ATI - Fundamentals Practice Quiz 1

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur r/t aortic valve stenosis. At which of the following anatomical areas should the nurse use stethoscope to auscultate aortic valve? 5th IC space just medial to MCL 2nd IC space to L of sternum 5th IC space to L of sternum 2nd IC space to R of sternum

2nd IC space to R of sternum

Nurse is demonstrating post-op deep breathing and cough exercises to client who will have emergency surgery for appendicitis. Which client statement indicates lack of readiness to learn? Client asks for nurse to repeat instructions before attempting exercises client reports severe pain Client asks how often deep breathing should be done post-op Client tells the nurse that this exercise will probably be painful after surgery

Client reports severe pain

Which of the following actions of a newly licensed nurse performing tracheostomy care would require intervention by the charge nurse (must be corrected)? Obtaining hydrogen peroxide for trach care Obtaining cotton balls for trach care Obtaining sterile gloves for trach care Obtaining sterile brush for trach care

Cotton balls- can be aspirated into trach opening

A nurse is prepping a client who is scheduled for a hysterectomy for transport to OR when the client states she no longer wants to have surgery. Which action should nurse take? Tell client it is too late to change her mind before surgery Telephone OR and cancel surgery Inform client's family about situation Notify provider about client's decision

Notify provider about client's decision

A nurse is admitting a client with decreased circulation in left leg. Which action should nurse take first? Evaluate pedal pulses Obtain medical history measure vitals assess for leg pain

evaluate pedal pulses

A nurse is teaching an assistive personnel about proper hand hygiene. Which statement from AP indicates understanding? "There are times I should use soap and water instead of alcohol-based sanitizer" "I will use cold water when I wash my hands to protect my skin from becoming too dry." "I will apply friction for at least 10 seconds while washing my hands." "After washing my hands I will dry them from the elbows down."

"There are times I should use soap and water instead of alcohol-based sanitizer"

A nurse is caring for a patient who is post-op with paralytic ileus. Which abdominal assessment is expected? Frequent bowel sounds with flatus Absent bowel sounds with distention Hyperactive bowel sounds with diarrhea Normal bowel sounds with increased peristalsis

Absent bowel sounds with distention

Which instruction should be followed for a child who is post-op following a tonsillectomy? Encourage frequent coughing to clear congestion from anesthesia. Place a heating pat at child's neck for comfort. Administer analgesics to the child on a routine schedule throughout the day. Provide the child with ice cream when oral intake is initiated.

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

Nurse on a med-surg unit is admitting a client. Which of the following does the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress

Assessment

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

Carefully remove the gloves and follow with hand hygiene

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

Confirm unresponsiveness

A nurse notices an irregularity in the pulse when measuring patient's vital signs. Which action should the nurse take? Measure pulse using Doppler ultrasound stethoscope. Check the client's pedal pulses. Count the apical pulse rate for 1 full minute, describe the rhythm in the chart. Take the pulse at each peripheral site and count the rate for 30 seconds.

Count the apical pulse rate for 1 full minute, describe the rhythm in the chart.

Following a procedure that will happen next month, a client may require a blood transfusion. The client expresses concern to the nurse that they may acquire infection from it. Which response is appropriate from the nurse? Ask provider to order EPO before surgery You should ask provider about iron supplements prior to surgery Request family member to donate blood Donate autologous blood before surgery

Donate autologous blood before surgery

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

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

An ED nurse is assessing a client who reports diarrhea and decreased urination for 4 days. Which action should the nurse take to assess for skin turgor- results from dehydration? Push fingernail bed until it blanches, release, observe how long it takes for it to regain color. Grasp a skin fold on chest under clavicle, release, not whether tenting occurs. Press skin in above ankle for 5 seconds, release, note the depression. Measure skin fold thickness at upper arm using calipers.

Grasp a skin fold on chest under clavicle, release, not whether tenting occurs.

A nurse in oncology clinic is assessing pt. undergoing treatment for ovarian cancer. Which statement indicates she is undergoing psychological distress? My parents are retired and they have to come help me with children I'm going to ask my husband to go to counseling with me. I keep having nightmares about my upcoming surgery My girlfriends bought me a nice wig

I keep having nightmares about my upcoming surgery

Correct order of abdominal assessment of adult client

Inspection, auscultation, percussion, palpation

Nurse on a med-surg unit is washing her hands prior to assisting in a surgical procedure. Which action indicates proper surgical handwashing? Nurse washes each part of her hands with 5 strokes Nurse washes from elbows down to hands Nurse washes with hands held higher than elbows Nurse uses minimal friction when washing her hands

Nurse washes with hands held higher than elbows

Which action should nurse take first when using nursing process to care for a new client? Identify goals for client care Obtain client information Document nursing care needs Evaluate effectiveness of care

Obtain client information

The nurse auscultates a high-pitched scratching sound during diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub

