ATI Week Three Quiz Three

A nurse is caring for a client who had fallen while getting out of bed and states, " I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? 1. "The provider was notified." 2. "An incident report was completed." 3. "An incident report was forwarded to risk management." 4. "The were no injuries sustained."

1. "The provider was notified."

A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of the steps the nurse should take to conduct the assessment. 1. Ask the client about having a history of abdominal pain. 2. Inspect the abdomen for skin integrity. 3. Palpate the abdomen lightly for tenderness. 4. Percuss the abdomen in each of the four quadrants. 5. Auscultate the abdomen for bowel sounds.

1. Ask the client about having a history of abdominal pain. 2. Inspect the abdomen for skin integrity. 5. Auscultate the abdomen for bowel sounds. 3. Palpate the abdomen lightly for tenderness. 4. Percuss the abdomen in each of the four quadrants.

An assistive personnel reports a client's vital signs as tympanic temperature 37.1 C (98.8 F), pulse 92 per minute, respiratory 18 per minute, and BP 98/58 mmHg. Which of the following vital signs should the nurse re-measure? 1. BP 2. Respiratory rate 3. Pulse rate 4. Temperature

1. BP

A nurse is preparing to teach a client who had a low literacy level. Which of the following methods should the nurse plan to include? 1. Have short teaching sessions. 2. Refer to the client in the third person during the session. 3. Emphasize four important points at each session. 4. Use a passive voice to explain the information.

1. Have short teaching sessions.

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? 1. Nausea 2. Petechiae 3. Cyanosis 4. Blood Pressure

1. Nausea

You are caring for Mr. Smith, which of the following includes objectives and subjective data? 1. Patient's cholesterol is elevated, and stated that he likes fried food. 2. Patient states she is having trouble sleeping and drink coffee at night. 3. Patient's BP is 132/68 and HR is 88. 4. Patient states he get frequent headaches and take aspirin for it.

1. Patient's cholesterol is elevated, and stated that he likes fried food.

A nurse is measuring a client's oral temperature. The client informs the nurse that he had just eaten some ice chips. Which of the following action should the nurse take? 1. Wait 30 minutes and return to measure the oral temperature. 2. Provide the client a sip of warm water, wait 5 minutes, and measure the temperature. 3. Document that the nurse was unable to measure the client's temperature. 4. Proceed to measure the oral temperature.

1. Wait 30 minutes and return to measure the oral temperature.

A nurse is evaluating the outcomes for an outpatient client who had depression. Which of the the following client statements indicates a need for further evaluation? 1. "I can't wait to have my family together next weekend!" 2. "I just don't like going to the movies like I used to." 3. "I had a great trip to the Smokey Mountains." 4. "Going back to work had been okay."

2. "I just don't like going to the movies like I used to."

A nurse is creating a discharge plan. Which of the following nursing statement indicates the nurse understand when discharge planning should be implemented? 1. "I will begin once the client's discharge order is written." 2. "I will begin upon the client's admission to the facility. " 3. "I will begin once the client's insurance company " 4. "I will begin 48 hours before the client's discharge."

2. "I will begin upon the client's admission to the facility. "

A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the nurse acting as an advocate? 1. A client who has previously undergone a procedure that is to be performed for a second time. 2. An older adult client who had no family and is uncertain about moving to assisted living. 3. A client who makes an informed decision not to participate in chemotherapy treatment. 4. A client who has been educated on treatment options and chooses alternative treatments.

2. An older adult client who had no family and is uncertain about moving to assisted living.

A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hours postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is at 94% and her apical hart rate is at 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report? 1. Recommendation 2. Assessment 3. Situation 4. Background

2. Assessment

A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Select all that apply. 1. Using the outcomes preprinted on the clinical pathway. 2. Developing culturally appropriate outcomes. 3. Doing whatever it takes for the patient, no matter the cost 4. Involving the patient and family in formulating outcomes.

2. Developing culturally appropriate outcomes. 4. Involving the patient and family in formulating outcomes.

A Native American is admitted to the hospital with a rash, cough, and fever. Which is the most important information for the nurse to gather from the nursing assessment? 1. Employment status 2. Immunization history 3. Food preference 4. Use of Alcohol

2. Immunization history

After suffering a heart attack, a patient needs cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow's Hierarchy of Needs, cardiac rehab addresses what level of need? 1. Safety and Security 2. Physiological 3. Self-esteem 4. Self-actualization

2. Physiological

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? 1. Speak using his usual tone of voice. 2. Stand directly in front of the client. 3. Determine if the client uses hearing aids. 4. Rephrase statements the client does not hear.

