ATI Test For Nursing Fundamentals Part I Practice Test
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Are you preparing for nursing exams? You can take this ATI Test For Nursing Fundamentals to improve your nursing basics. There are several facts that need to be cleared before pursuing the profession. Here we have got 100 questions for you so that you can practice more scenarios and topics to clear the exam. You can choose all the correct answers for a perfect score, whereas if you miss out on something, we will help you. All the best with this and as well as all other exams! You can share this quiz with other nursing aspirants also.
Questions and Answers
1.
A patient who had a mastectomy 6 months ago tells the nurse that she has not had much desire for sexual relations since her surgery. "My body is different now." Which of the following is an appropriate response from the nurse?
A.
"Really, you look just fine to me. There's no need to feel undesirable
B.
I'm interested in finding out more about how your body feels to you".
C.
"Consider an afternoon at a spa. A facial will make you feel more attractive"
D.
"it is still too soon to expect to feel normal. Give it a little more time
Correct Answer
B. I'm interested in finding out more about how your body feels to you".
Explanation Showing interest in a client is a therapeutic communication technique of offering self; asking more about how the client feels is a therapeutic communication technique of encouraging a description of prescription. Telling the client she looks fine is using the nontherapeutic communication technique of giving an opinion. Assuming she feels undesirable is not therapeutic and it is called interpreting. Suggesting a facial is using a nontherapeutic technique of giving advice. Telling her it is too soon to feel normal and to give it more time is belittling the client's feelings and giving false reassurance.
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2.
Which of the following factors positively affect self-concept? Select all that apply
A.
Diabetes mellitus
B.
Parental approval
C.
Success at school
D.
Receiving a promotion at work
E.
Excessive use of alcohol
Correct Answer(s)
B. Parental approval C. Success at school D. Receiving a promotion at work
Explanation Parental approval, success at school, and receiving a promotion at work will have a positive impact on the individual's self-concept, as these situations promote good feelings about self-concept. A chronic illness usually have a negative impact on self-concept, as the client is required to adapt to the changes. Excessive use of alcohol is a symptom of a poor self-concpt
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3.
A diabetic patient lost his wife 4 months ago. Tearful, he says, "How could you possibly understand what I am going through?" Which of the following would be an appropriate response?
A.
"It takes time to get over the loss of a loved one."
B.
"You are right; I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."
C.
"Why don't you try something to take your mind off your troubles, like watching a funny movie."
D.
"I might not share your exact situation, but I do know what people go through when they deal with a loss."
Correct Answer
B. "You are right; I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."
Explanation By stating that she is not in his situation, the nurse is using the therapeutic communication technique of validation, whereby she shows sensitivity to the meaning behind his behavior. She is also creating a supportive and nonjudgmental environment, and inviting him to express his frustrations. Telling the patient to try a distraction dismisses the client's feelings and gives common advice instead of expert advice. Saying she knows what clients feel is presumptive and inappropriate.
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4.
Which of the following types of stress is being experienced by a middle adult client who is stressed by the concerns of caring for young adults still in the home and her aging parents?
A.
Situational
B.
Developmental
C.
Social
D.
Cultural
Correct Answer
B. Developmental
Explanation Developmental stress is related to the stages of life. Situational stress is an unexpected, sudden stressor, such as a job loss. Social and cultural stresses are widespread problems, such as poverty that affects a community as a whole
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5.
A home health nurse performs a 3-day postpartum visit for a first-time mother. The household includes her husband, her mother, and her father. What type of family form is represented here?
A.
Nuclear
B.
Extended
C.
Blended
D.
Alternative
Correct Answer
B. Extended
Explanation In an extended family, in an addition to the nuclear members, grandparents and other family members may live in the same household. A blended family includes step children in addition to the nuclear members. An alternative family can have single adults, cohabiting partners, or same-gender partners.
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6.
Which of the following is a priority nursing intervention for a family with a history of violence?
A.
Educating the family about anger management
B.
Refining the family's communication skills
C.
Viewing the family in context
D.
