ATI Pediatrics Proctored Exam 9 2025
VERIFIED A+
AQnurseQisQadministeringQ1QLQofQ0.9%QsodiumQchlorideQtoQaQclientQwhoQisQpostoperativeQandQh
asQfluidQvolumeQdeficit.QWhichQofQtheQfollowingQchangesQshouldQtheQnurseQidentifyQasQanQindica
tionQthatQtheQtreatmentQwasQsuccessful?
IncreaseQinQhematocritQincrea
seQinQrespiratoryQrateQDecreas
eQinQheartQrate
DecreaseQinQcapillaryQrefillQtimeQ-QCorrectQAnswer:
DecreaseQinQheartQrate
FluidQvolumeQdeficitQcausesQtachycardia.QWithQcorrectionQofQtheQimbalance,QtheQheartQrateQshoul
dQreturnQtoQtheQexpectedQrange.
IncorrectQAnswers:
IncreaseQinQhematocrit:
FluidQvolumeQdeficitQcausesQanQincreaseQinQhematocritQlevelQdueQtoQdepletionQofQextracellularQfl
uid.QWithQcorrectionQofQtheQimbalance,QtheQhematocritQlevelQshouldQdecrease.
increaseQinQrespiratoryQrate
FluidQvolumeQdeficitQcausesQanQincreaseQinQrespiratoryQrate.QWithQcorrectionQofQtheQimbalance,
QtheQrespiratoryQrateQshouldQreturnQtoQtheQexpectedQrange.
DecreaseQinQcapillaryQrefillQtime
FluidQvolumeQdeficitQslowsQcapillaryQrefill.QWithQcorrectionQofQtheQimbalance,QcapillaryQrefillQti
meQshouldQreturnQtoQtheQexpectedQrange.
AQnurseQisQcaringQforQaQclientQwhoQisQscheduledQtoQbeQtransferredQtoQaQlong-
termQcareQfacility.QTheQclient'sQfamilyQquestionsQtheQnurseQaboutQtheQreasonsQforQtheQtransfer.Q
WhichQofQtheQfollowingQresponsesQmadeQbyQtheQnurseQisQappropriate?
"TheQtransferQofQyourQfamilyQmemberQisQbeingQdoneQbecauseQtheQproviderQknowsQwhat'sQbest."Q
"WouldQyouQlikeQitQifQweQdiscussedQtheQtransferQwithQyourQfamilyQmember?"
"WhyQareQyouQsoQconcernedQaboutQthisQtransfer?"
"IQknowQhowQyouQfeel.QMyQparentQhadQtoQbeQtransferredQtoQaQlong-termQcareQfacility."Q-
QCorrectQAnswer:
"WouldQyouQlikeQitQifQweQdiscussedQtheQtransferQwithQyourQfamilyQmember?"
ThisQresponseQfacilitatesQtherapeuticQcommunicationQandQprovidesQgeneralQleadsQwhileQmaint
ainingQclientQconfidentiality.
IncorrectQAnswers:
"TheQtransferQofQyourQfamilyQmemberQisQbeingQdoneQbecauseQtheQproviderQknowsQwhat'sQbes
t."QThisQisQaQdefensiveQresponseQwhichQcanQhinderQfurtherQcommunication.
"WhyQareQyouQsoQconcernedQaboutQthisQtransfer?"
,AskingQaQwhyQquestionQcanQmakeQtheQrecipientQdefensiveQwhichQcanQhinderQfurtherQcommun
ication.
"IQknowQhowQyouQfeel.QMyQparentQhadQtoQbeQtransferredQtoQaQlong-
termQcareQfacility."QThisQisQaQsympatheticQresponse,QwhichQcanQinterfereQwithQaQthera
peuticQrelationship.
AQnurseQisQreviewingQtheQlaboratoryQresultsQofQaQfemaleQclientQwhoQhasQhypovolemia.QWhichQof
QtheQfollowingQlaboratoryQresultQwouldQbeQaQpriorityQforQtheQnurseQreportQtoQtheQprovider?
