ATI fundamental one exam questions and answers

A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR? Call for assistance. Begin chest compressions. Confirm unresponsiveness. Give rescue breaths. Confirm unresponsiveness. 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. Identify the client using two identifiers. A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? Change the topic because the client is trying to divert attention from the illness to the nurse. 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 the facility's chaplain Encourage the client to express his thoughts about death and dying. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? Lock the wheels on the bed and stretcher. Instruct the client to raise his arms above his head. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. Log roll the client. Lock the wheels on the bed and stretcher. A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Contact the family and ask them to stay with the client. Offer to call the client's minister. Sit and hold the client's hand. Leave the room and allow the client to cry privately. Sit and hold the client's hand. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Identify goals for client care. Obtain client information. Document nursing care needs. Evaluate the effectiveness of care. Obtain client information. A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "My parents are retired, and they have come to help out with our children." "I am going to ask my husband to go to counseling with me." "I keep having nightmares about my upcoming surgery." "My girlfriends bought me a nice wig." "I keep having nightmares about my upcoming surgery." MY ANSWER The nurse should recognize that nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate that the client is at risk for experiencing psychological distress. Temporal MY ANSWER The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is non-invasive and can be used to obtain a temperature in a toddler who may have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? The nurse washes each part of her hands with five strokes. The nurse washes from the elbows down to the hands. The nurse washes with her hands held higher than her elbows. The nurse uses minimal friction when washing her hands. The nurse washes with her hands held higher than her elbows. nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect? 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 collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses. Obtain a medical history. Measure vital signs. Ask the client if he is experiencing any pain in the leg. Evaluate pedal pulses. A charge nurse is observing a newly licensed nurse perform 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 Obtaining cotton balls for the tracheostomy care MY ANSWER Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing tracheal abscess. The charge nurse should intervene for this action. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Turn on the machine every 15 min to measure the client's blood pressure. Record only blood pressure readings needed for the 15-min intervals. Obtain manual and automatic readings and compare them. Disconnect the machine and measure the blood pressure manually every 15 min. Disconnect the machine and measure the blood pressure manually every 15 min. A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make? "Ask your provider to prescribe epoetin before the surgery." "You should take iron supplements prior to the surgery." "Request a family member donate blood for you." "Donate autologous blood before the surgery." "Donate autologous blood before the surgery." MY ANSWER Autologous blood transfusion is the collection and reinfusion of the client's own blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion; exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection. nurse is witnessing a client signing 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 The signature on the preoperative consent form is the client's. MY ANSWER 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. nurse is preparing to perform oral care for a client who is unresponsive. 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 Raise the level of the bed. MY ANSWER The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-inj