Using the family's strengths to define them
Correct Answer
C. Viewing the family in context
Explanation The priority intervention is to collect more data to determine which family member (s) is a victim of abuse and needs assistance to be protected. Teaching anger management is a good strategy, but first there must be a family assessment to determine if there are anger and safety issues. Refining communication skills and using family strengths are not the priorities if the safety of a family member is at risk
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7.
Which of the following approaches should be used when working with a family using an open structure for coping with crisis?
A.
Prescribing tasks unilaterally
B.
Convening a family meeting
C.
Delegating care to one member
D.
Speaking to the primary client privately
Correct Answer
B. Convening a family meeting
Explanation An open structure is loose, and convening a family meeting would give all family members input and an opportunity to express their feelings. Prescribing tasks and delegating care are too rigid for acceptance by a family with an open structure. Speaking to the primary client privately excludes the family.
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8.
Which of the following is a situational role change?
A.
A young adult getting married for the first time
B.
A toddler learning to control elimination
C.
An adolescent experiencing puberty
D.
A middle adult experiencing menopause
Correct Answer
A. A young adult getting married for the first time
Explanation Marriage adds the role of spouse. Puberty, menopause and elimination control are expected physiological growth and development phases and are not considered situational role changes.
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9.
Once a nurse has counseled a client about her situational role changes, and she has accepted them, what is the next step in her recovery?
A.
Apprehension
B.
Tension
C.
Resentment
D.
Adaptation
Correct Answer
D. Adaptation
Explanation A client who has accepted role changes will demonstrate adaptation. Resentment, tension, and apprehension are not behaviors or emotions consistent with acceptance.
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10.
A nurse recognizes that a helping relationship is established with a patient if the communication.
A.
Occurs spontaneously throughout the nurse-client relationship
B.
Has no time limits
C.
Is equally reciprocal between the nurse and the patient.
D.
Encourages the patient to express his thoughts and feelings
Correct Answer
D. Encourages the patient to express his thoughts and feelings
Explanation Therapeutic communication facilitates a helping relationship that maximizes the client's ability to openly express his thoughts and feelings. The communication is not reciprocal but client-focused. Therapeutic communication is limited to the boundaries of the therapeutic relationship. Therapeutic communication is planned by a health care professional.
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11.
When talking to a child who is seated, the nurse should
A.
Touch the child
B.
Stand facing the child
C.
Stand with a relaxed posture
D.
Sit at eye level with the child
Correct Answer
D. Sit at eye level with the child
Explanation The nurse should be at the same eye level as the child to facilitate communication. Touching may intimidate the child and bock communication. Standing will prevent the nurse from being at eye level with the child.
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12.
Behaviors of active listening. Select all that apply:
A.
Responding positively when giving feedback
B.
Writing down what the client says so that details are not forgotten
C.
Maintaining an open posture
D.
Establishing and maintaining an eye contact
E.
Nodding in agreement with the client throughout the conversation
Correct Answer(s)
A. Responding positively when giving feedback C. Maintaining an open posture D. Establishing and maintaining an eye contact
Explanation Having an open posture and leaning forward, establishing and maintaining eye contact, and responding positively when giving feedback are ways the nurse can demonstrate active listening. Writing down everything the client says will interfere with the nurse's ability to maintain eye contact and an open posture. Nodding in agreement throughout the conversation may be interpreted as agreement with what the client is saying when it was only intended to indicate attending to what was being said.
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13.
Which of the following are normal aging changes in the musculoskeletal system? Select all that apply;
A.
Wider stance resulting in posture changes
B.
Loss of height
C.
Increased range of motion
D.
Increased muscle bulk
E.
Thinning intervertebral discs
Correct Answer(s)
A. Wider stance resulting in posture changes B. Loss of height E. Thinning intervertebral discs
Explanation Normal aging changes of the musculoskeletal system includes posture changes, loss of height, and thinning intervertebral discs. Range of motion and muscle size also decrease
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14.
Assessment of the musculoskeletal system should start with
A.
Measuring limb length
B.
Testing range of motion
C.
Inspecting for symmetry and posture
D.
