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Ati RN Fundamentals 2023 Exam 3
Total Questions : 47
Showing 25 questions, Sign in for moreA nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)
A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Explanation
A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.
E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
A nurse is caring for a client who is scheduled for an appendectomy.
Exhibit 1 Exhibit 2 Exhibit 3
Nurses' Notes
1050:
Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the midabdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify. rebound tenderness noted. Reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea.
Peripheral IV to the left forearm with IV fluids infusing.
1200:
Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expressing concern about potential complications that could result from the surgery.
Medical History
1050:
Received influenza vaccine 1 month ago.
Thyroid disease, taking levothyroxine for 14 years. History of cholecystectomy 3 years ago.
Denies alcohol or illegal drug use. Reports smoking approximately 6 cigarettes per day for the past 10 years. Allergic to shellfish, latex, and penicillin.
Vital Signs
0945, Upon admission to emergency department (ED): Temperature 38.3°C(100.9° F)
Pulse rate 102/min Respiratory rate 22/min
Blood pressure 122/80 mm Hg Oxygen saturation 96% on room air Pain reported as 6 on a scale of 0 to 10.
1050, Upon admission to medical-surgical department Temperature 38,4° C (101.2° F)
Pulse rate 104/min Respiratory rate 22/min
Blood pressure 124/80 mm Hg Oxygen saturation 96% on room air Pain reported as 8 on a scale of 0 to 10
The nurse is preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.
A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?
A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?
A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?
A charge nurse is teaching a group of nurses about decreasing the risk for catheter- associated urinary tract infections in clients. Which of the following information should the nurse include in the teaching?
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)
A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?
A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take?
A nurse enters a client's room to perform a focused assessment. Which of the following client information should the nurse use to properly identify the client?
A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
A nurse is assessing a client who recently started taking an antibiotic. The nurse should identify that which of the following findings is an indication of a mild allergic reaction?
A charge nurse has four new clients arriving on the unit for admission. Which of the following clients should the nurse place in airborne precautions?
A nurse is assessing an older adult client's perception of sexuality. Which of the following statements made by the client indicates a need for intervention?
A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
A nurse is assessing a client who received morphine for severe pain 30 min ago. Which of the following findings is the nurse's priority?
A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?
A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, "I am looking forward to seeing my grandchildren grow up." The nurse should identify that the client is experiencing which of the following stages of grief?
A community health nurse is caring for a group of families. The nurse should identify that which of the following families is experiencing a maturational loss?
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