BUNQ21Qmg/dLQ(10QtoQ20Qmg/dL)
CreatinineQ1.4Qmg/dLQ(0.5QtoQ1.1Qmg/dL)
SodiumQ132QmEq/LQ(136QtoQ145QmEq/L)
PotassiumQ5.8QmEq/LQ(3.5QtoQ5QmEq/L)Q-QCorrectQAnswer:
PotassiumQ5.8QmEq/LQ(3.5QtoQ5QmEq/L)
WhenQusingQtheQurgentQversusQnonurgentQapproachQtoQclientQcare,QtheQnurseQshouldQdetermineQt
hatQthisQpotassiumQlevelQisQaboveQtheQexpectedQreferenceQrangeQandQshouldQbeQreportedQtoQtheQp
rovider.QPotassiumQaffectsQtheQcontractilityQofQtheQheartQandQthisQclientQwouldQbeQatQriskQforQde
velopingQdysrhythmias.
IncorrectQanswers:
BUNQ21Qmg/dLQ(10QtoQ20Qmg/dL)
ThisQBUNQlevelQisQslightlyQaboveQtheQexpectedQreferenceQrangeQandQisQanQexpectedQnon-
urgentQfindingQforQaQclientQwhoQhasQhypovolemia;Qtherefore,QthereQisQanotherQlaboratoryQresultQt
hatQisQaQpriorityQforQtheQnurseQtoQreportQtoQtheQprovider.
CreatinineQ1.4Qmg/dLQ(0.5QtoQ1.1Qmg/dL)
ThisQcreatinineQlevelQisQslightlyQaboveQtheQexpectedQreferenceQrangeQandQisQanQexpectedQnon-
urgentQfindingQforQaQclientQwhoQhasQhypovolemia;Qtherefore,QthereQisQanotherQlaboratoryQresultQ
thatQisQaQaQpriorityQforQtheQnurseQtoQreportQtoQtheQprovider.
SodiumQ132QmEq/LQ(136QtoQ145QmEq/L)
ThisQsodiumQlevelQisQslightlyQbelowQtheQexpectedQreferenceQrangeQandQisQanQexpectedQnon-
urgentQfindingQforQaQclientQwhoQhasQhypovolemia;Qtherefore,QthereQisQanotherQlaboratoryQresultQ
thatQisQaQpriorityQforQtheQnurseQtoQreportQtoQtheQprovider.
AQnurseQisQcaringQforQaQclientQwhoQreportsQdifficultyQfallingQasleep.QWhichQofQtheQfollowingQrec
ommendationsQshouldQtheQnurseQmake?
"DrinkQaQcupQofQhotQcocoaQbeforeQbedtime."Q"Mai
ntainQaQconsistentQtimeQtoQwakeQupQeachQday."Q"E
xerciseQ1QhourQbeforeQgoingQtoQbed."
"WatchQaQtelevisionQprogramQinQbedQbeforeQgoingQtoQsleep."Q-
QCorrectQAnswer:Q"MaintainQaQconsistentQtimeQtoQwakeQupQeachQday."
TheQclientQshouldQmaintainQaQconsistentQtimeQforQwakingQupQandQgoingQtoQsleep.QThisQhel
psQtoQestablishQanQinternalQsenseQofQsleepQandQwakingQonQaQdailyQbasisQandQhelpsQtoQmaint
ainQitQoverQtime.QThisQwillQhelpQpromoteQsleepQforQtheQclient.
,IncorrectQAnswers:
"DrinkQaQcupQofQhotQcocoaQbeforeQbedtime."
CocoaQcontainsQcaffeine,QwhichQisQaQstimulantQthatQcanQinterfereQwithQsleep.
"ExerciseQ1QhourQbeforeQgoingQtoQbed."
ExercisingQwithinQ2QhrQofQbedtimeQcanQinterfereQwithQsleep.
"WatchQaQtelevisionQprogramQinQbedQbeforeQgoingQtoQsleep."
TheQclientQshouldQavoidQwatchingQtelevisionQinQbedQbeforeQgoingQtoQsleepQtoQreduceQstimulation
QinQorderQtoQpromoteQrest.
