ATI fundamental one
A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR? Call for assistance. Begin chest compressions. Confirm unresponsiveness. Give rescue breaths.
Confirm unresponsiveness.
A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make? "Ask your provider to prescribe epoetin before the surgery." "You should take iron supplements prior to the surgery." "Request a family member donate blood for you." "Donate autologous blood before the surgery."
"Donate autologous blood before the surgery." MY ANSWER Autologous blood transfusion is the collection and reinfusion of the client's own 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; exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.
A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "My parents are retired, and they have come to help out with our children." "I am going to ask my husband to go to counseling with me." "I keep having nightmares about my upcoming surgery." "My girlfriends bought me a nice wig."
"I keep having nightmares about my upcoming surgery." MY ANSWER The nurse should recognize that 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 is instructing an assistive personnel (AP) about proper hand hygiene. Which of the following statements 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." "I will use cold water when I wash my hands to protect my skin from becoming too dry." "I will apply friction for at least 10 seconds while washing my hands." "After washing my hands I will dry them from the elbows down."
"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." 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 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? "It's for your safety. Dentures can slip and block your airway during surgery." "You wouldn't want your teeth to be lost or broken during surgery, would you?" "The anesthesiologist requires everyone to remove their dentures." "What worries you about being without your teeth?"
"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 for it
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? "Tell me what I can do to help you overcome your fear of giving yourself injections." "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." "You won't be able to go home unless you learn to give yourself insulin injections."
A "Tell me what I can do to help you overcome your fear of giving yourself injections
nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect? Frequent bowel sounds with flatus Absent bowel sounds with distention Hyperactive bowel sounds with diarrhea Normal bowel sounds with increased peristalsis
Absent bowel sounds with distention
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Encourage the child to cough frequently to clear congestion from anesthesia. Place a heating pad at the child's neck for comfort. Administer analgesics to the child on a routine schedule throughout the day and night. Provide the child with ice cream when oral intake is initiated
Administer analgesics to the child on a routine schedule throughout the day and night.
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? Attempt to increase the clients' self-motivation. Keep detailed records of each client's progress. Test client learning after each teaching session Avoid discussing areas that might cause client anxiety.
Attempt to increase the clients' self-motivation. MY ANSWER 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
nurse is drawing blood for laboratory testing from 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? Wash the gloved hands and then throw the gloves away. Prepare an incident report to document the event. Carefully remove the gloves and follow with hand hygiene. Ask the provider to order a blood culture to determine the risk of infection.
Carefully remove the gloves and follow with hand hygiene.
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? Measure the pulse using a Doppler ultrasound stethoscope. Check the client's pedal pulses. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. Take the pulse at each peripheral site and count the rate for 30 seconds.
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. MY ANSWER 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 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? Turn on the machine every 15 min to measure the client's blood pressure. Record only blood pressure readings needed for the 15-min intervals. Obtain manual and automatic readings and compare them. Disconnect the machine and measure the blood pressure manually every 15 min.
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. Which of the following actions should the nurse take? Change the topic because the client is trying to divert attention from the illness to the nurse. Encourage the client to express his thoughts about death and dying. Tell the client that religious beliefs are a personal matter. Offer to contact the client's minister or the facility's chaplain
Encourage the client to express his thoughts about death and dying.
A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses. Obtain a medical history. Measure vital signs. Ask the client if he is experiencing any pain in the leg.
Evaluate pedal pulses.
A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated? Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers.
Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. MY ANSWER The nurse should use this technique for collecting data on 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 collect data on skin turgor by grasping a skin fold on the back of the forearm.
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? Explain the x-ray procedure to the client. Help the client into a wheelchair before the transporter arrives. Ask if the client has any questions. Identify the client using two identifiers.
Identify the client using two identifiers.
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? Lock the wheels on the bed and stretcher. Instruct the client to raise his arms above his head. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. Log roll the client.
Lock the wheels on the bed and stretcher.
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? Identify goals for client care. Obtain client information. Document nursing care needs. Evaluate the effectiveness of care.
Obtain client information.
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? Obtaining hydrogen peroxide for the tracheostomy care Obtaining cotton balls for the tracheostomy care Obtaining sterile gloves for the tracheostomy care Obtaining a sterile brush for the tracheostomy care
Obtaining cotton balls for the tracheostomy care MY ANSWER Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing tracheal abscess. The charge nurse should intervene for this action.
nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take? Place the client supine. Keep both side rails up. Raise the level of the bed. Inspect the client's mouth using a finger sweep
Raise the level of the bed. MY ANSWER The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-inj
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? Tie the restraints to the side rails. Perform range-of-motion exercises to the wrists every 3 hr. Remove the restraints one at a time. Obtain a PRN prescription for the restraints.
Remove the restraints one at a time. MY ANSWER The nurse should remove one restraint at a time for a client who is violent or noncompliant.
A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy? Holding a community clinic to administer influenza immunizations. Screening groups of older adults in nursing care facilities for early influenza manifestations. Educating parents of young children about the dangers of influenza. Finding rehabilitation programs for older adults who have complications from influenza.
Screening groups of older adults in nursing care facilities for early influenza manifestations. MY ANSWER Screening older adults who have some manifestations of illness to determine if they have influenza is an exam
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? Contact the family and ask them to stay with the client. Offer to call the client's minister. Sit and hold the client's hand. Leave the room and allow the client to cry privately.
Sit and hold the client's hand.
A nurse is collecting data from a client who reports abdominal pain. Further findings reveal the client has a temperature of 39.2° C (102.6° F), a 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? Heart rate of 105 Soft, nontender abdomen Temperature Overdue menses
TEMP
urse is reinforcing teaching with 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 The emphasis the provider places on the dietary changes The learning theory the nurse uses to teach the dietary changes The extent of the dietary changes planned for the client
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 of the following actions by the nurse demonstrates proper surgical hand-washing technique? The nurse washes each part of her hands with five strokes. The nurse washes from the elbows down to the hands. The nurse washes with her hands held higher than her elbows. The nurse uses minimal friction when washing her hands.
The nurse washes with her hands held higher than her elbows.
nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? The client fully understands the provider's explanation of the procedure. The client has been informed about the risks and benefits of the procedure. The nurse witnessed the provider's explanation of the procedure. The signature on the preoperative consent form is the client's
The signature on the preoperative consent form is the client's. MY ANSWER 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 collecting data for an adult client. Identify the correct sequence of steps used for data collection of the abdomen. (Move the sequence of steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Palpation Percussion Auscultation
inspection ascull percuss pallpilation