ATI Fundamentals 1 Quiz
To use the NURSING PROCESS correctly, the nurse must FIRST
A. Identify the goals for the client's care
B. Obtain information about the client
C. State the client's nursing care needs
D. Evaluate the effectiveness of the client's care - ✅✅-B. Obtain information about
the client.
RATIONALE: while stating the client's needs, identifying goals, and evaluating the
effectiveness of the client's care is an appropriate step in the nursing process, it is
not the first step. The collection of data, or assessment, is the first step in the nursing
process.
A 3 YR OLD CHILD has had MULTIPLE TOOTH EXTRACTIONS while under
general anesthesia. The client returns from the PACU crying, but awake, from the
recovery room. Which APPROACH is likely to be successful?
A. Do not examine the mouth
B. Examine the mouth first
C. Examine the mouth last
D. Medicate the child for pain before examining the mouth - ✅✅-C. Examine the
mouth last
RATIONALE: it is always appropriate to leave the most distressing part of a physical
exam of a toddler until the end. Since the mouth is the area of discomfort, examining
it is likely to cause more crying and uncooperative behavior for the remainder of the
assessment.
The child just had oral surgery and is at risk for hemorrhage and swelling. It is
imperative that the mouth be examined. The child must be assessed for pain before
pain medication can be administered.
A nurse is performing an ABDOMINAL ASSESSMENT of an adult client. Identify the
correct sequence of steps used for this assessment.
RATIONALE: this sequence prevents altering the bowel sounds during an abdominal
assessment. The appropriate sequence for any other assessment of an adult client
is inspection, palpation, percussion, and auscultation.
A nurse is teaching a client who has cardiovascular disease how to reduce his intake
of sodium and cholesterol. The nurse understands that the MOST SIGNIFICANT
factor in PLANNING DIETARY CHANGES for this client is the
A. Involvement of the client in planning the change
B. Emphasis the provider places on the dietary changes
C. Financial ability of the client to make the dietary changes
D. Extent of the dietary changes planned for the client - ✅✅-A. Involvement of the
client in planning the change
RATIONALE: a client who is actively involved in planning dietary changes is more
receptive to the changes and is more likely to adhere to them.
The provider's approach and the extent of change is important when planning dietary
changes but is not the highest priority in this situation. If finances are an obstacle,
the nurse can advocate for the client by referring him to the appropriate social
service agencies.
While starting an IV for a client, the nurse notices that her GLOVED HANDS get
SPOTTED WITH BLOOD. The client has not been diagnosed with any infection
transmitted via the bloodstream. Which of the following should the nurse do as soon
as the task is completed?
A. Wash the gloved hands and then throw the gloves away
B. Prepare an incident report so that this occurrence will be documented
C. Remove the gloves carefully and follow with hand hygiene
, D. Ask the provider to order a blood culture to determine risk - ✅✅-C. Remove the
gloves carefully and follow with hand hygiene
RATIONALE: standard precautions require the use of gloves and hand hygiene in
the care of all clients. Unless there is a break in the nurse's skin, there is no need for
an incident report or further investigation. Washing the hands while still gloved is
unnecessary.
A nurse's neighbor is scheduled for ELECTIVE SURGERY. The neighbor's provider
indicated that a moderate amount of blood loss is expected during the surgery, and
the neighbor is anxious about acquiring an INFECTION from a BLOOD
TRANSFUSION. Which of the following is appropriate for the nurse to suggest?
A. Asking the provider about taking (epoetin) Epogen before the surgery
B. Taking iron supplements prior to the surgery
C. Requesting that a family member donate blood
D. Donating autologous blood before the surgery - ✅✅-D. Donating autologous
blood before the surgery
RATIONALE: autologous blood transfusion is the collection and re-infusion of the
client's own blood. With pre-op autologous blood donation, the blood is drawn from
the client 3-5 weeks before an ELECTIVE surgery and stored for transfusion at the
time of surgery. While blood bank tests greatly reduce the risks of acquiring certain
infectious diseases, these risks can not be eliminated entirely. Autologous blood is
the safest form of blood transfusion;
while taking Epogen prior to surgery may boost the client's hematocrit levels, it is
inappropriate if the client already has an adequate hematocrit. In addition, this action
may not eliminate the need and its related risks. While taking an iron supplement
prior to surgery may boost the client's hemoglobin levels, it is inappropriate if the
client already has an adequate hemoglobin level and intake of iron from dietary
sources. In addition, this action may not eliminate the need for a transfusion and its
related risks. The directed blood donation from a family member does not eliminate
the risk of acquiring an infection.
An assistive personnel tells the nurse, "I am unable to find a large blood pressure
cuff for a client who is obese. Can i just use the regular cuff if i can get it to stay on?"
The nurse replies that taking the blood pressure of a MORBIDLY OBESE client with
a REGULAR BP CUFF will result in a reading that is
A. Inaudible
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