AQnurseQonQaQmedical-
surgicalQunitQisQcaringQforQaQclientQwhoQhasQaQnewQprescriptionQforQwristQrestraints.QWhichQofQf
ollowingQactionsQshouldQtheQnurseQtake?
PadQtheQclient'sQwristQbeforeQapplyingQtheQrestraints.QEval
uateQtheQclient'sQcirculationQeveryQ8QhrQafterQapplication.
RemoveQtheQrestraintsQeveryQ4QhrQtoQevaluateQtheQclient'sQstatus.Q
SecureQtheQrestraintQtiesQtoQtheQbed'sQsideQrails.Q-
QCorrectQAnswer:QPadQtheQclient'sQwristQbeforeQapplyingQtheQrestr
aints.
TheQuseQofQrestraintsQwithoutQpaddingQcanQabradeQtheQclient'sQskin,QresultingQinQclientQinjury.
IncorrectQAnswers:
EvaluateQtheQclient'sQcirculationQeveryQ8QhrQafterQapplication.
TheQnurseQshouldQevaluateQtheQclient'sQcirculation,QrangeQofQmotion,QvitalQsigns,QandQoverallQstat
usQeveryQ15QminQafterQinitialQapplicationQofQrestraints.
RemoveQtheQrestraintsQeveryQ4QhrQtoQevaluateQtheQclient'sQstatus.
TheQnurseQshouldQremoveQtheQrestraintsQatQleastQeveryQ2QhrQtoQrepositionQtheQclientQandQasses
sQneedsQforQhygieneQandQtoileting.
SecureQtheQrestraintQtiesQtoQtheQbed'sQsideQrails.
TheQnurseQshouldQsecureQtheQrestraintQtiesQtoQaQpartQofQtheQbedQframeQthatQmovesQwithQtheQclie
ntQtoQreduceQtheQriskQofQinjury.
AQclientQwhoQisQnonambulatoryQnotifiesQtheQnurseQthatQtheirQtrashQcanQisQonQfire.QAfterQtheQnurs
eQconfirmsQtheQpresenceQofQtheQfire,QwhichQofQtheQfollowingQactionsQshouldQtheQnurseQtakeQnext
?
ActivateQtheQemergencyQfireQalarm.QExtingui
shQtheQfire.
EvacuateQtheQclient.
ConfineQtheQfire.Q-QCorrectQAnswer:
EvacuateQtheQclient.
AccordingQtoQtheQRACEQmnemonic,QtheQfirstQactionQinQresponseQtoQaQfireQisQtoQrescueQtheQclient
s,QmovingQthemQtoQaQsafeQarea.
, IncorrectQAnswers:
ActivateQtheQemergencyQfireQalarm.
AccordingQtoQtheQRACEQmnemonic,QtheQsecondQactionQinQresponseQtoQaQfireQisQtoQactivateQth
eQalarm.
ExtinguishQtheQfire.
AccordingQtoQtheQRACEQmnemonic,QtheQfourthQactionQinQresponseQtoQaQfireQisQtoQattemptQtoQexti
nguishQtheQfire.
ConfineQtheQfire.
AccordingQtoQtheQRACEQmnemonic,QtheQthirdQactionQinQresponseQtoQaQfireQisQtoQcontainQtheQfire
QbyQclosingQallQtheQdoorsQandQwindowsQinQtheQarea.QTheQnurseQshouldQalsoQturnQoffQoxygenQand
QelectricalQequipmentQinQtheQareaQofQtheQfire.
AQnurseQisQpreparingQtoQadministerQ0.9%QsodiumQchlorideQ750QmLQIVQtoQinfuseQoverQ7Qhr.QTh
eQnurseQshouldQsetQtheQinfusionQpumpQtoQdeliverQhowQmanyQmL/hr?Q-Q107QmL/hr
AQnurseQisQassessingQfourQadultQclients.QWhichQofQtheQfollowingQphysicalQassessmentQtechniques
QshouldQtheQnurseQuse?
UseQtheQFace,QLegs,QActivity,QCry,QandQConsolabilityQ(FLACC)QpainQratingQscaleQforQaQclientQ
whoQisQexperiencingQpain.
