ATI Proctored Test Prep
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
"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 sound does a heart murmur make?
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.
What sound does a pericardial friction rub make?
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.
What sound does a third heart sound make?
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.
Serous exudate
Clear, watery drainage
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
Exert pressure on the bony prominences when holding the eyelids open The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.
What is the order of an abdominal assessment?
Inspect, Auscultate, Percuss, Palpate
Where should you listen for Pulmonic valve?
Left 2nd Intercostal space
Where should you listen for Erb's Point?
Left 3rd Intercostal space
Where should you listen for Mitral valve?
Left 5th intercostal space, medial to midclavicular line
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?
Lower abdomen The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.
Where should you listen for Tricuspid valve?
Lower left sternal border 4th intercostal
A nurse is obtaining blood pressure in a 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 place the bladder of the cuff when measuring a lower extremity blood pressure.
Where should you listen for Aortic valve?
Right 2nd Intercostal space
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 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.
Serosanguineous exudate
pale, red, watery: mixture of serous and sanguineous
Purulent exudate
thick, yellow, green, tan, or brown
What is secondary prevention?
trying to detect a disease early and prevent it from getting worse. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.
What is tertiary prevention?
trying to improve your quality of life and reduce the symptoms of a disease you already have.
What is primary prevention?
trying to prevent yourself from getting a disease.
Sanguineous exudate
Bright red; indicates active bleeding
