to use the nursing process correctly, the nurse must first
obtain information about the client
a 3 year old child has had multiple tooth extractions while under general anesthesia.
the client returns from the post anesthesia care crying, but awake, from the recovery room. which approach is likely to be successful?
examine mouth last
abdominal assessment order:
inspection, auscultation, percussion, palpation
a nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the.
involvement of the client in planning the change
while starting an IV for a client, the nurse notices that her gloved hands get spotted with blood. the client has not been diagnosed with any infection transmitted via the bloodstream.
which of the following should the nurse do as soon as the task is completed
remove the gloves carefully and follow with hand hygiene
a nurse's neighbor is scheduled for elective surgery. the neighbor's provider indicated that a moderate moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. which of the following is appropriate for the nurse to suggest?
donating autologous blood before the surgery
an AP tells the nurse, "I am unable to find a large BP cuff for a client who is obese. Can I just use the regular cuff?" The nurse replies that using a regular cuff for an obese pt will result in a reading that is.
an AP says to the nurse, "this client is incontinent of stool 3 or 4 times a day. i get angry, and i think the client is just doing it to get attention. i think we should put diapers on her.
" what is the appropriate response?
it is very upsetting to see an adult client regress
a nurse is caring for a cline just diagnosed with type 1 diabetes mellitus. the client is resistant to learning self injection of insulin and asks the nurse to administer all the injections. the nurse explains the importance of learning self care and appropriately adds which of the following statements?
tell me what i can do to help you overcome your fear of giving yourself injections?
a client is admitted to the hospital in the terminal stage of cancer. the nurse enters the client's room to administer medications and finds the client crying. the appropriate action is to..
sit and hold the client's hand
when initiating CPR, the nurse must confirm which of the following assessment findings prior to beginning chest compressions?
absence of pulse
a client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. when assessing skin tutor, the nurse should..
grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back
a nurse tells a client that the provider has prescribed IV fluids. the client appears to be upset about the IV catheter insertion, but says nothing to the nurse. which of the following is an appropriate nursing response?
is there something about this procedure that concerns you?
a nurse is precepting a a newly licensed nurse who is preparing to help a client perform tracheostomy care. the nurse should intervene if the equipment the precept gathered included.
a hospitalized client needs a chest x ray. the radiology department calls the nursing unit and says that they are sending a transporter for the client.
when entering the client's room, the priority action is to
check the client's identification bracelet
at the surgical scrub sink, a surgical nurse demonstrates the proper surgical hand washing technique by scrubbing...
with her hands held higher than her elbows
a nurse on a rehabilitation unit is transferring a client from a bed to a chair.
to avoid back injury, which of the following techniques should the nurse use?
bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurses hands under the client's axillae
nurse has group of fatties. to make them lose weight...
attempt to develop the client's self motivation
client with appendicitis is learning coughing and deep breathing. prob didn't learn anything if.
reports severe pain
grabby confused client...
firmly tell the client to not grab
An older adult client appears agitated when the nurse requests that the client's dentures be removed prior to surgery and states, "I never go anywhere without my teeth.
" which is an appropriate nursing response?
"you seem worried. are you concerned someone may see you without your teeth?"
(when answering an ATI communication/responding question, you are correct in answering a response that recognizes and responds to the client's feelings)
While measuring a client's vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?
count the apical pulse rate for I full min, and describe the rhythm in the chart
when admitting a client, the nurse records which information in the client's record first?
assessment of the client (first step of nursing process)
ATI TIP #2
(when asked a priority setting question: assessment, analysis, planning, intervention, evaluation)
A nurse is caring for a client who requires rectal temperature monitoring. available at the client's bedside is a thermometer with a long, slender tip.
which of the following is the appropriate action for the nurse to take?
obtain a thermometer with a short, blunt insertion end (long slender is for axillary or oral)
A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 minutes. However, the machine is reading the client's blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which is an appropriate nursing action?
disconnect the machine, and measure the blood pressure manually every 15 min. (malfunctioning equipment is a safety risk, remove it)
A nurse is caring for a client who has hypertension.
Which approach is the priority when the nurse is measuring the clients blood pressure?
obtain the blood pressure under the same conditions each time
A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client's temp. is 102.6 F, her abdomen is soft without tenderness, and her menses is overdue by 2 days.
To which observation should the nurse give priority?
ATI TIP #3
with this kind of priority question, use mallow's hierarchy of needs: sleep & food, security, love & belonging, self-esteem, self-actualization.
An older adult just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour.
Which of the following nursing actions is appropriate?
help the client write down the questions to ask the provider, so that the client doesn't forget
A nurse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. the client's surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that..
the signature on the preoperative consent form is the client's
A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, thick is the most important nursing action initially?
evaluate pedal pulses (assessment of the reason for admission is first priority)
to use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should..
place bed in high horizontal position
A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery.
At this time, the nurse should..
ask the client why she has changed her mind
When assessing a client's heart sounds, the nurse hears a scratching sound during both systole and diastole. The sounds become for distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a..
pericardial friction rub
A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should..
lock the wheels on the bed and stretcher
A postoperative client has been diagnosed with paralytic ileum. When performing auscultation of the client's abdomen, the nurse expects the bowel sounds to be.
absent. (paralytic ileum is an immobile bowel)
before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of hand hygiene is the amount of..
which of the following should a group of comity health nurses plan as part of a primary prevention program for occupational pulmonary diseases?
elimination of the exposure
A nurse is caring for a client diagnosed with a terminal illness. The client asks serval questions about the nurse's religious beliefs related to death and dying. An appropriate nursing response is to
encourage the client to express his thought about death and dying
At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. the auscultate the aortic valve, the nurse should place the stethoscope at which location?
second intercostal space to the right of the sternum
which of the following should the nurse do first when preparing to provide tracheostomy care?
PREFORM HAND HYGIENE