Fundamentals ATI Adaptive

A. Evaluate pedal pulses For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework.

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A.Evaluate pedal pulses B.Obtain a medical history C.Measure vital signs D.Assess for leg pain

C. Dorsalis pedis

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? A.Popliteal B.Posterior tibial C.Dorsalis pedis D.Femoral

D. Supports self-determination ( The nurse must honor the client's autonomy and ability to make health care decisions. The client has the right to refuse treatment; as the client's advocate, the nurse must support that right)

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? A.Allows minimal treatment B. Benefits the client's family C. Offers hope for a cure D. Supports self-determination

C. Raise the level of the bed. 'The nurse should raise the bed to allow the use of proper body mechanics and reduce the risk of self-injury.

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.

D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button." The nurse should encourage the client to utilize nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation (TENS) while using PCA pump to reduce the amount of opioid dosing the client needs.

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

D. Evacuate clients from the unit

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility? A.Close the fire doors on the unit B.Use a fire extinguisher on the fire C. Pull the nearest fire alarm D.Evacuate clients from the unit

C. "What do you think caused the onset of your pain?" The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than a few words

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. "What do you think caused the onset of your pain?" D."Changing positions makes your pain worse, right?"

D. Pericardial friction rub A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery Sound that is heard best with the diaphragm of the stethoscope at the left sternal border.

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

D. "What is your source of strength and hope?" This is a broad, open-ended question that encourages the client to express feelings without any assumptions on the nurse's part.

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? A."When did you start to believe in your faith?" B."How often do you perform religious rituals?" C. "Which church do you regularly attend?" D."What is your source of strength and hope?"

A client who is 2 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 unstable vs stable priority-setting framework when caring for clients. Using this framework, unstable clients are prioritized due to needs that threaten survival)

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative, Which of the following clients should the nurse see first? A. A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage B. A client who is 2 days postoperative following colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage C. A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage D. A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine

D. Durable power of attorney document (A durable power of attorney for health care document, or health carre proxy, names a surrogate who can make health care decisions for the client if he is unable to do so)

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care Informed consent form decisions for me if l am not able. The nurse should identify that the client is referring to which Living will document of the following documents?