Assessing of muscle strength
Correct Answer
C. Inspecting for symmetry and posture
Explanation Assessment of the musculoskeletal system should start with inspection of the skeleton. Measuring limb length, testing range of motion and muscle strength are performed after inspection.
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15.
During an assessment, the client reports pain in the internal rotation of her right shoulder. This will most likely affect which of the following activities?.
A.
Brushing the back of her hair
B.
Fastening her bra behind her back
C.
Reaching for something in a cabinet above the sink
D.
Mopping the floor
Correct Answer
B. Fastening her bra behind her back
Explanation Fastening a bra from behind requires internal rotation of the shoulder. Brushing the back of the hair and reaching for something up high require external rotation of the shoulder. Mopping the floor requires flexion and extension of the shoulder
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16.
Unilateral hypertrophy of the arm muscles is most likely seen in an individual who regularly
A.
Lifts weights
B.
Plays soccer
C.
Moves furniture
D.
Plays tennis
Correct Answer
D. Plays tennis
Explanation A tennis player will use one arm primarily and unilateral hypertrophy will most likely result. Lifting weights, moving furniture and playing soccer will most likely result in bilateral muscle hypertrophy
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17.
Dorsiflexion of the feet is assessed by instructing the client to
A.
Point the toes toward the head
B.
Point the toes toward the floor
C.
Turn the soles of the feet outward
D.
Turn the soles of the feet inward
Correct Answer
A. Point the toes toward the head
Explanation Pointing the toes toward the head is dorsiflexion. Point the toes toward the floor results in plantar flexion.Turn the soles of the feet outward results in eversion, and turning the soles of the feet inward results in inversion.
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18.
Which of the following should be asked to assess a patient's cerebral function during a health history?
A.
"Do your fingers feel numb and tingly?"
B.
"Do you have difficulty remembering things?"
C.
"Do you have any problems keeping your balance?"
D.
"Do you have nay difficulties with your sense of taste?"
Correct Answer
B. "Do you have difficulty remembering things?"
Explanation Memory is tested during the mental status examination, which evaluates cerebral function. Numbness and tingling are abnormal findings of the sensory system. Balance is a test for muscle function, and the sense of taste is controlled by cranial nerves VII and IX.
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19.
When the triceps tendon is hit with a reflex hammer, the expected response is for the elbow to
A.
Flex
B.
Extend
C.
Internally rotate
D.
Pronate
Correct Answer
B. Extend
Explanation Striking the triceps tendon with a hammer results in extension of the elbow. The elbow does not flex, internally rotate, or pronate.
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20.
To evaluate STEREOGNOSIS, the nurse should ask the client to close his eyes and identify
A.
A number drawn in the palm of his hand
B.
A word whispered 30 cm from the ear
C.
A familiar object placed in his hand
D.
The vibration of a tuning fork placed on his foot
Correct Answer
C. A familiar object placed in his hand
Explanation Identifying a familiar object placed in the hand assesses for sterognosis. Graphesthesia is identifying a number drawn in the palm of the hand. Hearing whispered words tests CN VIII. Identifying a tuning fork tests the vibratory sense.
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21.
Which of the following is included in the assessment of the client's cognitive processes? Select all that apply
A.
Level of consciousness
B.
Mood
C.
Appearance
D.
Knowledge
E.
Judgment
Correct Answer(s)
D. Knowledge E. Judgment
Explanation All are components of a mental status examination. Assessment of knowledge and judgment are included in cognitive processes.
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22.
When performing a skin assessment, which of the following are normal findings? Select all that apply:
A.
No clubbing noted
B.
Capillary refill less than 2 seconds
C.
3+ pitting edema in feet bilaterally
D.
Numerous light brown macules, less than 3 mm in size, located on nose and cheeks
E.
Shiny and thin skin without hair on shins
Correct Answer(s)
A. No clubbing noted B. Capillary refill less than 2 seconds D. Numerous light brown macules, less than 3 mm in size, located on nose and cheeks
Explanation Expected skin findings include no clubbing, capillary refill less than 2 seconds, and light brown macules noted on the nose and cheeks. No edema should be present, and the skin should have a dull, opaque appearance with some hair present
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23.
