ATI - Fundamentals Practice Quiz 1

A nurse is caring for a patient who is post-op with paralytic ileus. Which abdominal assessment is expected?

Absent bowel sounds with distention Paralytic ileus is an immobile bowel. With this disorder, bowl sounds are absent and the abdomen is disinteded

Which instruction should be followed for a child who is post-op following a tonsillectomy?

Administer analgesics to the child on a routine schedule throughout the day To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route

A nurse is planning weight-loss strategies for a group of obese clients. Which of the following actions by the nurse will improve the clients' commitment to long-term weight loss?

Attempt to increase clients' self-motivation Motivation to learn is important in improving a client's commitment to achievement of health goal, as well as increasing the amount and speed of learning

Nurse is inserting IV catheter for client that results in blood spill on her gloved hand. Client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene Standard precautions require the use of gloves and hand hygiene in the care of all clients

Nurse is demonstrating post-op deep breathing and cough exercises to client who will have emergency surgery for appendicitis. Which client statement indicates lack of readiness to learn?

Client reports severe pain A client who is experiencing severe pain is not able to concentrate and therefore is not ready to learn a new activity

Which of the following actions of a newly licensed nurse performing tracheostomy care would require intervention by the charge nurse (must be corrected)?

Cotton balls- can be aspirated into tracheostomy opening Cotton ball particles can be aspirated into the tracheotomy opening, possibly causing tracheal abscess. The charge nurse should intervene for this action

A nurse notices an irregularity in the pulse when measuring patient's vital signs. Which action should the nurse take?

Count the apical pulse rate for 1 full minute, describe the rhythm in the chart. If the peripheral pulse is irregular, the nurse should auscultate the apical pusle for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record

A nurse on a medical surgical unit is admitting a client. Which of the following should the nurse document in the client's record first?

Data collection for the client The nurse should apply the nursing process and can use it to plan patient care and prioritize nursing actions

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes using an electronic BP machine. The nurse notices the machine begins to measure BP at varied intervals and readings are inconsistent. which action should the nurse take?

Disconnect the machine, measure the BP manually every 15 minutes If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed

Following a procedure that will happen next month, a client may require a blood transfusion. The client expresses concern to the nurse that they may acquire infection from it. Which response is appropriate from the nurse?

Donate autologous blood before surgery Autologous blood transfusion is the collection and reinfusion of the client's own blood. Blood is drawn from client 3-5 weeks before the surgical procedure and stored for transfusion at the time of surgery

A nurse is caring for a client who has a terminal illness. The client asks several questions regarding the nurse's religious beliefs related to death and dying. How should the nurse respond?

Encourage the client to express his thoughts about death and dying. The nurse should recognize the client's needs to talk about impending death and should encourage the client to discuss his thoughts on the subject. It is a therapeutic technique of reflecting.

An ED nurse is assessing a client who reports diarrhea and decreased urination for 4 days. Which action should the nurse take to assess for skin turgor- results from dehydration?

Grasp a skin fold on chest under clavicle, release, not whether tenting occurs. The nurse should use this technique for collecting data on skin turgor. If the client has good turgar and is properly hydrated, the skin will immediately return to normal. With dehydration, the skin will remain tented

A nurse in oncology clinic is assessing pt. undergoing treatment for ovarian cancer. Which statement indicates she is undergoing psychological distress?

I keep having nightmares about my upcoming surgery The nurse should recognize that nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate that the client is at risk for experiencing psychological distress

Nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which action should the nurse take FIRST?

Identify the client using 2 identifiers

Correct order of abdominal assessment of adult client

Inspection, auscultation, percussion, palpation The sequence prevents altering the bowel sounds and causing false results. The appropriate sequence for any other data collection for an adult client is inspection, palpation, percussion, and auscultation

A nurse is receiving client from PACU who is post-op following abdominal surgery. Which action should nurse take to transfer client from stretcher to bed?

Lock wheels of bed and stretcher Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client

A nurse is prepping a client who is scheduled for a hysterectomy for transport to OR when the client states she no longer wants to have surgery. Which action should nurse take?

Notify provider about client's decision Acting as the client advocate, the nurse should support the client in her decision and notify the provider

Nurse on a med-surg unit is washing her hands prior to assisting in a surgical procedure. Which action indicates proper surgical handwashing?

Nurse washes with hands held higher than elbows The nurse who is performing a surgical hand-washing technique should wash with their hands help higher than the elbows so that the water and soapsuds can drain away from the clean area toward the dirty area

Which action should nurse take first when using nursing process to care for a new client?

Obtain client information The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process build on the previous step, beginning with data collection.

Nurse is preparing to provide tracheostomy care for patient. Which action should nurse take first?

