ATI Fundamentals 1
A nurse is caring for a client who is postoperative and had paralytic ileus. Which of the following abdominal assessments should the nurse expect?
Absent bowel sounds with distention
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?
Carefully remove the gloves and follow with hand hygiene
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurses religious believes related to death and dying. Which of the following actions should the nurse take?
Encourage the client to client to express his thoughts about death and dying
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?
Identify th client using two identifiers
A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment
Inspection auscultation percussion palpation
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?
Lock the wheels on the bed and atretcher
A nurse is obtaining the blood pressure and the clients lower extremity. Which of the following actions should the nurse take?
Place the bladder of the cuff over the posterior aspect of the thigh
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?
Raise the level of the bed
A nurse is planning care for a client who reports abdominal pain. As assessment by the nurse reveals the client has a temperature of 39.2c (102.6f), heart rate of 105/min, a soft no tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurses priority?
Temperature
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?
Temporal
A nurse on a medical surgical unit is washing her hands prior to assisting with surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand washing techniques?
The nurse washes with her hands held higher than her elbows
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following described what the nurse is affirming by this actuon
The signature on the preoperative consent form is the clients
A nurse is caring for a client who is instant and has vital signs measures every 15 minutes by an electric blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings and inconsistent. Which of the following actions should the nurse take
Disconnect the machine and measure the blood pressure manually every 15 mins
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicated that the teaching has been effective?
I should expect my heart rate to take longer to return to normal after exercise as I get older
