ATI Learning System RN 3.0 Fundamentals 1 Quiz
A nurse in an oncology clinic is assessing the client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates that 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." 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 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 take? - "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?"
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessment 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. Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended.
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. 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-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? - Assessment - Plan of care - Nursing interventions performed - Evaluation of progress
Assessment
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? - 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. Motivation to learn is important in improving a client's committment 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 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 charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurse. Which of the following actions should the charge nurse teach as the first response to CPR? - Call for assistance. - Begin chest compressions. - Confirm unresponsiveness. - Give rescue breaths.
Confirm unresponsiveness. 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 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. 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 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? - 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. 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 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 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 she surgery. Which of the following actions should the nurse take? - Tell the client it is too late for her to change her mind because the surgery is already scheduled. - Telephone the operating room and cancel the surgery. - Inform the client's family about the situation. - Notify the provider about the client's decision.
Notify the provider about the client's decision.
A charge nurse is observing a newly licensed nurse performing 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. 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 preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? - Open all sterile supplies and solutions. - Stabilize the tracheostomy tube. - Don sterile gloves. - Perform hand hygiene.
Perform hand hygiene.
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? - "Drink a minimum of 1,000 milliliters of fluid daily." - "Increase your intake of refined-fiber foods." - "Sit on the toilet 30 minutes after eating a meal." - "Take a laxative every day to maintain regularity."
"Sit on the toilet 30 minutes after eating a meal." 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 obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? - Auscultate for the blood pressure at the dorsalis pedis artery. - Measure the blood pressure with the client sitting on the side of the bed. - Place the cuff 7.6 cm (3 in) above the popliteal artery. - Place the bladder of the cuff over the posterior aspect of the thigh.
Place the bladder of the cuff over the posterior aspect of the thigh. This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.
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? - Stand toward the client's stronger side. - Instruct the client to lean backward from the hips. - Place the wheelchair at a 45° angle to the bed. - Assume a narrow stance with feet 15 cm (6 in) apart.
Place the wheelchair at a 45° angle to the bed. Positioning the wheelchair at a 45° allows the client to pivot, lessening the amount of rotation required.
A nurse is preparing to perform mouth care for an unresponsive client. 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. 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 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 restaints.
Remove the restraints one at a time. The nurse should remove one restraint at a time for a client who is violent or noncompliant.
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? - 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 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.
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? - Fifth intercostal space just medial to the midclavicular line - Second intercostal space to the left of the sternum - Fifth intercostal space to the left of the sternum - Second intercostal space to the right of the sternum
Second intercostal space to the right of the sternum. 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 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. With this action, the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client.
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? - Rectal - Tympanic - Oral - Temporal
Temporal. 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 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 5 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. 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 witnessing a client sign 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. 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 performing an abdominal assessment for an adult client. Identify the correct dequence of steps for this assessment. (Move the sequence of steps into the box on the right, placeing them in the selected order of performance. Use all the steps.) - Inspection - Palpation - Percussion - Auscultation
inspection, auscultation, percussion, palpation. 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 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."
Tell me what I can do to help you overcome your fear of giving yourself injections." 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 demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements includes a lack of readiness to learn by the client? - The client asks the nurse to repeat the instructions before attempting the exercises. - The client reports severe pain. - The client asks the nurse how often deep breathing should be done after surgery. - The client tells the nurse that this exercise will probably be painful after surgery.
The client reports severe pain. A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity.
A nurse is providing postoperative 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? - "Ask your provider to prescribe epoetin before the surgery." - "You should ask your provider about taking iron supplements prior to the surgery." - "Request a family member to donate blood for you." - "Donate autologous blood before the surgery."
"Donate autologous blood before the surgery." 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 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? - "I should expect my heart rate to take longer to return to normal after exercise as I get older." - "Urinary incontinence is something I will have to live with as I grow older." - "I can expect to have less ear wax as I get older." - "My stomach will empty more quickly after meals as I grow older."
"I should expect my heart rate to take longer to return to normal after exercise as I get older."
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? - "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 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? - "The reading will be inaudible if the cuff is too small for the client." - "The width of the cuff bladder should be 75% of the circumference of the client's arm." - "As long as the cuff will circle the arm the reading will be accurate." - "Using a cuff that is too small will result in an inaccurately high reading."
"Using a cuff that is too small will result in an inaccurately high reading."
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. 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. 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 admitting 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. - Assess for leg pain.
Evaluate pedal pulses. 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.
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. 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 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. 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 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? - Audible click - Murmur - Third heart sound - Pericardial friction rub
Pericardial friction rub: 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 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/mi , a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? - Heart rate 105/min - Soft, nontender abdomen - Temperature - Overdue menses
Temperature. Elevated temperature is an emergent physiological need, which requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the situation. Overdue menses
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 - 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. 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.
