ATI Fundamentals Practice Quiz 1

A nurse is teaching a group of older adults about suspected changes of aging. Which statement by a group member indicates effective teaching? I should expect my HR to take longer to return to normal after exercise. Urinary incontinence is something I have to live with as I get 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 HR to take longer to return to normal after exercise. A nurse is caring for a patient who is post-op with paralytic ileus. Which abdominal assessment is expected? 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 planning care for a client with abdominal pain. An assessment reveals temperature of 102.6 F, HR 105, soft-non-tender abdomen, menses overdue by 2 days. Which of the following findings should be the priority? Heart rate Soft, non-tender abdomen Temperature Overdue menses - Temperature Which instruction should be followed for a child who is post-op following a tonsillectomy? Encourage frequent coughing to clear congestion from anesthesia. Place a heating pat at child's neck for comfort. Administer analgesics to the child on a routine schedule throughout the day. Provide the child with ice cream when oral intake is initiated. - Administer analgesics to the child on a routine schedule throughout the day. The nurse auscultates a high-pitched scratching sound during 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 nurse is teaching an assistive personnel about proper hand hygiene. Which statement from AP indicates understanding? "There are times I should use soap and water instead of alcohol-based sanitizer" "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 instead of alcohol-based sanitizer" A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes using an electronic BP machine. The nurse notices the machine begins to measure BP at varied intervals and readings are inconsistent. which action should the nurse take? Turn on the machine every 15 minutes to measure the BP. Record only BP readings needed for the 15-min intervals. Obtain manual and automatic readings & compare them. Disconnect the machine, measure the BP manually every 15 minutes. - Disconnect the machine, measure the BP manually every 15 minutes. A nurse is providing teaching to a client who has heart failure about how to reduce his sodium intake. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? Involvement of client in planning the change Emphasis provider places on the dietary changes 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 Nurse is obtaining vitals for a 2-year old child who is experiencing diarrhea and may have right ear infection. Which route should be used to measure temperature? Rectal tympanic oral temporal - Temporal- oral temp. is not suitable for kids under 3 A nurse is witnessing a client sign an informed consent form for surgery. What describes what the nurse is affirming this action? The client fully understands the provider's explanation of this procedure. The client has been informed about risks/benefits of procedure The nurse witnessed provider's explanation of procedure The signature on pre-op consent form is the client's - The signature on the pre-op consent form is the client's Nurse on a med-surg unit is admitting a client. Which of the following does the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress - Assessment Nurse on a med-surg unit is washing her hands prior to assisting in a surgical procedure. Which action indicates proper surgical handwashing? Nurse washes each part of her hands with 5 strokes Nurse washes from elbows down to hands Nurse washes with hands held higher than elbows Nurse uses minimal friction when washing her hands - Nurse washes with hands held higher than elbows A nurse at a screening clinic is assessing a client who reports a history of a heart murmur r/t aortic valve stenosis. At which of the following anatomical areas should the nurse use stethoscope to auscultate aortic valve? 5th IC space just medial to MCL 2nd IC space to L of sternum 5th IC space to L of sternum 2nd IC space to R of sternum - 2nd IC space to R of sternum A nurse notices an irregularity in the pulse when measuring patient's vital signs. Which action should the nurse take? Measure pulse using Doppler ultrasound stethoscope. Check the client's pedal pulses. Count the apical pulse rate for 1 full minute, 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, describe the rhythm in the chart. A nurse is caring for an an older adult client who becomes agitated when the nurse requests that the dentures must be removed prior to surgery. Which response 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 broken or lost 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 has a terminal illness. The client asks several questions regarding the nurse's religious beliefs related to death and dying. How should the nurse respond? Change the topic because the client is trying to divert attention from the illness. 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 facility's chaplain. - Encourage the client to express his thoughts about death and dying. A nurse is caring for a client who has T1DM and is resistant to learning selfinjection 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 injections. It's okay- your partner will be able to learn to give you injections. You won't be able to go home without learning how to give yourself injections. - Tell me what I can do to help you overcome your fear of giving yourself injections.