a loud thud, and after opening the bathroom door, sees the client lying on the floor. The nurse’s first reaction should be to

A. call for help.
B. determine unresponsiveness.
C. see if the client is breathing.
D. open the client’s airway.

Answer 11

B. determine unresponsiveness.

Question 12

ATI Practice Test - Learning System Fundamentals 2

A client admitted to a long-term care facility requires total care. In providing mouth care for the client, the appropriate nursing action is to

A. place the client on his back with a pillow under his head.
B. use a thumb and index finger to keep the client’s mouth open.
C. clean the client’s teeth with a stiff toothbrush.
D. turn the client on his side before starting mouth care.

Answer 12

D. turn the client on his side before starting mouth care.

Question 13

ATI Practice Test - Learning System Fundamentals 2

A provider prescribes a cleansing enema for a client having bowel surgery. Which of the following nursing interventions is appropriate during this procedure?

A. Place the solution bag 3 feet above the client.
B. Wear sterile gloves to insert the tubing.
C. Lubricate the anus prior to insertion.
D. Position the client on his left lateral side.

Answer 13

D. Position the client on his left lateral side.

Question 14

ATI Practice Test - Learning System Fundamentals 2

A nurse caring for preoperative client administers atropine as prescribed to

A. decrease oral and respiratory secretions.
B. reduce the risk of deep vein thrombosis postoperatively.
C. increase gastric pH and promote gastric emptying.
D. induce sedation and relieve anxiety.

Answer 14

A. decrease oral and respiratory secretions.

Question 15

ATI Practice Test - Learning System Fundamentals 2

When obtaining a urine specimen and culture and sensitivity from an indwelling catheter, the nurse should:

A. cleanse the entry port prior to withdrawing urine.
B. wear sterile gloves.
C. collect the specimen from the urometer port.
D. drain the bag and wait for a fresh urine sample to collect from the drainage bag.

Answer 15

A. cleanse the entry port prior to withdrawing urine.

Question 16

ATI Practice Test - Learning System Fundamentals 2

Following an accidental fall while playing volleyball, a client is sent home in a lower leg cast due to a hairline fracture of the tibia and must use crutches. When reinforcing teaching about the four-point gain, the nurse explains that the client should

A. keep his elbows extended.
B. be able to bear weight on both legs.
C. support the majority of his weight in the axillae.
D. hold the affected extremity up off the ground.

Answer 16

B. be able to bear weight on both legs.

Question 17

ATI Practice Test - Learning System Fundamentals 2

A client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by a secondary intention. When changing the client’s dressing, which observation should the nurse report to the charge nurse?

A. A halo of erythema on the surrounding skin
B. Pink, shiny tissue with a granular appearance
C. Seriosanguineous drainage
D. Tenderness when touched

Answer 17

A. A halo of erythema on the surrounding skin

Rationale:
This is an indication of infection.

Question 18

ATI Practice Test - Learning System Fundamentals 2

A client newly diagnosed with diabetes mellitus is admitted to the hospital. When obtaining a urine specimen from the client, the nurse should avoid

A. putting the empty urine specimen cup in the client’s bathroom.
B. placing the full specimen cup in a clean plastic bag on arrival at the laboratory pickup area.
C. attaching a label with the client’s identification to the specimen cup.
D. explaining to the client the procedure for obtaining the urine specimen.

Answer 18

B. placing the full specimen cup in a clean plastic bag on arrival at the laboratory pickup area.

Question 19

ATI Practice Test - Learning System Fundamentals 2

A client who has pancreatic cancer will be using patient-controlled analgesia (PCA) with morphine sulfate (Roxanol) to manage chronic pain. Which of the following instructions should the nurse reinforce with the client and family?

A. “Remember to press the button hen you begin to sense pain.”
B. “A nurse will check your blood pressure frequently to watch for an allergic reaction.”
C. “Your family should press the button for your if you’re sleeping so that you don’t miss a dose.
D. “The PCA is programmed to deliver a small doses of morphine q30 min.”

Answer 19

A. “Remember to press the button hen you begin to sense pain.”

Question 20

ATI Practice Test - Learning System Fundamentals 2

A client has just had an indwelling urinary catheter inserted. If the nurse took all of the following actions, he used improper technique when he

A. inserted the catheter an additional 1 to 2 inches after observing urine in the drainage tubing.
B. placed the client in the dorsal recumbent position with knees bent and legs apart.
C. cleansed the client’s urinary meatus with soap and water prior to inserting the catheter.
D. used sterile 0.9% sodium chloride to inflate the catheter’s retention balloon.

Answer 20

C. cleansed the client’s urinary meatus with soap and water prior to inserting the catheter.

Question 21

ATI Practice Test - Learning System Fundamentals 2

A nurse is caring for a client who is paralyzed on the right side following a cerebrovascular accident (CVA). When preparing to give a bed bath to the client, the nurse

A. put the bed in low semi-Fowler’s position.
B. adjust the bed to the lowest position.
C. raise the bed to the high horizontal position.
D. unplug the bed.

Answer 21

C. raise the bed to the high horizontal position.

Question 22

ATI Practice Test - Learning System Fundamentals 2

A nurse is caring for a client who is 1-day postoperative following abdominal surgery. What is the first action the nurse should take after discovering that the client’s wound has eviscerated?

