Exam (elaborations)
ATI Fundamental Quiz 1 QAB.Nguyen
- Course
- BIOD 101
- Institution
- Portage Learning
ATI Fundamental Quiz 1 QAB.Nguyen 2025
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Adult Health; Learning System 3.0: ATI Fundamental Quiz 1 1ATI Fundamental Quiz 1
1. 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?
o Audible click
An audible clicking sound occurs in clients who have prosthetic valve replacement surgery.
o Murmur
A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through
valves or ventricular outflow tracts. Low- and medium-frequency sounds are more easily heard with the bell of the
stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur
can be a manifestation of valvular disease.
o Third heart sound
A third heart sound is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling
during diastole. It is best heard at the mitral area, with the client lying on the left side. An S3 is commonly heard in
children and young adults. In older adults and clients who have heart disease, an S3 often indicates heart failure.
o 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.
2. A nurse is obtaining the blood pressure in a clients lower extremity. Which of the following actions should the
nurse take?
o Auscultate for the blood pressure at the dorsalis pedis artery.
The nurse should auscultate for the blood pressure at the popliteal artery.
o Measure the blood pressure with the client sitting on the side of the bed.
The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie
supine with the knee flexed.
o Place the cuff 7.6 cm (3 in) above the popliteal artery.
The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.
o 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.
3. A charge nurse is teaching adult cardiopulmonary resuscitation to a group of newly licensed nurses. Which of the
following actions should the charge nurse teach as the first response in CPR?
o Call for assistance.
The nurse should call for assistance by activating the emergency response team. However, there is another action
the nurse should take first.
, Adult Health; Learning System 3.0: ATI Fundamental Quiz 1 2
o Begin chest compressions.
The nurse should begin chest compressions. However, there is another action the nurse should take first.
o 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.
o Give rescue breaths.
The nurse should give rescue breaths. However, there is another action the nurse should take first.
4. 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?
o Explain the x-ray procedure to the client.
The nurse should explain the x-ray procedure to the client. However, there is another action the nurse should take
first.
o Help the client into a wheelchair before the transporter arrives.
The nurse should have the client ready for the procedure. However, there is another action the nurse should take
first.
o Ask if the client has any questions.
The nurse should inquire if the client has any questions about the procedure. However, there is another action the
nurse should take first.
o 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.
5. A nurse is caring for a child who is post operative following a tonsillectomy. Which of the following actions should
the nurse take?
o Encourage the child to cough frequently to clear congestion from anesthesia.
The child should be discouraged from coughing or clearing the throat following a tonsillectomy because these
actions can contribute to bleeding.
o Place a heating pad at the child's neck for comfort.
The nurse should offer an ice collar, not a heating pad, to ease the child’s pain.
o Administer analgesics to the child on a routine schedule throughout the day and night.
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