ATI FUNDAMENTALS PREDICTOR 2024 QUESTION WITH ANSWERS [REVISION QUIZS] A GRADED WITH NGN
1. A nurse is assessing the heart sounds of a client who has
... [Show More] developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?
A. Audible click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
2. A nurse is ob- taining the blood pressure in a client's lower ex- tremity. Which of
D. Pericardial friction rub
Pericardial friction rub MY ANSWER
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 typi- cally has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward.
Audible click
An audible clicking sound occurs in clients who have pros- thetic valve replacement surgery.
Murmur
A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. Low- and medium-fre- quency sounds are more easily heard with the bell of
the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease.
Third heart sound
A third heart sound is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best heard at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates heart failure.
D. Place the bladder of the cuff over the posterior aspect of the thigh
Measure the blood pressure with the client sitting on the side of the bed.
the following ac- tions should the nurse take?
A. Auscultate for the blood pres- sure at the dorsalis pedis artery.
B. Measure the blood pressure with the client sit- ting on the side of the bed.
C. Place the cuff 7.6 cm (3in) above the popliteal artery
D. Place the blad- der of the cuff over the posteri- or aspect of the thigh.
3. A charge nurse is teaching adult cardiopul- monary resusci- tation (CPR) to a group of new-
ly licensed nurs- es. Which of
the following ac- tions should the charge nurse teach as the first response in CPR?
A. Call for assis- tance
The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed.
Auscultate for the blood pressure at the dorsalis pedis artery.
The nurse should auscultate for the blood pressure at the popliteal artery.
Place the cuff 7.6 cm (3 in) above the popliteal artery. The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.
Place the bladder of the cuff over the posterior aspect of the thigh.
MY ANSWER
This is the correct position for the nurse to place the blad- der of the cuff when measuring a lower extremity blood pressure.
C. Confirm unresponsiveness
Confirm unresponsiveness. MY ANSWER
The nurse should apply the nursing process priority-set- ting 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 begin- ning CPR. If a client is unresponsive, the nurse should [Show Less]