Ati fundamental 1
Ati fundamental 1
A nurse is caring for a client who has a terminal illness. The client asks several
questions about the nurse's reli
... [Show More] gious beliefs related to death and dying. Which of the
following actions should the nurse take?
A) Change the topic because the client is trying to divert attention from the illness to the
nurse.
B) Encourage the client to express his thoughts about death and dying?
C) Tell the client that religious beliefs are a personal matter.
D) Offer to contact the client's minister or the facility's chaplain.
B
A nurse should recognize the client's need to talk about impending death, and
encourage the client to discuss his thoughts on the subject. This is therapeutic
technique of reflecting. Depending on the situation, the nurse can also share some
thoughts on this topic. Self-disclosure is a communication skill that can help open lines
of communication when appropriate. If the nurse does not want to share personal
beliefs, the communication skills of offering self and listening to the client's thoughts are
appropriate.
A nurse is preparing to provide tracheostomy care for a client. Which of the following
actions should the nurse take first?
A) Open all sterile supplies and solutions.
B) Stabilize the tracheostomy tube.
C) Don sterile gloves.
D) Perform hand hygiene.
D
According to evidence-based practice, the nurse should first perform hand hygiene
before touching the client or performing any skills, such as tracheostomy care. This is
vital because contamination of the nurse's hands is a primary source of infection.
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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?
A) Measure the pulse using a Doppler ultrasound stethoscope.
B) Check the client's pedal pulses.
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C) Count the apical pulse rate for a full minute and describe the rhythm in the chart.
D) Take the pulse at each peripheral site and count the rate for 30 seconds.
C
If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 1
minute to obtain an accurate rate. The nurse should document irregularity in the client's
medical record.
A nurse on a med-surg unit is caring for a client. Which of the following actions should
the nurse take first when using the nursing process?
A) Identify goals for client care.
B) Obtain client information
C) Document nursing care needs
D) Evaluate the effectiveness of care
B
The nursing process is based on scientific process. The first step in the scientific
process is the collection of data. Therefore, the first step is assessing and obtaining
information about the client.
A nurse is receiving a client from the PACU (post-anesthetic care unit) who is
postoperative following abdominal surgery. Which of the following actions should the
nurse take to transfer the client from stretcher to the bed?
A) Lock the wheels on the bed and stretcher
B) Instruct the client to raise his arms above his head
C) Elevate the stretch 2.5 cm (1 inch) above the height of the bed
D) Log roll the client
A
Locking the wheels prevents the client from falling to the floor by not allowing the cart of
bed to move apart or away from the client.
A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
A) Evaluate pedal pulses
B) Obtain medical history
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C) Measure vital signs
D) Assess for leg pain
A
For a client who has decreased circulation in the leg, evaluating pedal pulses is critical
in order to determine adequate blood supply to the foot. The nurse should apply the
safety and risk reduction priority-setting framework. This framework assigns priority to
the factor 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.
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the
following abdominal assessments should the nurse expect? [Show Less]
