ATI Fundamentals

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland?

" tilt your head back and swallow."

The nurse observes an assistive personnel preparing to obtain blood pressure with a regular sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

" using a cuff that is too small will result in an inaccurately high reading." Blood pressure readings can be falsely high if the cuff is too small for the client

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquid fluids; advanced diet as tolerated." Which of the following responses should the nurse make?

" I am going to listen to your abdomen." A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the clients abdomen to determine the presence of bowel sounds before clear liquids can be administered

A nurse on an air oncology unit receives report at the beginning of her shift about four clients who are postoperative which of the following clients should the nurse see first?

A client who is two days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage. The nurse should apply the stable versus unstable priority setting framework when caring for clients. Using this framework, unstable clients are prioritized due to needs that threaten survival = ABC An ostomy bag full of blood indicates that the clients Bellas hemorrhaging, and the nurse must report this finding to the surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. Is finding poses an immediate threat to the clients circulation.

A nurse is preparing to the administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding?

Elevate the HOB. Clients following brain injury usually can't swallow effectively thus cannot protect their airway from aspiration

A nurse on medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first?

Evacuate the client from the room. The acronym RACE can help nurses remember the order of the actions to take in the event of a fire. RACE = Rescue, activate, confine, and extinguish

A nurse is beginning her shift and reviewing the medication administration records for her clients. She notes the dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage. After assessing the client for adverse effects of the medication, the nurse should notify the provider about her observations to determine the next action.

A nurse is caring for a client who requires peripheral IV insertion. When she's in the side, which of the following sites should nurse select?

Choose a vein that is soft on palpation The nurse should select a vein that is soft and has a bouncy feeling when pressure is released upon palpation.

The nurse is measuring the clients vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders?

Glaucoma

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the clients risk of aspiration?

Elevate the HOB

A nurse is changing the dressing for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

Nurses using the Braden scale to predict the pressure ulcer risk of a client in a long term care facility. Using the scale, which of the following parameters should the nurse evaluate?

Nutrition Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a clients risk of developing pressure ulcers.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first?

Perform hand hygiene

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube. decreases risk of aspiration of any GI contents

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take me to collect in the specimen?

Place the stool specimen collection container in a biohazard bag

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take first?

Position the client on his left side

A nurse is caring for a group of clients. Which of the following tasks should the nurse assigned to an assistive personnel?

Provide oral care to a client who cannot take oral fluids Providing oral care to a client who cannot take oral fluids is within the range of function for an AP. Therefore, the nurse can assign this task to the AP.

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line

The nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?

Sodium 123 mEq/L The expected reference range for sodium is 136-145 mEq/L Low sodium levels can cause confusion and lead to seizures, coma, and death

The nurse is preparing to assist an older client with ambulation following bedrest for three days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain?

cerebellum The nurse should suspect injury to the cerebellum at the client is experiencing difficulty controlling balance and coordination. A clients movements can become uncoordinated, unsure, and clumsy following injury to this area of the brain.

A nurse is caring for a client Who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

hyperglycemia Stress causes an increased secretion of cortisol, which can lead to hypertension and hyperglycemia.