ATI FUndamental

a nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes?

Average Rationale: 0 to 4+ Diminished: 1+ or less Brisk: 3+ more Hyperactive: 4+

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication? The motivation of communication is evident Feedback is provided A message is communicated to the group of clients Multiple channels are used by the sender

Feedback is provided

A nurse is caring for a client who has a gastric ulcer. The nurse should explain theta prolonged exposure of the body to stress can also cause which of the following to occur? Hyperglycemia Hypotension Heightened immune response Bleeding tendencies

Hyperglycemia Rationale: Stress can cause an increased secretion of cortisol, which can lead to hypertension and hyperglycemia

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse sue first? Inspect both breaths simultaneously Squeeze the nipples Palpate the breast and tail of spence Palpate the axillary lymph nodes

Inspect both breaths simultaneously

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? Select all that apply carefully reinsert the intestine through the opening in the wound Place the client in a supine position with the hips and knees flexed Leave the room to call the surgeon Cover the wound and intestine with a sterile, moistened dressing Monitor the client for manifestation of shock

Place the client in a supine position with the hips and knees flexed Cover the wound and intestine with a sterile, moistened dressing Monitor the client for manifestation of shock

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? Insert the rectal tube 6in Wear sterile gloves to insert the tubing Position the patient on the left side Hold the solution bag 91 cm above the clients rectum

Position the patient on the left side Rationale: facilitates the flow of the enema into the sigmoid and descending colon

A nurse is performing a straight urinary catherization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? Applying sterile gloves to open catheter package Wiping the labia minora in an anteroposterior direction Spreading the labia with the dominant hand Using a cotton ball to wipe the right and left majora

Wiping the labia minora in an anteroposterior direction

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescriptions states "clear liquids; advanced diet as tolerated." Which of the following responses should the nurse make?

"I am going to listen to your stomach" The nurse should auscultate the stomach first to determine the presence of bowel sounds before clear liquids can be administered

A nurse is caring for a client who has chronic disease. The kidneys regulate body fluids as well as assisting with which of the following functions? Regulation of acid-base balance Reabsorption of nutrients for cellular growth Regulation of body temperature Secretion of hormones needed for growth

Regulation of acid-base balance

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the am immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? Change the tube infusion tubing Flush the IV catheter Remove the IV catheter Apply a cool compress to the site

Remove the IV catheter

A nurse is caring for an adult client who is grieving the death of a loved one. Which of the following increases the client's risk of developing complicated grief? The deceased was closed friend The client lived far from the deceased The death was sudden The client has not visited the deceased in a long time

The death was sudden