ATI Learning System RN 3.0 Fundamentals 1 Quiz (Questions and Answers With Rationale

ATI Learning System RN 3.0 Fundamentals 1 Quiz (Questions and Answers With Rationale

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?

- Audible click

- Murmur

- Third heart sound

- Pericardial friction rub

{{Correct Ans- 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.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

- Auscultate for the blood pressure at the dorsalis pedis artery.

- Measure the blood pressure with the client sitting on the side of the bed.

- Place the cuff 7.6 cm (3 in) above the popliteal artery.

- Place the bladder of the cuff over the posterior aspect of the thigh.

{{Correct Ans- 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.

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurse. Which of the following actions should the charge nurse teach as the first response to CPR?

- Call for assistance.

- Begin chest compressions.

- Confirm unresponsiveness.

- Give rescue breaths.

{{Correct Ans- 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.

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?

- Explain the x-ray procedure to the client.

- Help the client into a wheelchair before the transporter arrives.

- Ask if the client has any questions.

- Identify the client using two identifiers.

{{Correct Ans- 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.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

- Encourage the child to cough frequently to clear congestion from anesthesia.

- Place a heating pad at the child's neck for comfort.

- Administer analgesics to the child on a routine schedule throughout the day and night.

- Provide the child with ice cream when oral intake is initiated.

{{Correct Ans- Administer analgesics to the child on a routine schedule throughout the day and night.

To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route.

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

- The involvement of the client in planning the change

- The emphasis the provider places on the dietary changes

- The learning theory the nurse uses to teach the dietary changes

- The extent of the dietary changes planned for the client

{{Correct Ans- The involvement of the client in planning the change.

According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits.

A charge nurse is observing a newly licensed nurse performing tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

- Obtaining hydrogen peroxide for the tracheostomy care

- Obtaining cotton balls for the tracheostomy care

- Obtaining sterile gloves for the tracheostomy care

- Obtaining a sterile brush for the tracheostomy care

{{Correct Ans- Obtaining cotton balls for the tracheostomy care.

Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

- Place the client supine.

- Keep both side rails up.

- Raise the level of the bed.

- Inspect the client's mouth using a finger sweep.

{{Correct Ans- Raise the level of the bed.

The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury.

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

- The client fully understands the provider's explanation of the procedure.

- The client has been informed about the risks and benefits of the procedure.

- The nurse witnessed the provider's explanation of the procedure.

- The signature on the preoperative consent form is the client's.

{{Correct Ans- The signature on the preoperative consent form is the client's.

The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

- Open all sterile supplies and solutions.

- Stabilize the tracheostomy tube.

- Don sterile gloves.

- Perform hand hygiene.

{{Correct Ans- Perform hand hygiene.

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse take?

- "It's for your safety. Dentures can slip and block your airway during surgery."

- "You wouldn't want your teeth to be lost or broken during surgery, would you?"

- "The anesthesiologist requires everyone to remove their dentures."

- "What worries you about being without your teeth?"

{{Correct Ans- "What worries you about being without your teeth?"