TEST BANK FOR RN ATI FUNDAMENTALS ALL

TEST BANK FOR RN ATI FUNDAMENTALS (ALL

CHAPTERS 1- 58 WITH QUESTIONS AND

ANSWERS)/FUNDAMENTALS OF NURSING 10TH

EDITION (10.0) ATI, CONTENT MASTERY SERIES

REVIEW MODULE

Question 1 A nurse is providing care to a client who is at risk for falls. Which of the following actions should the nurse take first?

• Place a fall-risk identification band on the client.
• Complete a fall-risk assessment.
• Implement fall prevention interventions.
• Educate the client and family about fall risks.

Answer: B. Complete a fall-risk assessment.

Rationale: The first step in preventing falls is to identify those at risk. A comprehensive fall-risk assessment allows the nurse to determine the specific interventions needed for the client.

Question 2 A nurse is teaching a group of new nursing assistants about the use of gait belts. Which of the following instructions should the nurse include?

• Place the gait belt over the client's clothing.
• Fasten the gait belt around the client's chest.
• Use the gait belt only when transferring clients from bed to chair.
• Remove the gait belt during ambulation to promote independence.

Answer: A. Place the gait belt over the client's clothing. 1 / 4

Rationale: Gait belts should be placed over the client's clothing to ensure comfort and safety.Placing it around the waist, not the chest, provides proper support during transfers and ambulation.

Question 3 A nurse is caring for a client with a nasogastric (NG) tube for decompression. Which of the following actions should the nurse take?

• Check the tube placement every 24 hours.
• Flush the tube with 20 mL of air every 4 hours.
• Secure the tube to the client's gown.
• Maintain the head of the bed at 30 degrees.

Answer: D. Maintain the head of the bed at 30 degrees.

Rationale: Keeping the head of the bed elevated at 30 degrees helps prevent aspiration and promotes effective decompression.

Question 4 A nurse is administering a cleansing enema to a client. Which of the following actions should the nurse take?

• Position the client on their right side.
• Insert the enema tube 8 inches into the rectum.
• Hold the enema container 18 inches above the anus.
• Administer the solution at a temperature of 105°F (40.5°C).

Answer: C. Hold the enema container 18 inches above the anus.

Rationale: Holding the enema container 18 inches above the anus ensures a proper flow of solution without causing discomfort or injury to the client.

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Question 5 A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

• Inflate the catheter balloon with 5 mL of sterile water before insertion.
• Cleanse the urethral meatus using an antiseptic solution.
• Apply sterile gloves before opening the catheter kit.
• Position the client in a semi-Fowler's position.

Answer: B. Cleanse the urethral meatus using an antiseptic solution.

Rationale: Cleansing the urethral meatus with an antiseptic solution reduces the risk of introducing pathogens into the urinary tract during catheter insertion.

Question 6 A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?

• Soak feet in warm water daily.
• Trim toenails straight across.
• Apply lotion between the toes.
• Walk barefoot to increase circulation.

Answer: B. Trim toenails straight across.

Rationale: Trimming toenails straight across helps prevent ingrown toenails, which can lead to infection, especially in clients with diabetes.

Question 7 A nurse is planning care for a client who requires bilateral wrist restraints. Which of the following interventions should the nurse include?

• Remove the restraints every 4 hours. 3 / 4

• Tie the restraints to the side rails of the bed.
• Perform range-of-motion exercises.
• Assess the client's skin integrity every 2 hours.

Answer: D. Assess the client's skin integrity every 2 hours.

Rationale: Regularly assessing skin integrity helps prevent complications such as pressure ulcers and circulation issues in clients with restraints.

Question 8 A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy. Which of the following instructions should the nurse include?

• Keep the oxygen tank at least 5 feet away from heat sources.
• Increase the oxygen flow rate if shortness of breath occurs.
• Smoke only in a well-ventilated area.
• Use wool blankets and clothing to avoid static electricity.

Answer: A. Keep the oxygen tank at least 5 feet away from heat sources.

Rationale: Oxygen tanks should be kept away from heat sources to prevent fires. Increasing the oxygen flow rate and smoking near oxygen are dangerous, and wool can cause static electricity.

Question 9 A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to prevent deep vein thrombosis (DVT)?

• Encourage the client to perform leg exercises every hour.
• Massage the client's legs to promote circulation.
• Keep the client's legs elevated above heart level.
• Apply warm compresses to the client's legs.

Answer: A. Encourage the client to perform leg exercises every hour.

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