Perform hand hygiene The nurse should first perform hand hygiene before touching the client or performing any skill such as a tracheostomy care. It is important because contamination of the nurse's hands is primary source of infection

Nurse is obtaining BP in client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh This is the correct position for the nurse to the place the bladder of the cuff when measuring a lower extremity blood pressure

Nurse on rehab unit is preparing to transfer a client who is unable to ambulate from bed to wheelchair. Which technique should nurse use?

Place wheelchair at 45 degree angle to bed Positioning the wheelchair at a 45 degree angle allows the client to pivot, lessening the amounts of rotation required

A nurse is performing mouth care for unresponsive client. Which action should nurse plan to take? Place client supine Keep both side rails up Raise level of bed Inspect client's mouth using finger sweep

Raise level of bed The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury

The provider prescribes soft wrist restraints for an older adult client who is violent and attempting to pull out IV lines. Which action is appropriate for client in restraints?

Remove the restraints one at a time The nurse should remove one restraint at a time for a client that is violent or noncompliant

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur r/t aortic valve stenosis. At which of the following anatomical areas should the nurse use stethoscope to auscultate aortic valve?

Second intercostal space to the right of the sternum to the right of the sternum The aortic valve is located in the second inter-coastal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection that can be heard clearly at the aortic area with the client leaning forward

A nurse is providing teaching to a client who has heart failure about how to reduce his sodium intake. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits

Nurse observes another staff member using a regular size BP cuff for a client who is obese. Which explanation should she give?

Using cuff that is too small results in inaccurately high reading Blood pressure cuffs come in various sizes and the correct cuff is necessary to obtain a reliable measurement. BP readings can be falsey high if the cuff is too small for the client

A nurse is caring for an an older adult client who becomes agitated when the nurse requests that the dentures must be removed prior to surgery. Which response should the nurse make?

What worries you about being without your teeth? This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason for it

Nurse is obtaining vitals for a 2-year old child who is experiencing diarrhea and may have right ear infection. Which route should be used to measure temperature?

Temporal It is non invasive and can be used to obtain a temp in a toddler who may have a ear infection and who is having diarrhea

A nurse is witnessing a client sign an informed consent form for surgery. What describes what the nurse is affirming this action?

The signature on the pre-op consent form is the client's The nurse acts as a witness to attest that it is the client's signature on the pre-op consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits

A nurse is teaching an assistive personnel about proper hand hygiene. Which statement from AP indicates understanding?

"There are times I should use soap and water instead of alcohol-based sanitizer" While alcohol-based hand rubs are as effective as soap and water, the CDC recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or bodily fluids

A community health nurse is preparing a campaign about seasonal influenza. Which plan should nurse include as secondary prevention?

Screening groups of older adults in skilled nursing facilities for early signs of influenza Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness of providing care to prevent illness from becoming severe

A nurse is caring for a client who has T1DM and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

Tell me what I can do to help you overcome your fear of giving yourself injections. This response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and support the client in learning how to give the injections

Teaching for an older adult who has constipation should include which of the following recommendations?

Sit on toilet 30 minutes after eating a meal Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation

A nurse is teaching CPR to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness The nurse should prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Establishing unresponsiveness is required before beginning CPR

A nurse is admitting a client with decreased circulation in left leg. Which action should nurse take first?

Evaluate pedal pulses For a client that has decreased evaluating pedal pulses is critical in order to determine adequate blood supply in the foot. The nurse should apply the safety and risk reduction priority setting framework when caring for this client. The nurse should use the Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risks poses the greatest threat to the client

A nurse is teaching a group of older adults about suspected changes of aging. Which statement by a group member indicates effective teaching?

I should expect my heart rate to take longer to return to normal after exercise as I get older Older adults experience decreased cardiac output, which causes increase pusle rate during exercise. However, the pusle rate also takes longer to return to normal after exercise

The nurse auscultates a high-pitched scratching sound during diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub A pericardial friction rub has a scratching, grating, or squeaking leathery sound. It tends to be high frequency and best heard with the diaphragm of the stethoscope at the 3rd intercostal space of the left sternal border. It can be heard with infective pericarditis, myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems. Clients who develop percarditis typically have chest pain which can become worse with inspiration or coughing and could be helped by sitting up and leaning forward

A nurse is caring for a client who is in the terminal stage of cancer. Which action should the nurse take when she observes the client crying?

Sit and hold client's hand With this action, the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client

A nurse is planning care for a client with abdominal pain. An assessment reveals temperature of 102.6 F, HR 105, soft-non-tender abdomen, menses overdue by 2 days. Which of the following findings should be the priority?

Temperature Elevated temp is an emergent physiological need which requires priority intervention by the nurse. The nurse should consider Maslow's Hiearchy of needs which first is the physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and lastly achieving full potential and the ability to problem solve and cope with life situations