When assessing a skin temperature, which side of the hand should be used?
A.
Fingertips
B.
Dorsal surface
C.
Palmar surface
D.
Base of the hand
Correct Answer
B. Dorsal surface
Explanation The dorsal surface of the hand is the most sensitive to temperature changes.
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24.
Assessment of an older adult reveals significant skin tenting over the forearm. Why?
A.
Loss of adipose tissue and elasticity
B.
Parchment-like skin
C.
Significant flaking and dryness
D.
Skin tags
Correct Answer
A. Loss of adipose tissue and elasticity
Explanation Tenting is a result of loss of adipose tissue and elasticity of the skin. Thin, parchment-like skin,dryness, and skin tags do not cause tenting
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25.
A patient just had a knee arthroplasty. Which of the following should be examined to assess the peripheral vascular system of the affected extremity? Select all that apply
A.
Range of motion
B.
Skin color
C.
Skin temperature
D.
Presence of skin lesions
E.
Capillary refill
F.
Edema
Correct Answer(s)
B. Skin color C. Skin temperature E. Capillary refill F. Edema
Explanation Assessment of peripheral vascular system should include skin color, skin temperature, capillary refill and edema. Determining range of motion will assess joint function. Inspecting for skin lesions is a routine included in the skin assessment
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26.
Which of the following are expected changes in the breast tissue after menopause? Select all that apply
A.
Clear discharge from nipples
B.
More pendulous
C.
Breast tissue replaced by adipose tissue
D.
Firmer
E.
Nodular
Correct Answer(s)
B. More pendulous C. Breast tissue replaced by adipose tissue
Explanation The breast becomes more pendulous, replaced by adipose tissue, and may feel softer. Discharge from nipples is an abnormal finding
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27.
During palpation of the breast, the client is instructed to extend an arm over her head, and a small pillow or folded towel is placed under her shoulder. What for?
A.
Spread tissue more evenly over the chest wall for easier palpation
B.
Keep client from guarding during the exam
C.
Expose the tail of Spence for eaisier inspection
D.
Determine whether or not a breast mass is consistently irregular when palpating a nodule.
Correct Answer
A. Spread tissue more evenly over the chest wall for easier palpation
Explanation This position spreads the tissue more evenly over the chest wall for easier palpation. It does not keep the client from guarding, exposing the tail of Spence, or determining the irregularity of breast mass.
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28.
What is the most appropriate way to auscultate breathe sounds?
A.
Listen to the top of the anterior chest and then the top of the posterior chest
B.
Compare side to side proceeding from top to bottom
C.
Listen only to the posterior chest
D.
Complete one side of the chest before proceeding to the other side
Correct Answer
B. Compare side to side proceeding from top to bottom
Explanation Comparing side to side breath sounds is the correct technique to use. This allows the nurse to make comparisons between right and left lungs in a systematic way. The nurse should listen to the anterior and posterior aspects of the chest in a consistent manner.
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29.
The proper placement of a stethoscope for auscultating the aortic valve is the
A.
Second ICS just left of the sternum
B.
Second ICS just right of the sternum
C.
Fourth ICS just left of the sternum
D.
Fourth ICS just right of the sternum
Correct Answer
B. Second ICS just right of the sternum
Explanation The aortic valve is best auscultated at the second intercostal space (ICS) just right of the sternum. This is because the aortic valve is located in the second intercostal space on the right side of the sternum. Placing the stethoscope at this location allows for optimal sound transmission and detection of any abnormalities or murmurs associated with the aortic valve.
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30.
Which of the following is assessed when performing palpation of the thorax and lung? Select all that apply:
A.
Breath sounds
B.
Respiratory effort
C.
Tactile fremitus
D.
Surface characteristics
E.
Chest excursion
Correct Answer(s)
C. Tactile fremitus D. Surface characteristics E. Chest excursion
Explanation Tactile fremitus, surface characteristics, and chest excursion are all assessed during palpation. Breath sounds are assessed by auscultation. Respiratory effort is assessed by inspection
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31.
