1. a nurse is assessing the heart sounds of a client pericardial friction
who has developed chest pain that becomes worse rub
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 heart sounds should the
nurse document?
2. a nurse is obtaining the blood pressure in a clients place the bladder
lower extremity. which action should the nurse take? of the cuff over the
posterior aspect of
the thigh
3. a charge nurse is teaching adult CPR to a group of new confirm unrespon-
nurses. which actions should the charge nurse teach siveness
as the first response in CPR?
4. a nurse is caring for a client who requires a chest xray. identify the client
prior to the client being transported for the procedure, using two identi-
which actions should the nurse take first? fiers
5. a nurse is caring for a child who is postop following a administer anal-
tonsillectomy. which actions should the nurse take? gesics to the
child on a routine
schedule through-
out the day and
night
6. a nurse is providing teaching to a client who has heart the involvement of
failure about how to reduce his daily intake of sodium. the client in plan-
which factors is the most important in determining the ning the change
clients ability to learn new dietary habits?
7. a charge nurse is observing a new nurse perform obtaining cotton
tracheostomy care for a client. which actions by the balls for the trach
new nurse requires intervention? care
8. a nurse is preparing to perform mouth care for an raise the level of
unresponsive client. which actions should the nurse the bed
plan to take?
, ATI Fundamentals CMS 2023
9. a nurse is witnessing a client sign an informed con- the signature on
sent form for surgery. which describes what the nurse the preop consent
is affirming by this action? form is the clients
10. a nurse is preparing to provide tracheostomy care for perform hand hy-
a client. which actions should the nurse take first? giene
11. a nurse is caring for an older adult client who becomes what worries you
agitated when the nurse requests that the clients den- about being with-
tures be removed prior to surgery. which responses out your teeth?
should the nurse make?
12. a nurse in an oncology clinic is assessing a client who i keep hav-
is undergoing treatment for ovarian cancer. which as- ing nightmares
sessment statements by the client indicates she is about my upcom-
experiencing psychological distress? ing surgery
13. a nurse on a med surg unit is caring for a client. which obtain client infor-
actions should the nurse take first when using the mation
nursing process?
14. a nurse is caring for an older adult client who is violent remove the re-
and attempting to disconnect her IV lines. the provider straints one at a
prescribes soft wrist restraints. which actions should time
the nurse take while the client is in restraints?
15. a nurse is planning care for a client who reports ab- temperature
dominal pain. an assessment by the nurse reveals the
client has a temp of 102.6, HR of 105, a soft nontender
abdomen, and menses overdue by 2 days. which find-
ings should be the nurses priority?
16. a nurse is inserting an IV catheter for a client that re- carefully remove
sults in a blood spill on her gloved hand. the client has the gloves and fol-
no documented bloodstream infection. which action low with hand hy-
should the nurse take? giene
17.
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