A. Have the client lie on his back with his knees flexed.
B. Cover the incision with a moist sterile dressing.
C. Ask the charge nurse to notify the client’s surgeon.
D. Measure the client’s vital signs.

Answer 22

B. Cover the incision with a moist sterile dressing.

Question 23

ATI Practice Test - Learning System Fundamentals 2

A client receiving chemotherapy has developed stomatitis. An appropriate lunch selection for this client is

A. cheese omelet, cherry gelatin, milkshake.
B. hot dog on a soft roll, potato chips, orange juice.
C. Haddock, french fries, tomato juice.
D. Chicken Caesar salad, lemon-lime soda.

Answer 23

A. cheese omelet, cherry gelatin, milkshake.

Rationale:
Stomatitis is an inflammation of the mouth.

Question 24

ATI Practice Test - Learning System Fundamentals 2

When reinforcing teaching about colostomy care, the nurse reminds the client to replace the bag.

A. every other day.
B. every 4 to 6 hr.
C. daily.
D. as often as needed.

Answer 24

D. as often as needed.

Question 25

ATI Practice Test - Learning System Fundamentals 2

A client’s postoperative orders include administering a medication the nurse has never heard of. The drug reference available on the nursing unit does not list the medication. The nurse should

A. call the charge nurse and ask her to question the order.
B. give the medication as prescribed by the provider.
C. call the facility’s pharmacy and ask for a package insert.
D. Ask a more senior staff nurse for more information.

Answer 25

C. call the facility’s pharmacy and ask for a package insert.

Question 26

ATI Practice Test - Learning System Fundamentals 2

In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will

A. require skin grafting for the wound to heal.
B. have the wound sutured closed at a later date.
C. be at an increased susceptibility for infection.
D. have well-approximated wound edges.

Answer 26

C. be at an increased susceptibility for infection.

Question 27

ATI Practice Test - Learning System Fundamentals 2

A client awake at 0100 says to the nurse, “The staff is making too much noise, and I haven’t had a decent night’s sleep since my wife died a year ago. Please get me a cup of hot tea to help me relax and quench my thirst.” Which of the following should the nurse do?

A. Get the cup of hot tea the client requested.
B. Close the door to eliminate noise of the hallway.
C. Offer to get a warm glass of milk for the client.
D. Suggest that the client get more exercise during the day.

Answer 27

C. Offer to get a warm glass of milk for the client.

Question 28

ATI Practice Test - Learning System Fundamentals 2

A nurse overseeing an assistive personnel (AP) instructs the AP to include a draw sheet on the occupied bed she is making. THe nurse explains that the purpose of the draw sheet is to

A. absorb urine, feces, and bodily secretions.
B. promote warmth and comfort.
C. give the bed a neat appearance.
D. aid in positioning the client.

Answer 28

D. aid in positioning the client.

Question 29

ATI Practice Test - Learning System Fundamentals 2

An nurse is performing an eye irrigation for a client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation?

A. Cleansing the eyelids prior to the irrigation.
B. Having the client sit upright with her head tilted back.
C. Wearing gloves during the procedure.
D. Asking the client to look at thee ceiling during the irrigation.

Answer 29

C. Wearing gloves during the procedure.

Question 30

ATI Practice Test - Learning System Fundamentals 2

A nurse is observing a client who is postoperative following thoracic surgery. Which of the following manifestations should alert the nurse to the possibility of early hypovolemic shock?

A. Bradycardia
B. Warm, flushed skin
C. Hypertension
D. Tachycardia

Answer 30

D. Tachycardia

Question 31

ATI Practice Test - Learning System Fundamentals 2

A nurse is caring for a client who has just had a mastectomy and has a closed wound-suction device (Hemovac) in place. Which nursing action will ensure proper operation of the device?

A. Emptying the device when it’s full
B. Collapsing the device whenever it is 1/2 to 2/3 full of air
C. Keeping the tubing above the level of the surgical incision
D. Irrigating the tubing with sterile 0.9% sodium chloride q8h

Answer 31

B. Collapsing the device whenever it is 1/2 to 2/3 full of air

Question 32

ATI Practice Test - Learning System Fundamentals 2

An assistive personnel reports that a client’s intravenous (IV) infusion has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client’s infusion line and insertion site?

A. The infusion slows or stops while the tubing is not kinked.
B. The area around the injection site feels warm when touched.
C. Swelling, hardness, or pain located around the insertion site.
D. blood fails to return in the tubing when the bottle lowered.

Answer 32

B. The area around the injection site feels warm when touched.

Question 33

ATI Practice Test - Learning System Fundamentals 2

When reinforcing teaching for a client who has diabetes mellitus, the nurse should first

A. advise the client that bathing regularly is very important.
B. ask which hygienic measures the client is presently using.
C. demonstrate to the client the proper procedure for performing foot care.
D. observe the client giving a return demonstration of cleansing his dentures.

Answer 33

B. ask which hygienic measures the client is presently using.

Question 34

ATI Practice Test - Learning System Fundamentals 2

A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes,what should the nurse use to reduce skin irritation around the incision?

A. Large absorbent pads
B. Silicone spray
C. Hypoallergenic tape
D. Montgomery straps

Answer 34

D. Montgomery straps

Question 35

ATI Practice Test - Learning System Fundamentals 2

A client is recovering from gallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour?

A. Eight to 12
B. One to two
C. Four to five
D. 15 to 20

Answer 35

C. Four to five