EnsureQtheQbladderQofQtheQbloodQpressureQcuffQsurroundsQ80%QofQtheQclient'sQarm.
ObtainQanQapicalQheartQrateQbyQauscultatingQatQtheQthirdQintercostalQspaceQleftQofQtheQsternum.
QPalpateQtheQclient'sQabdomenQbeforeQauscultatingQbowelQsounds.Q-QCorrectQAnswer:
EnsureQtheQbladderQofQtheQbloodQpressureQcuffQsurroundsQ80%QofQtheQclient'sQarm.
TheQnurseQshouldQuseQaQbloodQpressureQcuffQwithQaQbladderQthatQsurroundsQ80%QofQtheQclient'sQ
armQcircumferenceQtoQgiveQanQaccurateQreading.
IncorrectQAnswers:
UseQtheQFace,QLegs,QActivity,QCry,QandQConsolabilityQ(FLACC)QpainQratingQscaleQforQaQclientQ
whoQisQexperiencingQpain.
TheQnurseQshouldQuseQanQage-appropriateQpain-
ratingQscale,QsuchQasQtheQvisualQanalogQorQnumericalQscale,QwhenQassessingQtheQpainQlevelQofQan
Qadult.QTheQFLACCQpainQratingQscaleQisQusedQforQclientsQagedQfromQ2QmonthsQtoQ7QyearsQold.
ObtainQanQapicalQheartQrateQbyQauscultatingQatQtheQthirdQintercostalQspaceQleftQofQtheQsternum
.QTheQnurseQshouldQplaceQtheQstethoscopeQatQtheQpointQofQmaximalQimpulse,QwhichQisQatQtheQ
fifthQintercostalQspaceQatQtheQmidclavicularQlineQleftQofQtheQsternum.
PalpateQtheQclient'sQabdomenQbeforeQauscultatingQbowelQsounds.
WhenQassessingQanQadultQclient'sQabdomen,QtheQnurseQshouldQauscultateQbowelQsoundsQbeforeQp
erformingQpalpationQinQorderQnotQtoQchangeQtheQcharacterQofQtheQsounds.
VERIFIED A+
AQnurseQisQadministeringQ1QLQofQ0.9%QsodiumQchlorideQtoQaQclientQwhoQisQpostoperativeQandQh
asQfluidQvolumeQdeficit.QWhichQofQtheQfollowingQchangesQshouldQtheQnurseQidentifyQasQanQindica
tionQthatQtheQtreatmentQwasQsuccessful?
IncreaseQinQhematocritQincrea
seQinQrespiratoryQrateQDecreas
eQinQheartQrate
DecreaseQinQcapillaryQrefillQtimeQ-QCorrectQAnswer:
DecreaseQinQheartQrate
FluidQvolumeQdeficitQcausesQtachycardia.QWithQcorrectionQofQtheQimbalance,QtheQheartQrateQshoul
dQreturnQtoQtheQexpectedQrange.
IncorrectQAnswers:
IncreaseQinQhematocrit:
FluidQvolumeQdeficitQcausesQanQincreaseQinQhematocritQlevelQdueQtoQdepletionQofQextracellularQfl
uid.QWithQcorrectionQofQtheQimbalance,QtheQhematocritQlevelQshouldQdecrease.
increaseQinQrespiratoryQrate
FluidQvolumeQdeficitQcausesQanQincreaseQinQrespiratoryQrate.QWithQcorrectionQofQtheQimbalance,
QtheQrespiratoryQrateQshouldQreturnQtoQtheQexpectedQrange.
DecreaseQinQcapillaryQrefillQtime
FluidQvolumeQdeficitQslowsQcapillaryQrefill.QWithQcorrectionQofQtheQimbalance,QcapillaryQrefillQti
meQshouldQreturnQtoQtheQexpectedQrange.
AQnurseQisQcaringQforQaQclientQwhoQisQscheduledQtoQbeQtransferredQtoQaQlong-
termQcareQfacility.QTheQclient'sQfamilyQquestionsQtheQnurseQaboutQtheQreasonsQforQtheQtransfer.Q
WhichQofQtheQfollowingQresponsesQmadeQbyQtheQnurseQisQappropriate?