Pericardial friction rub

Nurse is obtaining BP in client's lower extremity. Which of the following actions should the nurse take? Ausculate for BP at dorsalis pedis artery Measure BP with client sitting at edge of bed. Place cuff 3 in above popliteal artery Place the bladder of the cuff over the posterior aspect of the thigh

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

Nurse on rehab unit is preparing to transfer a client who is unable to ambulate from bed to wheelchair. Which technique should nurse use? Stand on client's strong side Instruct client to lean backward from hips Place wheelchair at 45 degree angle to bed Assume narrow stance

Place wheelchair at 45 degree angle to bed

A nurse is performing mouth care for unresponsive client. Which action should nurse plan to take? Place client supine Keep both side rails up Raise level of bed Inspect client's mouth using finger sweep

Raise level of bed

The provider prescribes soft wrist restraints for an older adult client who is violent and attempting to pull out IV lines. Which action is appropriate for client in restraints? Tie restraints to side rails Perform wrist ROM every 3 hr Remove restraints one at a time Obtain PRN order for restraints

Remove the restraints one at a time

A community health nurse is preparing a campaign about seasonal influenza. Which plan should nurse include as secondary prevention? Holding community clinic for flu shots Screening groups of older adults in skilled nursing facilities for early signs of influenza Educating parents of young children about dangers of influenza Finding rehab programs for older adults with complications from the flu

Screening groups of older adults in skilled nursing facilities for early signs of influenza

A nurse is caring for a client who is in the terminal stage of cancer. Which action should the nurse take when she observes the client crying? Contact family and ask them to stay with the client Offer to call client's minister Sit and hold client's hand Leave the room and allow the client to cry privately.

Sit and hold client's hand

Teaching for an older adult who has constipation should include which of the following recommendations? Drink a minimum of 1000 mL fluid daily Increase intake of refined-fiber foods. Sit on toilet 30 minutes after eating a meal Take a laxative every day to maintain regularity

Sit on toilet 30 minutes after eating a meal (To prevent constipation, must drink 1500 mL or more, and increase intake of coarse-fiber foods/whole-grains).

A nurse is caring for a client who has T1DM and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? Tell me what I can do to help you overcome your fear of giving yourself injections. I am sure your provider will not be pleased that you refuse to give yourself injections. It's okay- your partner will be able to learn to give you injections. You won't be able to go home without learning how to give yourself injections.

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

A nurse is planning care for a client with abdominal pain. An assessment reveals temperature of 102.6 F, HR 105, soft-non-tender abdomen, menses overdue by 2 days. Which of the following findings should be the priority? Heart rate Soft, non-tender abdomen Temperature Overdue menses

Temperature

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

The involvement of the client in planning the change

A nurse is witnessing a client sign an informed consent form for surgery. What describes what the nurse is affirming this action? The client fully understands the provider's explanation of this procedure. The client has been informed about risks/benefits of procedure The nurse witnessed provider's explanation of procedure The signature on pre-op consent form is the client's

The signature on the pre-op consent form is the client's

Nurse observes another staff member using a regular size BP cuff for a client who is obese. Which explanation should she give? Reading will be inaudible if cuff is too small Width of cuff bladder should be 75% of circumference of arm As long as cuff will circle arm, reading is accurate Using cuff that is too small results in inaccurately high reading

Using cuff that is too small results in inaccurately high reading

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

What worries you about being without your teeth?

A nurse is receiving client from PACU who is post-op following abdominal surgery. Which action should nurse take to transfer client from stretcher to bed? Lock wheels of bed and stretcher Instruct client to raise arms above head Elevate stretcher 1 inch above height of bed Log roll client

lock wheels of bed and stretcher

Nurse is preparing to provide tracheostomy care for patient. Which action should nurse take first? Open all sterile supplies and solutions. Sterilize tracheostomy tube don sterile gloves perform hand hygiene

perform hand hygiene

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes using an electronic BP machine. The nurse notices the machine begins to measure BP at varied intervals and readings are inconsistent. which action should the nurse take? Turn on the machine every 15 minutes to measure the BP. Record only BP readings needed for the 15-min intervals. Obtain manual and automatic readings & compare them. Disconnect the machine, measure the BP manually every 15 minutes.

Disconnect the machine, measure the BP manually every 15 minutes.

Nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which action should the nurse take FIRST? Explain procedure to client. Help client into wheelchair before the transporter arrives Ask if client has any questions Identify the client using 2 identifiers

Identify the client using 2 identifiers

Nurse is obtaining vitals for a 2-year old child who is experiencing diarrhea and may have right ear infection. Which route should be used to measure temperature? Rectal tympanic oral temporal

Temporal- oral temp. is not suitable for kids under 3

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

Attempt to increase clients' self-motivation

A nurse is teaching a group of older adults about suspected changes of aging. Which statement by a group member indicates effective teaching? I should expect my HR to take longer to return to normal after exercise. Urinary incontinence is something I have to live with as I get older. I can expect to have less ear wax as I get older. My stomach will empty more quickly after meals as I grow older.

I should expect my HR to take longer to return to normal after exercise.