ATI Fundamentals Proctored Exam with Rationales

ATI Fundamentals Proctored Exam with Rationales | LATEST 2020/ 2021 1. A nurse is caring for a client who has bilateral cats on her hands. Which of the following actions should the nurse take when assisting the c ...

ATI Fundamentals Proctored Exam with Rationales | LATEST 2020/ 2021 1. A nurse is caring for a client who has bilateral cats on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A. Sit at the bedside when feeding the client -The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse’s full attention during the feeding B. Order pureed foods -incorrect: Without any mouth or throat injuries that make chewing or swallowing difficult, the client should be served foods of an appropriate variety of textures. Pureed foods are for clients who cannot chew, have difficulty swallowing, or do not have teeth. C. Make sure feedings are provided at room temperature -incorrect: The nurse should ask the client if the food is the correct temperature D. Offer the client a drink of fluid after every bite -incorrect: If the client is unable to communicate, the nurse should offer the client fluids after every 3 or 4 mouthfuls. However, there is no indication that this client is unable to communicate. Therefore, the client should tell the nurse when she would like a drink. 2. A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid -incorrect: The nurse can use the deltoid muscle for injecting small volumes of medication for children 18 months of age or older, but its proximity to several nerves and arteries make it a riskier choice. B. Ventrogluteal -incorrect: This is a safe site for IM injections for clients older than 7 months. C. Vastus lateralis -The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children. D. Dorsogluteal -incorrect: This site is unsafe to use because of its proximity to the sciatic nerve and the superior gluteal nerve and artery. 3. A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system -incorrect: The nurse should apply a fecal collection system to divert the feces away from the area of skin irritation; however, there is another action the nurse should take first. B. Apply a barrier cream -incorrect: The nurse should apply a barrier cream to decrease skin breakdown in the perianal area from the feces; however, there is another action the nurse should take first. C. Cleanse and dry the area -incorrect: The nurse should cleanse and dry the perianal area to decrease skin irritation; however, there is another action the nurse should take first. D. Check the client’s perineum -The nurse should apply the nursing process priority-setting framework to plan care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client’s status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation. 4. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site -incorrect: Redness at the infusion site is an indication of phlebitis or infection. B. Edema at the infusion site -Edema due to fluid entering subcutaneous tissue is an indication of infiltration. C. Warmth at the infusion site -incorrect: Warmth at the infusion site is an indication of phlebitis or infection. D. Oozing of blood at the infusion site -incorrect: Oozing of blood at the infusion site is an indication that the IV system is not intact. 5. A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine -Caffeine is a stimulant. The nurse should suggest that the client avoid caffeinated beverages. B. Take a sleep medication regularly at bedtime -incorrect: Sleep-promoting medication is a last resort. The nurse should not suggest this type of medication for the client before recommending other nonpharmacological interventions. C. Watch television for 30 minutes in bed to relax prior to falling asleep -incorrect: Clients should associate going to bed with sleep. Therefore, the client should not get into bed until she is sleepy. D. Advise the client to take several naps during the day -incorrect: Napping in the daytime can prevent sound sleep at night 6. A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A. Eggs -incorrect: this is a complete protein, contains all of the essential amino acids necessary for the synthesis of protein in the body. B. Soybeans -incorrect: this is a complete protein, contains all of the essential amino acids necessary for the synthesis of protein in the body. C. Lentils