ATI RN FUNDAMENTALS EXAM PROCTORED

1. A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. A lesion with uniform pigmentation Variations in pigmentation are a possible indication of a skin malignancy. A lesion with uniform pigmentation is not an expected indication of a skin malignancy. b. New appearance of petechiae Petechiae are capillaries that have burst under the skin and appear as small spots on the skin. Although they can be indications of other conditions, petechiae are not an expected indication of a skin malignancy. c. A mole with asymmetrical appearance An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part d. The presence of a papule Papules are solid elevations that are palpable in the skin and are less than 1 cm (0.39 in) in size. They are not an expected indication of a skin malignancy. 2. A nurse is assessing a client who reports pain following physical therapy. Which of the following questions should the nurse as when assessing the quality of the client’s pain? a. “Is your pain constant or intermittent?” Asking the client whether the pain is constant or intermittent determines the onset, duration, and pattern of the pain. b. “What would you rate your pain on a scale of 0 to 10?” Asking the client to rate the pain using the pain scale determines the intensity of the pain. 2 | Page c. “Does the pain radiate?” Asking the client whether the pain radiates determines the pain’s location. d. “Is your pain sharp or dull?” Asking the client whether the pain is sharp or dull, crushing, throbbing, aching, burning, electric- like, or shooting helps determine the quality of the pain. 3. A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? a. Verify the client’s name on their identification bracelet with the medication administration record. The nurse should verify the client’s name on their identification bracelet when administering medication; however, this action is not a part of performing medication reconciliation. b. Call the pharmacy to determine whether the client’s medications are available. The nurse should call the pharmacy if the client’s medications are not available to administer at the appropriate time; however this action is not a part of performing medication reconciliation c. Compare the client’s home medications with the provider’s prescriptions. The nurse should compare the client’s home medications with the provider’s prescriptions when performing medication reconciliation. d. Place the client’s home medication bottles in a secure location. The nurse should place the client's home medications in a secure location to ensure safe handling of prescribed medications; however, this action is not a part of performing medication reconciliation. 4. A nurse is auscultating the anterior chest of a client who was admitted to a medicalsurgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.) a. Crackles 3 | Page Unlike these breath sounds, crackles (also called rales) are discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways. b. Rhonchi Rhonchi are dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions. c. Friction rub Friction rub is a scratching sound that persists throughout the respiratory cycle. d. Normal breath sounds These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration. 5. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? a. Administer the medication with the needle at 45o angle. The nurse should insert the needle at 45o to 90omangle for a subcutaneous injection. b. Administer the medication into the client’s nondominant arm. The nurse should administer enoxaparin into the abdomen, at least 5cm (2 inches) from the umbilicus. c. Pull the client’s skin laterally or downward prior to administration. The Z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection. d. Massage the injection site after the administration. The nurse should not massage the injection following the injection of an anticoagulant due to the risk for bruising. 6. A nurse is using an open irrigation technique to irrigate a client’s indwelling urinary catheter. Which of the following actions should the nurse take? a. Place the client in a side-lying position. b. Instill 15 mL of irrigation fluid into the catheter with each flush. c. Subtract the amount of irrigant used from the client’s urine output. 4 | Page d. Perform the irrigation using a 20-mL syringe. 7. A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nurse use? a. Alginate Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. b. Gauze Moistened gauze promotes healing in stage 4 or unstageable injuries by causing debridement and allowing granulation of the wound bed. c. Transparent Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and sharing. d. Hydrocolloid Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. 8. A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? a. Insert the needle at a 15o angle The nurse should instruct the client to insert the needle at a 45o to 90o angle to administer into the subcutaneous tissue. b. Aspirate for blood return prior to administration The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. c. Administer the medication into the abdomen The nurse should instruct the client to administer the medication into the abdomen at least 5.08cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. d. Massage the site following the injection 5 | Page The nurse should instruct the client not to massage the site because this can cause tissue damage and bruising. 9. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? a. Pad the client’s wrist before applying restraints. The use of restraints without padding can abrade the client’s skin, resulting in client injury. b. Evaluate the client’s circulation every 8hr after application. The nurse should evaluate the client’s circulation, range of motion, vital signs, and overall status every 15 min after the initial application of restraints. c. Remove the restraints every 4hr to evaluate the client’s status. The nurse should remove the restraints at least every 2hr to reposition the client and assess needs for hygiene and toileting. d. Secure the restraint ties to the bed’s side rails. The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury. 10. A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? a. Make sure the client’s room has at least six air exchanges per hour. A protective environment requires at least 12 air exchanges per hour. b. Make sure the client wears mask when outside her room if there is construction in the area. An allogenic stem cell transplant compromises the client’s immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. c. Place the client in a private room that provides negative-pressure airflow. The nurse should place the client in a private room that provides positive-pressure airflow. 6 | Page d. Wear an N95 respirator when giving the client direct care. The nurse should wear an N95 respirator mask when caring for a client who require airborne precautions, not a protective environment. 11. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? a. Use a bed-exit alarm system The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client’s condition places them at risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. b. Raise four side rails while the client is in bed Raising four side rails when the client is in bed is a form of restraint and increases the risk for falls and injury. c. Apply soft wrist restraint Applying one soft wrist restraint is a physical restraint requiring a prescription. Other forms of distraction or interventions to maintain client safety should be attempted for clients who have dementia. d. Dim the lights in the client’s room Dimming the lights in the room for a client who has dementia can reduce visibility and increase the risk of injury. 12. A nurse is preparing to administer 0.9% sodium chloride 750mL IV to infuse over 7 hr. the nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 107 mL/hr 13. A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should