ATI: Fundamentals of Nursing CMS Review 2023 -2024 A+ A nurse provides an introduction to a client as the first step of a comprehensive physical examination. What strategies should the nurse use with the client? - ANSWER --Use a mix of open and close ended questions -reduce environmental noise -perform the general survery before the examination A nurse in a provider's office is documenting findings following an examination performed for a client new to th e practice. What parameters should the nurse include as part of the general survey? - ANSWER --Posture -Skin lesions -Speech A nurse is collecting data for a clients comprehensive physical examination. After inspecting the client's abdomen, what should the nurse perform next? - ANSWER -Auscultation A nurse is preparing to perform a comprehensive physical examination of an older client. What interventions should the nurse use in consideration of the client's age? - ANSWER --Plan to allow plenty of time for po sition changes -make sure the client has any essential sensory aids in place -Tell the client to take their time answering questions -invite the client to use the bathroom before beginning the examination A nure in a providers office is performing a physical examination of an older client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? - ANSWER -
Dorsal surface A nurse is caring for a client in the e mergency department who has an oral body tempertature of 38.3 'C, pulse rate 114/min, and respiratory rate 22/min. What interventions should the nurse take? - ANSWER --obtain culture specimens before initiating antimicrobials -encourage the client to rest a nd limit activity -assist client with oral hygiene frequently A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. What instruction is priority for measuring vital signs for this client? - ANSWER -Do no t measure the client's temp rectally A nurse is instructing a group of assistive personnel in measuring a clients respiratory rate. What guidelines should the nurse include? - ANSWER --place the client in semi -fowlers position -have the client rest an arm across the abdomen -observe one full respiratory cycle before counting the rate A nurse is measuring the BP of a client who has a fractured femur. The BP reading is 140/94 mm Hg, and the client denies any history of hypertension. What action should the nu rse take first? - ANSWER -ask the client if they are having pain A nurse is providing an admission assessment on a client. The nurse determines the clients radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the clients pu lse deficit? - ANSWER -16/min; Pulse deficit is the difference between apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to the peripheral pulse points 84-68= 16 A nurse in a pro viders office is preparing to test a clients cranial nerve function. What directions should the nurse include when testing cranial nerve V? - ANSWER -Clench your teeth Tell me when you feel a touch
Dorsal surface A nurse is caring for a client in the e mergency department who has an oral body tempertature of 38.3 'C, pulse rate 114/min, and respiratory rate 22/min. What interventions should the nurse take? - ANSWER --obtain culture specimens before initiating antimicrobials -encourage the client to rest a nd limit activity -assist client with oral hygiene frequently A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. What instruction is priority for measuring vital signs for this client? - ANSWER -Do no t measure the client's temp rectally A nurse is instructing a group of assistive personnel in measuring a clients respiratory rate. What guidelines should the nurse include? - ANSWER --place the client in semi -fowlers position -have the client rest an arm across the abdomen -observe one full respiratory cycle before counting the rate A nurse is measuring the BP of a client who has a fractured femur. The BP reading is 140/94 mm Hg, and the client denies any history of hypertension. What action should the nu rse take first? - ANSWER -ask the client if they are having pain A nurse is providing an admission assessment on a client. The nurse determines the clients radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the clients pu lse deficit? - ANSWER -16/min; Pulse deficit is the difference between apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to the peripheral pulse points 84-68= 16 A nurse in a pro viders office is preparing to test a clients cranial nerve function. What directions should the nurse include when testing cranial nerve V? - ANSWER -Clench your teeth Tell me when you feel a touch