"TheQtransferQofQyourQfamilyQmemberQisQbeingQdoneQbecauseQtheQproviderQknowsQwhat'sQbest."Q
"WouldQyouQlikeQitQifQweQdiscussedQtheQtransferQwithQyourQfamilyQmember?"
"WhyQareQyouQsoQconcernedQaboutQthisQtransfer?"
"IQknowQhowQyouQfeel.QMyQparentQhadQtoQbeQtransferredQtoQaQlong-termQcareQfacility."Q-
QCorrectQAnswer:
"WouldQyouQlikeQitQifQweQdiscussedQtheQtransferQwithQyourQfamilyQmember?"
ThisQresponseQfacilitatesQtherapeuticQcommunicationQandQprovidesQgeneralQleadsQwhileQmaint
ainingQclientQconfidentiality.
IncorrectQAnswers:
"TheQtransferQofQyourQfamilyQmemberQisQbeingQdoneQbecauseQtheQproviderQknowsQwhat'sQbes
t."QThisQisQaQdefensiveQresponseQwhichQcanQhinderQfurtherQcommunication.
"WhyQareQyouQsoQconcernedQaboutQthisQtransfer?"
,AskingQaQwhyQquestionQcanQmakeQtheQrecipientQdefensiveQwhichQcanQhinderQfurtherQcommun
ication.
"IQknowQhowQyouQfeel.QMyQparentQhadQtoQbeQtransferredQtoQaQlong-
termQcareQfacility."QThisQisQaQsympatheticQresponse,QwhichQcanQinterfereQwithQaQthera
peuticQrelationship.
AQnurseQisQreviewingQtheQlaboratoryQresultsQofQaQfemaleQclientQwhoQhasQhypovolemia.QWhichQof
QtheQfollowingQlaboratoryQresultQwouldQbeQaQpriorityQforQtheQnurseQreportQtoQtheQprovider?
BUNQ21Qmg/dLQ(10QtoQ20Qmg/dL)
CreatinineQ1.4Qmg/dLQ(0.5QtoQ1.1Qmg/dL)
SodiumQ132QmEq/LQ(136QtoQ145QmEq/L)
PotassiumQ5.8QmEq/LQ(3.5QtoQ5QmEq/L)Q-QCorrectQAnswer:
PotassiumQ5.8QmEq/LQ(3.5QtoQ5QmEq/L)
WhenQusingQtheQurgentQversusQnonurgentQapproachQtoQclientQcare,QtheQnurseQshouldQdetermineQt
hatQthisQpotassiumQlevelQisQaboveQtheQexpectedQreferenceQrangeQandQshouldQbeQreportedQtoQtheQp
rovider.QPotassiumQaffectsQtheQcontractilityQofQtheQheartQandQthisQclientQwouldQbeQatQriskQforQde
velopingQdysrhythmias.
IncorrectQanswers:
BUNQ21Qmg/dLQ(10QtoQ20Qmg/dL)
ThisQBUNQlevelQisQslightlyQaboveQtheQexpectedQreferenceQrangeQandQisQanQexpectedQnon-
urgentQfindingQforQaQclientQwhoQhasQhypovolemia;Qtherefore,QthereQisQanotherQlaboratoryQresultQt
hatQisQaQpriorityQforQtheQnurseQtoQreportQtoQtheQprovider.
CreatinineQ1.4Qmg/dLQ(0.5QtoQ1.1Qmg/dL)
ThisQcreatinineQlevelQisQslightlyQaboveQtheQexpectedQreferenceQrangeQandQisQanQexpectedQnon-
urgentQfindingQforQaQclientQwhoQhasQhypovolemia;Qtherefore,QthereQisQanotherQlaboratoryQresultQ
thatQisQaQaQpriorityQforQtheQnurseQtoQreportQtoQtheQprovider.
SodiumQ132QmEq/LQ(136QtoQ145QmEq/L)
ThisQsodiumQlevelQisQslightlyQbelowQtheQexpectedQreferenceQrangeQandQisQanQexpectedQnon-
urgentQfindingQforQaQclientQwhoQhasQhypovolemia;Qtherefore,QthereQisQanotherQlaboratoryQresultQ
thatQisQaQpriorityQforQtheQnurseQtoQreportQtoQtheQprovider.
