ATI Proctored -- Fundamentals

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. (Move the sequence of steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Inspection Palpation Percussion Auscultation

1. Inspection 2. Auscultation 3. Percussion 4. Palpation

A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? A. "I should expect my heart rate to take longer to return to normal after exercise as I get older." B. "Urinary incontinence is something I will have to live with as I grow older." C. "I can expect to have less ear wax as I get older." D. "My stomach will empty more quickly after meals as I grow older."

A. "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 increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands I will dry them from the elbows down."

A. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? A. Attempt to increase the clients' self-motivation. B. Keep detailed records of each client's progress. C. Test client learning after each teaching session. D. Avoid discussing areas that might cause client anxiety.

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

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher. B. Instruct the client to raise his arms above his head. C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. D. Log roll the client.

A. Lock the wheels on the bed and stretcher. The nurse should ask the client to cross his arms across his chest to prevent injuring the arms during the transfer. The stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed. Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery.

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

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

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness to the nurse. B. Encourage the client to express his thoughts about death and dying. C. Tell the client that religious beliefs are a personal matter. D. Offer to contact the client's minister or the facility's chaplain.

B. Encourage the client to express his thoughts about death and dying.

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for the tracheostomy care B. Obtaining cotton balls for the tracheostomy care C. Obtaining sterile gloves for the tracheostomy care D. Obtaining a sterile brush for the tracheostomy care

B. Obtaining cotton balls for the tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carefully remove the gloves and follow with hand hygiene. D. Ask the provider to order a blood culture to determine the risk of infection.

C. Carefully remove the gloves and follow with hand hygiene.

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assistance. B. Begin chest compressions. C. Confirm unresponsiveness. D. Give rescue breaths.

C. Confirm unresponsiveness.

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A. Place the client supine. B. Keep both side rails up. C. Raise the level of the bed. D. Inspect the client's mouth using a finger sweep.

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

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? A. Tie the restraints to the side rails. B. Perform range-of-motion exercises to the wrists every 3 hr. C. Remove the restraints one at a time. D. Obtain a PRN prescription for the restraints.

C. Remove the restraints one at a time. The nurse should remove one restraint at a time for a client who is violent or noncompliant. The nurse should ensure that the restraints are removed and range-of-motion exercises are performed every 2 hr.

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 C (102.6 F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. Heart rate 105/min B. Soft, nontender abdomen C. Temperature D. Overdue menses

C. Temperature Elevated temperature is an emergent physiological need, which requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the situation.

A nurse on a medical-surgical unit is washing her hands prior to assessing with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? A. The nurse washes each part of her hands with 5 strokes. B. The nurse washes from the elbows down to the hands. C. The nurse washes with her hands held higher than her elbows. D. The nurse uses minimal friction when washing her hands.

C. 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.

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? A. "Ask your provider to prescribe epoetin before the surgery." B. "You should ask your provider about taking iron supplements prior to the surgery." C. "Request a family member to donate blood for you." D. "Donate autologous blood before the surgery."

D. "Donate autologous blood before the surgery." A blood donation from a family member does not eliminate the risk of acquiring an infection.

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? A. "It's for your safety. Dentures can slip and block your airway during surgery." B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires everyone to remove their dentures." D. "What worries you about being without your teeth?"

D. "What worries you about being without your teeth?"

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only blood pressure readings needed for the 15-min intervals. C. Obtain manual and automatic readings and compare them. D. Disconnect the machine, and measure the blood pressure manually every 15 min.

D. Disconnect the machine, and measure the blood pressure manually every 15 min. 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.

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? A. Explain the x-ray procedure B. Help the client into a wheelchair before the transporter arrives C. Ask if the client has any questions D. Identify the client using two identifiers

D. Identify the client using two identifiers The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Once the client's identity is determined, the nurse can then proceed with the other options. This action is the priority action because it provides for the safety of the client. It is a nursing responsibility to be certain that each client receives only what has been prescribed. The nurse must assure that the correct client is being transported for a chest x-ray.

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation. D. Notify the provider about the client's decision.

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

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A. Auscultate for the blood pressure at the dorsalis pedis artery. B. Measure the blood pressure with the client sitting on the side of the bed. C. Place the cuff 7.6 cm (3 in) above the popliteal artery. D. Place the bladder of the cuff over the posterior aspect of the thigh.

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

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? A. Rectal B. Tympanic C. Oral D. Temporal

D. Temporal The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair. The rectal route is very accurate for obtaining body temperature in young children; however, it should not be used for clients who have diarrhea.

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? A. The client fully understands the provider's explanation of the procedure. B. The client has been informed about the risks and benefits of the procedure. C. The nurse witnessed the provider's explanation of the procedure. D. The signature on the preoperative consent form is the client's.

D. The signature on the preoperative consent form is the client's. 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.