Fundamentals ATI

A nurse is performing an abdominal assessment for an adult client. What is the correct sequence of steps for this assessment

Inspection Auscultation Percussion Palpation

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. What statement should the nurse make to the client?

"donate autologous blood before the surgery."

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

A nurse is measuring vital signs for a client and notices an irrregularity in the pulse. What action should the nurse take?

count the apical pulse rate for 1 full minute and describe the rhythm in the chart

A nurse is preparing to perform mouth care for an unresponsive client. Which action should the nurse plan to take?

raise the level of the bed

A nurse is caring for an older adult who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. What actions should the nurse take while the client is in restraints?

remove the restraints one at a time

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. What statement by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery"

A nurse is teaching a group of older adults about expected changes of aging. What statement 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"

A nurse is caring for a client who is postoperative and has paralytic ileus. Which abdominal assessment should the nurse expect?

absent bowel sounds with distention

A nurse is providing teaching to an older adult client who has constipation. What statement should the nurse include in the teaching?

"sit on the toilet 30 mins after eating a meal"

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. What statement by the AP indicates an understanding of the teaching?

"there are times I should use soap and water rather than an alcohol-based hand rub to clean my hands"

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. What explanation should the nurse give the AP?

"using a cuff that is too small will result in an inaccurately high reading"

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 response should the nurse make?

"what worries you about being without your teeth?"

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

assessment

A nurse is planning weight loss strategies for a group of clients who are obese. What action by the nurse will improve the clients commitment to a long-term goal of weight loss?

attempt to increase the clients' self-motivation

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. What action should the nurse take?

carefully remove the gloves and follow with hand hygiene

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

confirm unresponsiveness

A nurse is caring for a client who is unstable and has vital signs measured every 15 mins 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?

disconnect the machine and measure the blood pressure manually every 15 min

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. What action should the nurse take?

encourage the client to express his thoughts about death and dying

A nurse is admitting a client who has decreased circulation in his left leg. What action should the nurse take first?

evaluate pedal pulses

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. What action should the nurse take to assess the client's skin turgor?

grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back

a nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, what action should the nurse take first?

identify the client using two identifiers

a nurse is receiving a client from the PACU who is postoperative following abdominal surgery. What action should the nurse take to transfer the client from the stretcher to the bed?

lock the wheels on the bed and stretcher

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. What actions should the nurse take?

notify the provider about the client's decision

A nurse on a medical-surgical unit is caring for a client. What action should the nurse take first when using the nursing process?

obtain client information

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 tracheostomy care

A nurse is preparing to provide tracheostomy care for a client. What action should the nurse take first?

perform hand hygiene

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 sounds should the nurse document?

pericardial friction rub

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 nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. What technique should the nurse use?

place the wheelchair at a 45 degree angle to the bed

A community health nurse is preparing a campaign about seasonal influenza. What plan should the nurse include as a secondary prevention?

screening groups of older adults in nursing care facilities for early influenza manifestations

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 anatomical area should the nurse place the stethoscope to auscultate the aortic valve?

second intercostal space to the left of the sternum

A nurse is caring for a client who is in the terminal stage of cancer. What action should the nurse take when she observes the client crying?

sit and hold the client's hand

A nurse is caring for a client who has type 1 mellitus and is resistant to learning self-injection of insulin. What statement should the nurse make?

tell me what i can do to help you overcome your fear of giving yourself injections

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 celsius (102.6 F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. What finding should be the nurses priority?

temperature

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 route should the nurse use to obtain the temperature?

temporal

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. What statement indicates a lack of readiness to learn by the client?

the client reports severe pain

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?

the involvement of the client in planning the change

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which action by the nurse demonstrates proper surgical hand-washing technique?

the nurse washes with her hands held higher than her elbows

A nurse is witnessing a client sign an informed form for surgery. What describes what the nurse is affirming by this action?

the signature on the preoperative consent form is the client's