What is the right sequence when performing an abdominal assessment?
A.
Inspection, palpation, percussion, auscultation
B.
Auscultation, inspection, palpation, and percussion
C.
Percussion, inspection, auscultation and palpation
D.
Inspection, auscultation, percussion and palpation
Correct Answer
D. Inspection, auscultation, percussion and palpation
Explanation This sequence allows the client's bowel sounds to be heard without being disturbed or distorted by percussion or palpation assessments
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32.
When performing percussion, which of the following sounds should be heard over most of the abdomen?
A.
Dullness
B.
Tympany
C.
Grating
D.
Gurgling
Correct Answer
B. Tympany
Explanation The abdomen is primarily filled with air, and tympany is the sound that will predominate. Dullness is heard over the liver or a distended bladder. A grating sound may indicate a friction rub. Gurgling sounds are heard through a stethoscope and indicate peristalsis.
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33.
Which of the following should be assessed when examining the face?
A.
Lymph nodes
B.
Perception of light touch of the face
C.
Symmetry of facial features
D.
ROM of the neck
E.
Presence of involuntary movements
Correct Answer(s)
B. Perception of light touch of the face C. Symmetry of facial features E. Presence of involuntary movements
Explanation Assessment of the perception of light touch to the face indicates that the sensory portion of the trigeminal nerve (CN V) is intact. symmetry of facial movements and presence of involuntary movements of the face are also assessed. Lymph nodes and ROM of the neck are assessed while examining the neck.
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34.
Asking the client to tip her head to one side and slightly forward, palpating either side of the trachea at the lower half of the neck, and then asking the client to swallow is the correct technique for examining what?
A.
Lymph nodes
B.
ROM of the neck
C.
Symmetry of the skull
D.
Thyroid gland
Correct Answer
D. Thyroid gland
Explanation This is the correct technique in assessing the thyroid gland.
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35.
A patient told you that the results of her Snellen eye test were that the acuity for both of her eyes was 20/30. What does this mean
A.
Patient sees at 20 ft what the normal sighted person sees at 30 ft.
B.
Patient sees at 30 ft what the normal sighted person sees at 20 ft.
C.
Patient sees at 10 ft what the normal sighted person sees at 50 ft.
D.
Patient sees at 50 ft what the normal sighted person sees at 20 ft
Correct Answer
A. Patient sees at 20 ft what the normal sighted person sees at 30 ft.
Explanation The first number indicates the number of feet from the Snellen eye chart that the client is standing, and the second number is the distance at which a normal-sighted person can read the line of the Snellen eye chart.
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36.
What part of the eye examination should occur first?
A.
Extraocular movements
B.
Internal structures
C.
Visual acuity
D.
Visual fields
Correct Answer
C. Visual acuity
Explanation Visual acuity should be assessed first during an eye examination. Assessing extraocular movements, internal structures and visual fields may interfere with the ability of the client to read and demonstrate accurate visual acuity
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37.
An 85-year old man was admitted to the ER with an oral body temperature of 101 F, a pulse rate of 114 / min, and a respiratory rate of 22 / min. He is restless with warm skin. Which of the following interventions are appropriate for him? Select all that apply:
A.
Obtain culture specimen before initiating prescribed antimicrobials
B.
Allow for adequate rest
C.
Restrict fluids
D.
Provide oral care
E.
Only change bed linens when client requests it
F.
Apply additional blanket if client feels chilled
Correct Answer(s)
A. Obtain culture specimen before initiating prescribed antimicrobials B. Allow for adequate rest D. Provide oral care F. Apply additional blanket if client feels chilled
Explanation Cultures may be ordered to rule out the presence of infection and the specimens for culture should be obtained prior to any antibiotic therapy to prevent any interference with infection detection. Rest helps conserve energy and decreases metabolism. Oral care provides comfort for the client's dry mucous membranes. Additional blanket will keep client warm if he feels chilly. Fluids should be encouraged because of fever. The client is likely to sweat, so bed linens should be changed as often as needed
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38.
