ATI Fundamentals Quiz

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? a. "Tell me what I can do to help you overcome your fear of giving yourself injections." b. "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." c. "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." d. "You won't be able to go home unless you learn to give yourself insulin injections."

a. This response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections.

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll wear nonsterile gloves." B. "I'll use adhesive remover each time." C. "I'll take my pain pill after I change the dressing." D. "I'll fold the dressing with the soiled surface facing outward."

a. Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clean and do not need to be sterile unless the provider specifically prescribes sterile gloves for dressing changes.

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? a. Obtaining hydrogen peroxide for the tracheostomy care b. Obtaining cotton balls for the tracheostomy care c. Obtaining sterile gloves for the tracheostomy care d. Obtaining a sterile brush for the tracheostomy care

b. Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? a. Frequent bowel sounds with flatus b. Absent bowel sounds with distention c. Hyperactive bowel sounds with diarrhea d. Normal bowel sounds with increased peristalsis

b. Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended.

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? A. Eggs B. Cereal C. Peanut butter D. Pasta

a. Complete proteins contain all of the essential amino acids to support growth and homeostasis. Examples of complete proteins include eggs, meat, poultry, seafood, milk, yogurt, cheese, soybeans, and soybean products.

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea

a. The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? A. Exhale slowly to reach the goal volume B. Hold the breath for 5 sec after goal volume is reached C. Continue to breathe deeply between each cycle D. Limit the repeat pattern of breathing to 5 breaths

b. The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia.

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? a. Identify goals for client care. b. Obtain client information. c. Document nursing care needs. d. Evaluate the effectiveness of care.

b. The nursing process is based on the scientific process. The first step in the scientific process is the collection of data. Therefore, the first step in the nursing process is assessing and obtaining information about the client.

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? a. "Drink a minimum of 1,000 milliliters of fluid daily." b. "Increase your intake of refined-fiber foods." c. "Sit on the toilet 30 minutes after eating a meal." d. "Take a laxative every day to maintain regularity."

c. Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.

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? A. Hold the irrigator 1.25 cm (0.5 in) above the eye B. Direct the irrigation solution up toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelids open D. Direct the irrigation from the outer canthus to the inner canthus of the eye

c. Motivation to learn is important in improving a client's commitment to achievement of a health goal, as well as increasing the amount and speed of learning.

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? a. Wash the gloved hands and then throw the gloves away. b. Prepare an incident report to document the event. c. Carefully remove the gloves and follow with hand hygiene. d. Ask the provider to order a blood culture to determine the risk of infection.

c. Standard precautions require the use of gloves and hand hygiene in the care of all clients.

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

2, 4, 3, 1 The appropriate sequence for the nurse to perform the abdominal assessment is to inspect, auscultate, percuss, and then palpate. This sequence prevents altering the bowel sounds and causing false results. The appropriate sequence for any other assessment for an adult client is inspection, palpation, percussion, and auscultation.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? a. The nurse washes each part of her hands with 5 strokes. b. The nurse washes from the elbows down to the hands. c. The nurse washes with her hands held higher than her elbows. d. The nurse uses minimal friction when washing her hands.

c. The nurse who is performing a surgical hand-washing technique should wash with her hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? a. Encourage the child to cough frequently to clear congestion from anesthesia. b. Place a heating pad at the child's neck for comfort. c. Administer analgesics to the child on a routine schedule throughout the day and night. d. Provide the child with ice cream when oral intake is initiated.

c. 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 nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia? A. Speech-language pathologist B. Social worker C. Physical therapist D. Occupational therapist

a. A speech-language pathologist can perform a thorough evaluation of the client for dysphagia and help the client learn to eat safely. For example, a speech-language pathologist can instruct the client in learning the supraglottic swallow: take a breath, hold the breath while swallowing, cough after swallowing, and swallow again to clear the mouth.

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? a. The involvement of the client in planning the change b. The emphasis the provider places on the dietary changes c. The learning theory the nurse uses to teach the dietary changes d. The extent of the dietary changes planned for the client

a. 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.

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times? A. Suction equipment B. Clean gloves C. Blankets D. Oxygen

a. The greatest risk to a client who is having a seizure is an injury from aspirating secretions or emesis; therefore, the nurse must have suction equipment available for clearing the mouth of secretions or emesis to reduce this risk.

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A. Increased blood pressure B. Decreased blood glucose level C. Decreased oxygen use D. Increased gastrointestinal motility

a. The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in blood pressure and heart rate as a result of sympathetic stimulation.

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? a. The client asks the nurse to repeat the instructions before attempting the exercises. b .The client reports severe pain. c. The client asks the nurse how often deep breathing should be done after surgery. d. The client tells the nurse that this exercise will probably be painful after surgery.

b. A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity.

