ATI Learning System Fundamentals Quiz 1 (question and answers)

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? 1. change the topic because the client is trying to divert attention from the illness to the nurse. 2. Encourage the client to express his thought about death and dying. 3. Tell the client that religious beliefs are a personal matter 4. Offer to contact the client's minister or the facility's chaplain. - ANS2. Encourage the client to express his thought about death and dying. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? 1. open all sterile supplies and solutions 2. Stabilize the tracheostomy tube. 3. Don sterile gloves 4. Perform hand hygiene. - ANS4. Perform hand hygiene. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? 1. Measure the pulse using a doppler ultrasound stethoscope 2. check the client's pedal pulses. 3. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. 4. Take the pulse at each peripheral site and count the rate for 30 seconds. - ANS3. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. 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? 1. Identify goals for client care 2. Obtain client information 3. Document nursing care needs. 4. Evaluate the effectiveness of care - ANS2. Obtain client information 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? 1. Lock the wheels on the bed and stretcher 2. Instruct the client to raise his arms above his head. 3. Elevate the stretcher 2.3 cm (1in) above the height of the bed 4. Log roll the client - ANS1. Lock the wheels on the bed and stretcher A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? 1. Evaluate pedal pulses. 2. Obtain a medical history. 3. Measure vital signs. 4. Assess for leg pain. - ANS1. Evaluate pedal pulses. A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? 1. Frequent bowel sounds with flatus. 2. Absent bowel sounds with distention. 3. Hyperactive bowel sounds with diarrhea. 4. Normal bowel sounds with increased peristalsis - ANS2. Absent bowel sounds with distention. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? 1. "Drink a minimum of 1,000 milliliters of fluid daily." 2. "Increase your intake of refined-fiber foods." 3. "Sit on the toilet 30 minutes after eating a meal." 4. "Take a laxative every day to maintain regularity." - ANS3. "Sit on the toilet 30 minutes after eating a meal." 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? 1. Audible click 2. Murmur 3. Third heart sound 4. Pericardial friction rub - ANS4. Pericardial friction rub A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? 1. The client asks the nurse to repeat the instruction before attempting the exercises 2. The client reports severe pain 3. The client asks the nurse who often deep breathing should be done after surgery 4. The client tells the nurse that this exercise will probably be painful after surgery - ANS2. The client reports severe pain A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicated that the teaching has been effective? 1. "I should expect my heart rate to take longer to return to normal after exercise as I get older." 2. "Urinary incontinence is something I will have to deal with as I grow older." 3. "I can expect to have less ear wax as I get older." 4. "My stomach will empty more quickly after meals as I grow older." - ANS1. "I should expect my heart rate to take longer to return to normal after exercise as I get older." A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? 1. "Tell me what I can do to help you overcome your fear of giving yourself injection." 2. "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." 3. "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." 4. "You won't be able to go home unless you learn to give yourself insulin injections." - ANS1. "Tell me what I can do to help you overcome your fear of giving yourself injection." A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion Which of the following statements should the nurse make to the client? 1. "Ask your provider to prescribe epoetin before the surgery." 2. "You should ask your provider about taking iron supplements prior to the surgery." 3. "Request a family member to donate blood for you." 4. "Donate autologous blood before the surgery." - ANS4. "Donate autologous blood before th