Fundamentals 1 ATI

When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of the following assessment prior to beginning chest compressions?

Absence of pulse

When admitting a client, the nurse records which information in the client's record first?

Assessment of the client

A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve their commitment to a long term goal of weight loss?

Attempt to develop the client's self-motivation

A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?

Bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurse's hands under the client's axillae

A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client's blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?

Disconnect the machine, and measure the blood pressure manually every 15 minutes

A nurse's neighbor is scheduled for elective surgery. The neighbor's provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?

Donating autologous blood before the surgery

Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases?

Elimination of the exposure

A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, which is the most important nursing action initially?

Evaluate the pedal pulses

A 3 year old child has had mutliple tooth extractions while under general anesthesia. The client returns from the postanesthesia care crying, but awake, from the recovery room. Which approach is likely to be successful?

Examine the mouth last

A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is a nursing action?

Firmly tell the client not to grab

A nurse tells the client that a provider has prescribed IV fluids. The client appears to be upset about the IV catheter insertion, but says nothing to the nurse. Which of the following is an appropriate nursing response?

Is there something about this procedure that concerns you?

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her." Which is the appropriate nursing response?

It is very upsetting to see an adult client regress

A nurse is caring for a client who requires rectal temperature monitoring. Available at the client's bedside is a thermometer with a long, slinder tip. Which of the following is the appropriate action for the nurse to take?

Obtain a thermometer with a short, blunt insertion end

Which of the following should the nurse do first when preparing to provide tracheostomy care?

Perform hand hygiene

At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the heart valve, the nurse should place the stethoscope at which location?

Second intercostal space to the right of the sternum

A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self care and appropriately adds which of the following statements?

Tell me what I can do to help you overcome your fear of giving yourself injections

A nurse admits a client to a same-day surgery center for an exploritory laparotomy procedure this morning. The client's surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that

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

Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of hand hygiene is the amount of

friction

A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client's skin turgor, the nurse should

grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back

An assistive personnel (AP) tells the nurse, "I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?" The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is

high

A nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor of planning dietary changes for this client is the

involvement of the client in planning the change

To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should

place the bed in a high horizontal position

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client

reports severe pain