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? a. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. b. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. c. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. d. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers.

b. The nurse should use this technique for assessing skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; with dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skin fold on the back of the forearm.

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? A. Retention B. Oliguria C. Diuresis D. Dysuria

c. Diuresis or polyuria is the excretion of a high volume of urine. This condition has many causes, including metabolic and hormonal imbalances and diuretic therapy for treating renal, cardiovascular, and pulmonary disorders.

A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? A. Supine B. Lateral C. Fowler's D. Trendelenburg

c. Sitting upright promotes full expansion of both lungs and facilitates ventilation and perfusion.

A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims' B. Prone C. Supine D. Fowler's

d. This describes Fowler's position. Although various definitions exist for Fowler's position, generally a low Fowler's position means 30° of elevation, semi Fowler's is 45° to 60°, and high Fowler's is 60° to 90° of elevation.

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? a. "Ask your provider to prescribe epoetin before the surgery." b. "You should ask your provider about taking iron supplements prior to the surgery." c. "Request a family member to donate blood for you." d. "Donate autologous blood before the surgery."

d. Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? a. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." b. "I will use cold water when I wash my hands to protect my skin from becoming too dry." c. "I will apply friction for at least 10 seconds while washing my hands." d. "After washing my hands I will dry them from the elbows down."

a. While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

b. After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra.

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? a. Explain the x-ray procedure to the client. b. Help the client into a wheelchair before the transporter arrives. c. Ask if the client has any questions. d. Identify the client using two identifiers.

d. 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 performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test

d. The blanch test is used to check capillary refill, which is an indicator of peripheral circulation and tissue perfusion.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? a. Auscultate for the blood pressure at the dorsalis pedis artery. b. Measure the blood pressure with the client sitting on the side of the bed. c. Place the cuff 7.6 cm (3 in) above the popliteal artery. d. Place the bladder of the cuff over the posterior aspect of the thigh.

d. This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? a. Open all sterile supplies and solutions. b. Stabilize the tracheostomy tube. c. Don sterile gloves. d. Perform hand hygiene.

d. According to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurse's hands is a primary source of infection.

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? a. Fifth intercostal space just medial to the midclavicular line b. Second intercostal space to the left of the sternum c. Fifth intercostal space to the left of the sternum d. Second intercostal space to the right of the sternum

d. The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross? A. Anger B. Bargaining C. Depression D. Acceptance

c. During the stage of depression, the client has realized the full impact of the loss or impending death and might express hopelessness and despair.

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.

c. The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury.

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? a. Turn on the machine every 15 min to measure the client's blood pressure. b. Record only blood pressure readings needed for the 15-min intervals. c. Obtain manual and automatic readings and compare them. d. Disconnect the machine, and measure the blood pressure manually every 15 min.

d. If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.

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? a. Lock the wheels on the bed and stretcher. b. Instruct the client to raise his arms above his head. c. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. c. Log roll the client.

a. Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client.

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? a. Attempt to increase the clients' self-motivation. b. Keep detailed records of each client's progress. c. Test client learning after each teaching session. d. Avoid discussing areas that might cause client anxiety.

a. Motivation to learn is important in improving a client's commitment to achievement of a health goal, as well as increasing the amount and speed of learning.

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? a. Holding a community clinic to administer influenza immunizations. b. Screening groups of older adults in nursing care facilities for early influenza manifestations. c. Educating parents of young children about dangers of influenza. d. Finding rehabilitation programs for older adults who have complications from influenza.

b. Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.

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? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration

b. 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 planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2° C (102.6° F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? a. Heart rate 105/min b. Soft, nontender abdomen c. Temperature d. Overdue menses

c. Elevated temperature is an emergent physiological need, which requires priority intervention by the nurse. However, fever and pain can contribute to tachycardia.

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? a. Measure the pulse using a Doppler ultrasound stethoscope. b. Check the client's pedal pulses. c. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. d. Take the pulse at each peripheral site and count the rate for 30 seconds.

c. If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record.

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? a. "My parents are retired, and they have come to help out with our children." b. "I am going to ask my husband to go to counseling with me." c. "I keep having nightmares about my upcoming surgery." d. "My girlfriends bought me a nice wig."

c. Nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate that the client is at risk for experiencing psychological distress.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? a. Stand toward the client's stronger side. b. Instruct the client to lean backward from the hips. c. Place the wheelchair at a 45° angle to the bed. d. Assume a narrow stance with feet 15 cm (6 in) apart.

c. Positioning the wheelchair at a 45° allows the client to pivot, lessening the amount of rotation required.

