ATI Fundamentals Practice Quiz 1 - 10/06

A nurse is teaching a group of older adults about expected age-related changes. Which of the following statements by a group member indicates 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. - Older adults experience decreased cardiac output, which causes an increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.

A nurse is caring for a client who has a stage 3 pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the patient's pain level. - The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should determine the client's level of pain prior to the procedure to evaluate the need for administration of an analgesic. Medicating the client approximately 30 minutes prior to wound care will decrease pain and increase comfort.

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger above heart level. - The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection. Note: You don't want the finger above the heart level that is when the nurse is required to intervene.

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open. - The nurse should hold the upper lid against the eyebrow and lower lid against the cheekbone when irrigating the eye.

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take?

Instruct the guard to ask the inmate. - The nurse is not able to supply this information to the guard. In order for the guard to obtain this information, the client must offer the information freely. Therefore, the nurse should instruct the guard to ask the client for this information.

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?

Limit drinking liquids with food. - Drinking beverages with food leads to early satiety and bloating, which results in the client consuming fewer calories.

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide?

What worries you about being without your teeth? - This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing. - The nurse should apply the safety and risk-reduction priority-setting framework, which 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, and/or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound increases the risk of peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

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 eye disorders?

Glaucoma - The nurse should identify that an obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to an increase in intraocular pressure, resulting in damage to the eye.

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

Cranial Nerve XII - Hypoglossal which innervates the tongue by observing a range of tongue movements.

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of information should the nurse include?

A 10 month old infant can pull up to a standing position. - A 8 to 10 month old infant can pull up to a standing position.

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Assessment - When caring for a client, the nurse should apply the nursing process priority-setting framework. The nursing process is used to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an 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, he or she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision Note: ADPIE - Assessment Diagnosis Plan Implementations Evaluate