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Ati nurs 104 fundamentals quiz
Ati nurs 104 fundamentals quiz
Total Questions : 27
Showing 10 questions Sign up for moreA nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?
Explanation
A. Emphasizing four important points is helpful, but it may be more effective to limit the number of points to ensure the client can focus on and remember key concepts.
B. Short teaching sessions are recommended for clients with low literacy levels because they are easier to understand and retain. Breaking down information into smaller, manageable segments can help prevent overwhelming the client.
C. Referring to the client in the third person may create distance and is not conducive to fostering a supportive, clear, and engaging learning environment.
D. Using passive voice can make the information less clear and harder for the client to understand. Active voice is generally more direct and effective in communication.
A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?
Explanation
A. Bilateral bowel sounds in the lower quadrants are normal and do not require further investigation unless they are abnormal in frequency or tone.
B. A symmetrical convex sphere shape of the abdomen can be a normal finding, especially in a well-nourished individual.
C. Ecchymosis (bruising) may be a sign of trauma, bleeding disorders, or other underlying health conditions that require further investigation.
D. A concave umbilicus may be normal or could indicate a past surgical history or conditions like malnutrition, but it doesn't inherently require investigation unless associated with other symptoms.
A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?
Explanation
A. Documenting that the nurse was unable to measure the temperature is unnecessary if the nurse can follow the correct procedure of waiting and measuring after a proper interval.
B. The nurse should wait at least 30 minutes after the client has eaten or consumed ice chips before measuring the oral temperature to ensure an accurate reading.
C. Proceeding immediately to measure the temperature after consuming ice chips may result in an inaccurate reading, as it can lower the temperature of the mouth.
D. Providing warm water and waiting 5 minutes may not be sufficient to correct the cooling effect of the ice chips on the oral cavity.
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?
Explanation
A. Wheezes are high-pitched continuous sounds heard during exhalation, commonly associated with asthma due to narrowed airways.
B. Rhonchi are low-pitched sounds caused by airflow obstruction in the larger airways and typically clear with coughing.
C. Crackles (or rales) are high-pitched sounds heard during inhalation and are often associated with fluid in the lungs, such as in pneumonia or heart failure.
D. Stridor is a high-pitched sound heard during inspiration and is often indicative of upper airway obstruction.
A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?
Explanation
A. The dorsal surface of the foot and the dorsal surface of the hand are less reliable areas to assess for cyanosis in dark-skinned individuals.
B. Cyanosis in clients with dark skin can be more difficult to detect in the skin but is often visible in the conjunctivae of the eyes, as it reflects the oxygenation status of the blood.
C. The dorsal surface of the hand is also not an ideal area for assessing cyanosis in dark skin.
D. The pinnae of the ears can show signs of cyanosis but may not be as reliable as the conjunctivae, especially in dark-skinned individuals.
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
Explanation
A. Testing visual acuity assesses cranial nerve II (the optic nerve), not cranial nerve III.
B. Eliciting the gag reflex involves cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.
C. Cranial nerve III (the oculomotor nerve) controls the constriction of the pupil in response to light, so checking the pupillary response to light is the appropriate assessment for this cranial nerve.
D. Observing for facial symmetry is more related to the function of cranial nerve VII (the facial nerve).
A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?
Explanation
A. Wearing sterile gloves when moving sterile items is appropriate practice and should not be intervened with.
B. Positioning the wrapped package so the outer flap is away from the nurse is correct to prevent contamination when opening.
C. The nurse should avoid holding sterile items too far above the sterile field to prevent contamination from falling or being exposed to non-sterile areas. Items should be held as close as possible to the sterile field, typically no more than 2 inches (5 cm).
D. Holding the bottle of solution with the label away from the palm of the hand is proper to maintain sterility.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?
Explanation
A. Asking "Would it help to discuss your feelings about this hospitalization?" is more closed and may not effectively promote discussion about the client's health history.
B. Asking "What brought you to the hospital?" is an open-ended question that allows the client to provide a comprehensive answer and facilitates a meaningful discussion about their health and hospitalization.
C. "Would you tell me about all of your medical issues?" is too broad and could overwhelm the client. A more specific question would be more effective.
D. "Do you want to talk about your health concerns?" is a yes/no question and may not encourage open communication.
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?
Explanation
A. Contact precautions are used for infections that are spread through direct contact with contaminated surfaces or items.
B. Droplet precautions are used for infections spread through respiratory droplets, such as influenza.
C. Protective isolation is used for clients with weakened immune systems, but TB requires airborne precautions, not protective isolation.
D. Tuberculosis (TB) is transmitted via airborne particles, so the nurse should initiate airborne precautions, including the use of an N95 respirator, negative pressure rooms, and other measures to prevent the spread of TB.
A nurse is providing nail care for a client. Which of the following actions should the nurse take?
Explanation
A. Filing nails in a rounded shape may lead to ingrown nails, so a straight-across filing is recommended for safety and proper nail care.
B. An orange stick is commonly used to clean under the nails, as it is gentle and reduces the risk of injury to the nail bed.
C. Pushing the cuticles back with a metal nail file can cause injury and infection. A soft tool like an orangewood stick is preferred.
D. Trimming the nails at the lateral corners is not recommended as it can cause the nails to become ingrown. Nails should be trimmed straight across.
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