ATI Fundamentals

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 Place the client supine. To prevent the risk of aspiration, the nurse should raise the client's head to 30° or turn the client to a side-lying position. Raise the level of the bed. MY ANSWER The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury. Keep both side rails up. To prevent straining and the risk of self-injury, the nurse should lower the near side rail before performing mouth care. Inspect the client's mouth using a finger sweep. To prevent the risk of care-giver injury, the nurse should never insert fingers into the mouth of an unresponsive client.

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 signature on the preoperative consent form is the client's. MY ANSWER 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. The client has been informed about the risks and benefits of the procedure. It is the responsibility of the provider who will perform the procedure to inform the client about the risks and benefits and to obtain consent. The nurse witnessed the provider's explanation of the procedure. It is not necessary for the nurse to witness the provider's explanation of the procedure. The client fully understands the provider's explanation of the procedure. It is the responsibility of the provider who will perform the procedure to ensure that the client understands the explanation of the procedure.

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. The involvement of the client in planning the change B. The emphasis the provider places on the dietary changes C. The learning theory the nurse uses to teach the dietary changes D. The extent of the dietary changes planned for the client

A. The involvement of the client in planning the change The extent of the dietary changes planned for the client The extent of the changes planned can influence the client's ability to learn new dietary habits; however, it is not the most important factor. The involvement of the client in planning the change MY ANSWER 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. The emphasis the provider places on the dietary changes The emphasis the provider places on the dietary changes can influence the client's ability to learn new dietary habits; however, it is not the most important factor. The learning theory the nurse uses to teach the dietary changes The learning theory the nurse uses to teach dietary changes can influence the client's ability to learn new dietary habits; however, it is not the most important factor.

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 Obtaining hydrogen peroxide for the tracheostomy care Half-strength peroxide solution is used to clean the inner cannula. Obtaining cotton balls for the tracheostomy care MY ANSWER Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action. Obtaining sterile gloves for the tracheostomy care Tracheostomy care is a sterile procedure requiring the use of sterile gloves. Obtaining a sterile brush for the tracheostomy care Pipe cleaners, or a small sterile brush, can be used to remove thick or crusty secretions from the inner cannula.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia. B. Place a heating pad at the child's neck for comfort. C. Administer analgesics to the child on a routine schedule throughout the day and night. D. Provide the child with ice cream when oral intake is initiated.

C. Administer analgesics to the child on a routine schedule throughout the day and night.

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 Confirm unresponsiveness. MY ANSWER 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. Give rescue breaths. The nurse should give rescue breaths. However, there is another action the nurse should take first. Begin chest compressions. The nurse should begin chest compressions. However, there is another action the nurse should take first. Call for assistance. The nurse should call for assistance by activating the emergency response team. However, there is another action the nurse should take first.

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 to the client. 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 Identify the client using two identifiers. MY ANSWER 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. Explain the x-ray procedure to the client. The nurse should explain the x-ray procedure to the client. However, there is another action the nurse should take first. Ask if the client has any questions. The nurse should inquire if the client has any questions about the procedure. However, there is another action the nurse should take first. Help the client into a wheelchair before the transporter arrives. The nurse should have the client ready for the procedure. However, there is another action the nurse should take first.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Don sterile gloves. D. Perform hand hygiene.

D. Perform hand hygiene

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible click B. Murmur C. Third heart sound D. Pericardial friction rub

D. Pericardial friction rub Pericardial friction rub MY ANSWER 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. Audible click An audible clicking sound occurs in clients who have prosthetic valve replacement surgery. 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. 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.

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 (3in) 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 Measure the blood pressure with the client sitting on the side of the bed. The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed. Auscultate for the blood pressure at the dorsalis pedis artery. The nurse should auscultate for the blood pressure at the popliteal artery. Place the cuff 7.6 cm (3 in) above the popliteal artery. The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery. Place the bladder of the cuff over the posterior aspect of the thigh. MY ANSWER This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.