3. Determine if the client uses hearing aids. Use the nursing process to answer this question: Assessment, Diagnose, Planning, Implementation, Evaluation

The RN is communication with her patient, which of the following actions is an example of an active listening behavior? 1. Taking frequent notes 2. Sitting with legs crossed. 3. Leaning in, facing the patient.

3. Leaning in, facing the patient.

While assisting an older adult patient, the nurse notes clubbing of the fingers. This is a sign of: 1. Poor Hygiene 2. Iron Deficiency 3. Long term hypoxia 4. Fungal infection

3. Long term hypoxia

A nurse is caring for a client who had returned to the unit following a surgical procedure. The client's oxygen saturation is at 85%. Which of the following action should the nurse take first? 1. Administer prescribed analgesic medication. 2. Encourage coughing and deep breathing 3. Raise the head of the bed. 4. Administer oxygen at 2L/min

3. Raise the head of the bed.

A nurse is preforming a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? 1. Vital signs 2. Severity of the condition 3. Self-report of pain 4. Nonverbal behavior

3. Self-report of pain

A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take? 1. Document in the chart that an incidence report has been filed. 2. Make a copy of the incident report for the provider. 3. Submit an incident report to the risk manager. 4. Place the incident report in the client's chart.

3. Submit an incident report to the risk manager.

A nurse is assessing a client for pitting edema and notes an indentation of 6mm (0.25 inch) at the point pressure. Which of the following notations should the nurse use to document the severity of the client's edema? 1. +1 2. +4 3. +2 4. +3

4. +3 Grade 0: No pitting edema Grade 1: The pressure leaves an indentation of 0-2 millimeters (mm) that rebounds immediately. This is the least severe type of pitting edema. Grade 2: The pressure leaves an indentation of 3-4 mm that rebounds in fewer than 15 seconds. Grade 3: The pressure leaves an indentation of 5-6 mm that takes up to 30 seconds to rebound. Grade 4: The pressure leaves an indentation of 8 mm or deeper. It takes more than 20 seconds to rebound.

While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as to which of the following? 1. A third heart sound (S3) 2. An expected heart sound 3. A fourth heart sound (S4) 4. A systolic murmur

4. A systolic murmur

A nurse is teaching an adult client who has a low literacy level about self administration of a subcutaneous medication. Which of the following strategies should the nurse use to promote the client's understanding? 1. Provide the client with written material using large print. 2. Simplify terms using acronyms. 3. Provide a long teaching session. 4. Ask the client to demonstrate the skill.

4. Ask the client to demonstrate the skill.

A nurse is caring for a client who requests prescription pain medication. Which of the following action should the nurse perform first? 1. Administer the medication. 2. Reposition the client. 3. Review the effects of the pain medication. 4. Determine the location of the pain.

4. Determine the location of the pain. Use the nursing process to answer this question: Assessment, Diagnose, Planning, Implementation, Evaluation

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment finding require further investigation by the nurse? 1. Concave Umbilicus 2. Bilateral bowel sounds in lower quadrants 3. Symmetrical convex sphere shape 4. Ecchymosis

4. Ecchymosis (Blood or bleeding under the skin due to trauma of any kind; typically black and blue at first, with color changes as healing progresses.)

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instructions? 1. Wraps the blood pressure cuff snugly around the client's arm 2. Checks the instrument gauge to ensure the reading starts at zero 3. Centers the cuff bladder over the client brachial artery 4. Places the client's arm above the level of the client's heart

4. Places the client's arm above the level of the client's heart

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? 1. Place the client of bed rest in Semi-Fowler's position. 2. Prepare to administer anti-biotics. 3. Instruct the client to limit fluid intake to less than 2,000 ml/day. 4. Repeat auscultation after asking the client to breathe deeply and cough.

4. Repeat auscultation after asking the client to breathe deeply and cough.

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality? 1. Preventing an unidentified health care worker from viewing a health record on the computer screen. 2. Using a computer terminal in a non-public area. 3. Logging out of the computer before leaving a terminal. 4. Sharing computer password with coworkers.

4. Sharing computer password with coworkers.

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?

The posterior tibial pulse is located on the inner ankle, one-third of the way along the line between the tip of the medial malleolus )end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm higher, where it runs behind the medial malleolus.

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse.

When assessing the apical pulse, the nurse would place the stethoscope between the fifth and sixth ribs at the left midclavicular line of the client's chest. The midclavicular line is the point of maximum impulse. This is the location of the apex of the heart.