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching? A. "Support the majority of your weight on the axillae." B. "Keep your elbows extended." C. "Bear weight on both of your legs." D. "Move both crutches forward at the same time."

c. The client should keep 3 points on the ground at all times. Therefore, he must be able to bear weight on both legs.

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? a. The client fully understands the provider's explanation of the procedure. b. The client has been informed about the risks and benefits of the procedure. c. The nurse witnessed the provider's explanation of the procedure. d. The signature on the preoperative consent form is the client's.

d. The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.

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 make? a. "It's for your safety. Dentures can slip and block your airway during surgery." b. "You wouldn't want your teeth to be lost or broken during surgery, would you?" c. "The anesthesiologist requires everyone to remove their dentures." d. "What worries you about being without your teeth?"

d. This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason for it.

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?"

c. 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 teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? a. "I should expect my heart rate to take longer to return to normal after exercise as I get older." b. "Urinary incontinence is something I will have to live with as I grow older." c. "I can expect to have less ear wax as I get older." d. "My stomach will empty more quickly after meals as I grow older."

a. Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.

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.

a. 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. This framework assigns priority to the factor 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.

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring

a. The nurse should hold a multidose bottle with the label against the palm of the hand when pouring to prevent contaminating the label with spilled medication that could cause information on the label to fade or become illegible.

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to place a towel between the heating pad and my skin." B. "I'll need to turn up the temperature if I can't feel the heat." C. "I'll sleep on top of the heating pad to increase the heat penetration." D. "Keeping the heat continuously on my back will help it heal."

a. The nurse should instruct the client to place a towel between the heating pad and the skin to reduce the risk of burns.

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? A. Elevating the finger above heart level B. Rubbing the fingertip with an alcohol pad C. Puncturing the side of the fingertip D. Wrapping the finger in a warm cloth

a. 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.

A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? a. Assessment b. Plan of care c. Nursing interventions performed d. Evaluation of progress

a. When caring for this client, 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, he must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision.

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? a. Tie the restraints to the side rails. b. Perform range-of-motion exercises to the wrists every 3 hr. c. Remove the restraints one at a time. d. Obtain a PRN prescription for the restraints.

c. The nurse should remove one restraint at a time for a client who is violent or noncompliant.

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? a. Rectal b. Tympanic c. Oral d. Temporal

d. The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair.

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? a. Contact the family and ask them to stay with the client. b. Offer to call the client's minister. c. Sit and hold the client's hand. d. Leave the room and allow the client to cry privately.

c. With this action, the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client

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. Which of the following heart sounds should the nurse document? a. Audible click b. Murmur c. Third heart sound d. Pericardial friction rub

d. 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 preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take? a. Tell the client it is too late for her to change her mind because the surgery is already scheduled. b. Telephone the operating room and cancel the surgery. c. Inform the client's family about the situation. d. Notify the provider about the client's decision.

d. Acting as the client advocate, the nurse should support the client in her decision and notify the provider.

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? a. "The reading will be inaudible if the cuff is too small for the client." b. "The width of the cuff bladder should be 75% of the circumference of the client's arm." c. "As long as the cuff will circle the arm the reading will be accurate." d. "Using a cuff that is too small will result in an inaccurately high reading."

d. Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client.

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? A. Document the finding B. Measure the client's apical pulse rate C. Talk with the client about factors that can affect the pulse rate D. Notify the provider about the client's radial pulse rate

b. The first action the nurse should take using the nursing process is to assess or collect data from the client. This pulse rate is below the expected reference range for an adult. The nurse and a coworker should measure the apical and radial pulse rates simultaneously to determine if there is a pulse deficit. If the client's radial pulse rate is lower than the apical rate, the client might have a cardiovascular disorder.

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? a. Call for assistance. b. Begin chest compressions. c. Confirm unresponsiveness. d. Give rescue breaths.

c. 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 has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? a. Change the topic because the client is trying to divert attention from the illness to the nurse. b. Encourage the client to express his thoughts about death and dying. c. Tell the client that religious beliefs are a personal matter. d. Offer to contact the client's minister or the facility's chaplain.

c. The nurse should recognize the client's need to talk about impending death, and encourage the client to discuss his thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can help open lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skills of offering self and listening to the client's thoughts are appropriate.

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? A. Blood loss B. NPO status after surgery C. Nasogastric tube suctioning D. Impaired peristalsis of the intestines

d. Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to help the client ambulate to promote peristalsis.

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? A. Instill proparacaine hydrochloride eye drops B. Perform ocular irrigation of the right eye C. Place the client in a supine position with the head turned toward the affected side D. Ask the client about first aid performed at the scene

d. 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 first action the nurse should take is to assess the first aid that was performed at the scene to determine if eye irrigation was administered.