ATI practice questions

The nurse should instruct the client to consume a minimum of ____ mL of fluid to prevent constipation

1,000 mL

Murmur

A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. Low- and medium-frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease.

Pericardial friction rub

A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward.

Third heart sound

A third heart sound is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best heard at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates heart failure.

Audible click

An audible clicking sound occurs in clients who have prosthetic valve replacement surgery.

what is the first action requires with CPR?

Confirm unresponsiveness. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with 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, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

How do you assess skin turgor?

Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. The nurse should use this technique for assessing skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; with dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skin fold on the back of the forearm.

"Sit on the 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.

What is the proper position of a blood pressure cuff on a client's lower extremity?

Place the bladder of the cuff over the posterior aspect of the thigh.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Positioning the wheelchair at a 45° allows the client to pivot, lessening the amount of rotation required.

What is an example of second prevention?

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 or providing care to prevent illness from becoming severe.

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

The nurse acts as a witness to attest that it is the client's signature on the preoperative 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.

If the peripheral pulse is irregular, the nurse should auscultate the

apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record.

apex

bottom of heart

apical pulse is

pulse taken with a stethoscope and near the apex of the heart

The aortic valve is located in

the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. which of the following actions by the nurses demonstrates proper surgical hand-washing technique

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

oral temperature should not be used when

The oral route is not appropriate for use with children under the age of 3.