AQnurseQisQcaringQforQaQclientQwhoQreportsQdifficultyQfallingQasleep.QWhichQofQtheQfollowingQrec
ommendationsQshouldQtheQnurseQmake?
"DrinkQaQcupQofQhotQcocoaQbeforeQbedtime."Q"Mai
ntainQaQconsistentQtimeQtoQwakeQupQeachQday."Q"E
xerciseQ1QhourQbeforeQgoingQtoQbed."
"WatchQaQtelevisionQprogramQinQbedQbeforeQgoingQtoQsleep."Q-
QCorrectQAnswer:Q"MaintainQaQconsistentQtimeQtoQwakeQupQeachQday."
TheQclientQshouldQmaintainQaQconsistentQtimeQforQwakingQupQandQgoingQtoQsleep.QThisQhel
psQtoQestablishQanQinternalQsenseQofQsleepQandQwakingQonQaQdailyQbasisQandQhelpsQtoQmaint
ainQitQoverQtime.QThisQwillQhelpQpromoteQsleepQforQtheQclient.
,IncorrectQAnswers:
"DrinkQaQcupQofQhotQcocoaQbeforeQbedtime."
CocoaQcontainsQcaffeine,QwhichQisQaQstimulantQthatQcanQinterfereQwithQsleep.
"ExerciseQ1QhourQbeforeQgoingQtoQbed."
ExercisingQwithinQ2QhrQofQbedtimeQcanQinterfereQwithQsleep.
"WatchQaQtelevisionQprogramQinQbedQbeforeQgoingQtoQsleep."
TheQclientQshouldQavoidQwatchingQtelevisionQinQbedQbeforeQgoingQtoQsleepQtoQreduceQstimulation
QinQorderQtoQpromoteQrest.
AQnurseQonQaQmedical-
surgicalQunitQisQcaringQforQaQclientQwhoQhasQaQnewQprescriptionQforQwristQrestraints.QWhichQofQf
ollowingQactionsQshouldQtheQnurseQtake?
PadQtheQclient'sQwristQbeforeQapplyingQtheQrestraints.QEval
uateQtheQclient'sQcirculationQeveryQ8QhrQafterQapplication.
RemoveQtheQrestraintsQeveryQ4QhrQtoQevaluateQtheQclient'sQstatus.Q
SecureQtheQrestraintQtiesQtoQtheQbed'sQsideQrails.Q-
QCorrectQAnswer:QPadQtheQclient'sQwristQbeforeQapplyingQtheQrestr
aints.
TheQuseQofQrestraintsQwithoutQpaddingQcanQabradeQtheQclient'sQskin,QresultingQinQclientQinjury.
IncorrectQAnswers:
EvaluateQtheQclient'sQcirculationQeveryQ8QhrQafterQapplication.
TheQnurseQshouldQevaluateQtheQclient'sQcirculation,QrangeQofQmotion,QvitalQsigns,QandQoverallQstat
usQeveryQ15QminQafterQinitialQapplicationQofQrestraints.
RemoveQtheQrestraintsQeveryQ4QhrQtoQevaluateQtheQclient'sQstatus.
TheQnurseQshouldQremoveQtheQrestraintsQatQleastQeveryQ2QhrQtoQrepositionQtheQclientQandQasses
sQneedsQforQhygieneQandQtoileting.
SecureQtheQrestraintQtiesQtoQtheQbed'sQsideQrails.
TheQnurseQshouldQsecureQtheQrestraintQtiesQtoQaQpartQofQtheQbedQframeQthatQmovesQwithQtheQclie
ntQtoQreduceQtheQriskQofQinjury.
AQclientQwhoQisQnonambulatoryQnotifiesQtheQnurseQthatQtheirQtrashQcanQisQonQfire.QAfterQtheQnurs
eQconfirmsQtheQpresenceQofQtheQfire,QwhichQofQtheQfollowingQactionsQshouldQtheQnurseQtakeQnext
?
