ATI Learning System RN 3.0 Fundamentals 1 Quiz

ATI Learning System RN 3.0 Fundamentals 1 Quiz 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? - Audible click - Murmur - Third heart sound - Pericardial friction rub - ANSWER Pericardial friction rub: A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? - Auscultate for the blood pressure at the dorsalis pedis artery. - Measure the blood pressure with the client sitting on the side of the bed. - Place the cuff 7.6 cm (3 in) above the popliteal artery. - Place the bladder of the cuff over the posterior aspect of the thigh. - ANSWER Place the bladder of the cuff over the posterior aspect of the thigh. This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurse. Which of the following actions should the charge nurse teach as the first response to CPR? - Call for assistance. - Begin chest compressions. - Confirm unresponsiveness. - Give rescue breaths. - ANSWER Confirm unresponsiveness. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team. 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. - ANSWER Identify the client using two identifiers. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Once the client's identity is determined, the nurse can then proceed with the other options. This action is the priority action because it provides for the safety of the client. It is a nursing responsibility to be certain that each client receives only what has been prescribed. The nurse must assure that the correct client is being transported for a chest x-ray. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? - Encourage the child to cough frequently to clear congestion from anesthesia. - Place a heating pad at the child's neck for comfort. - Administer analgesics to the child on a routine schedule throughout the day and night. - Provide the child with ice cream when oral intake is initiated. - ANSWER Administer analgesics to the child on a routine schedule throughout the day and night. To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route.