NCLEX Review (ATI): Fundamentals

A nurse is caring for a child who is postoperative following a tonsillectomy. What action should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night. (To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route.)

A charge nurse is teaching adult CPR to a group of newly licensed nurses. What action should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness. (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.)

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 the client using two identifiers. (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.)

A nurse is obtaining the blood pressure in a client's lower extremity. What action should the nurse take?

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

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. What action by the newly licensed nurse requires intervention?

obtaining cotton balls for the trach care (Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.) -half-strength peroxide solution is used to clean the inner cannula, sterile procedure requiring sterile gloves, pipe cleaners/small sterile brush can be used to remove thick or crusty secretions from the inner cannula

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse 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. What heart sound should the nurse document?

pericardial friction rub (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.)

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. What factor is the most important in determining the client's ability to learn new dietary habits?

the involvement of the client in planning the change (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.)