ActivateQtheQemergencyQfireQalarm.QExtingui
shQtheQfire.
EvacuateQtheQclient.
ConfineQtheQfire.Q-QCorrectQAnswer:
EvacuateQtheQclient.
AccordingQtoQtheQRACEQmnemonic,QtheQfirstQactionQinQresponseQtoQaQfireQisQtoQrescueQtheQclient
s,QmovingQthemQtoQaQsafeQarea.
, IncorrectQAnswers:
ActivateQtheQemergencyQfireQalarm.
AccordingQtoQtheQRACEQmnemonic,QtheQsecondQactionQinQresponseQtoQaQfireQisQtoQactivateQth
eQalarm.
ExtinguishQtheQfire.
AccordingQtoQtheQRACEQmnemonic,QtheQfourthQactionQinQresponseQtoQaQfireQisQtoQattemptQtoQexti
nguishQtheQfire.
ConfineQtheQfire.
AccordingQtoQtheQRACEQmnemonic,QtheQthirdQactionQinQresponseQtoQaQfireQisQtoQcontainQtheQfire
QbyQclosingQallQtheQdoorsQandQwindowsQinQtheQarea.QTheQnurseQshouldQalsoQturnQoffQoxygenQand
QelectricalQequipmentQinQtheQareaQofQtheQfire.
AQnurseQisQpreparingQtoQadministerQ0.9%QsodiumQchlorideQ750QmLQIVQtoQinfuseQoverQ7Qhr.QTh
eQnurseQshouldQsetQtheQinfusionQpumpQtoQdeliverQhowQmanyQmL/hr?Q-Q107QmL/hr
AQnurseQisQassessingQfourQadultQclients.QWhichQofQtheQfollowingQphysicalQassessmentQtechniques
QshouldQtheQnurseQuse?
UseQtheQFace,QLegs,QActivity,QCry,QandQConsolabilityQ(FLACC)QpainQratingQscaleQforQaQclientQ
whoQisQexperiencingQpain.
EnsureQtheQbladderQofQtheQbloodQpressureQcuffQsurroundsQ80%QofQtheQclient'sQarm.
ObtainQanQapicalQheartQrateQbyQauscultatingQatQtheQthirdQintercostalQspaceQleftQofQtheQsternum.
QPalpateQtheQclient'sQabdomenQbeforeQauscultatingQbowelQsounds.Q-QCorrectQAnswer:
EnsureQtheQbladderQofQtheQbloodQpressureQcuffQsurroundsQ80%QofQtheQclient'sQarm.
TheQnurseQshouldQuseQaQbloodQpressureQcuffQwithQaQbladderQthatQsurroundsQ80%QofQtheQclient'sQ
armQcircumferenceQtoQgiveQanQaccurateQreading.
IncorrectQAnswers:
UseQtheQFace,QLegs,QActivity,QCry,QandQConsolabilityQ(FLACC)QpainQratingQscaleQforQaQclientQ
whoQisQexperiencingQpain.
TheQnurseQshouldQuseQanQage-appropriateQpain-
ratingQscale,QsuchQasQtheQvisualQanalogQorQnumericalQscale,QwhenQassessingQtheQpainQlevelQofQan
Qadult.QTheQFLACCQpainQratingQscaleQisQusedQforQclientsQagedQfromQ2QmonthsQtoQ7QyearsQold.
ObtainQanQapicalQheartQrateQbyQauscultatingQatQtheQthirdQintercostalQspaceQleftQofQtheQsternum
.QTheQnurseQshouldQplaceQtheQstethoscopeQatQtheQpointQofQmaximalQimpulse,QwhichQisQatQtheQ
fifthQintercostalQspaceQatQtheQmidclavicularQlineQleftQofQtheQsternum.
PalpateQtheQclient'sQabdomenQbeforeQauscultatingQbowelQsounds.
WhenQassessingQanQadultQclient'sQabdomen,QtheQnurseQshouldQauscultateQbowelQsoundsQbeforeQp
erformingQpalpationQinQorderQnotQtoQchangeQtheQcharacterQofQtheQsounds.