Which of the following increases the pulse rate? Select all that apply:
A.
Hyperthyroidism,
B.
Walking on treadmill
C.
Blood loss
D.
Anxiety
E.
Acute pain
Correct Answer(s)
A. Hyperthyroidism, B. Walking on treadmill C. Blood loss D. Anxiety E. Acute pain
Explanation Hyperthyroidism is a condition where the thyroid gland produces an excess amount of thyroid hormone, which can increase the pulse rate. Walking on a treadmill can increase the heart rate and pulse rate due to the physical activity involved. Blood loss leads to a decrease in blood volume, which triggers the body to compensate by increasing the heart rate. Anxiety can stimulate the release of stress hormones, such as adrenaline, which can elevate the pulse rate. Acute pain can also activate the body's stress response, leading to an increase in heart rate.
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39.
Which of the following decreases the pulse rate? Select all that apply:
A.
Calcium channel blockers
B.
Acute pain
C.
Anxiety
D.
Blood loss
E.
Hypothermia
Correct Answer(s)
A. Calcium channel blockers E. Hypothermia
Explanation Calcium channel blockers are medications that work by blocking the entry of calcium into the smooth muscle cells of the heart and blood vessels, leading to relaxation and dilation of the blood vessels. This ultimately results in a decrease in the pulse rate. Hypothermia, on the other hand, refers to a decrease in body temperature. This decrease in temperature can slow down the body's metabolic processes, including the heart rate, leading to a decrease in the pulse rate.
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40.
In which of the following scenarios would a simultaneous use of apical and radial sites be used to assess the pulse rate?
A.
A 2-month old infant during a routing check-up
B.
A 16-year old patient who has been stable for 3 hours following an appendectomy
C.
A 76-year old client showing a tachycardia and an irregular rhythm on the cardiac monitor
D.
A 56-year old patient with an order to receive a stat dose of Digoxin
E.
A 20-yeard patient in the ER with a hand laceration
Correct Answer
C. A 76-year old client showing a tachycardia and an irregular rhythm on the cardiac monitor
Explanation A simultaneous use of apical and radial sites would be used to assess the pulse rate in a 76-year old client showing a tachycardia and an irregular rhythm on the cardiac monitor. This is because in this scenario, the client's heart rate and rhythm are abnormal, and it is important to accurately assess the pulse rate from both the apical (heard with a stethoscope) and radial (felt at the wrist) sites to determine the severity and nature of the irregularities. By comparing the pulse rates from both sites, healthcare professionals can gather more comprehensive information about the client's cardiovascular status and make appropriate interventions.
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41.
In which of the following scenarios would the use of the apical site be appropriate to assess the pulse rate? Select all that apply:
A.
A 2-month old infant during a routing check-up
B.
A 20-yeard patient in the ER with a hand laceration
C.
A 16-year old patient who has been stable for 3 hours following an appendectomy
D.
A 56-year old patient with an order to receive a stat dose of Digoxin
Correct Answer(s)
A. A 2-month old infant during a routing check-up D. A 56-year old patient with an order to receive a stat dose of Digoxin
Explanation The apical site is appropriate to assess the pulse rate in a 2-month old infant during a routine check-up because it is more accurate in infants and young children. It is also appropriate to use the apical site in a 56-year old patient with an order to receive a stat dose of Digoxin because Digoxin can affect the electrical conduction of the heart, and the apical site provides a more accurate assessment of the heart's rhythm in such cases.
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42.
In which of the following scenarios would the use of the radial site be appropriate to assess the pulse rate? Select all that apply
A.
A 19-year old patient in the ER with a hand laceration to be sutured.
B.
A 56 year old client with an order to receive a stat dose of digoxin
C.
A 75-year old patient on a cardiac monitor
D.
A 26-yeard old patient who has been stable for 3 hours following an appendectomy
Correct Answer(s)
A. A 19-year old patient in the ER with a hand laceration to be sutured. D. A 26-yeard old patient who has been stable for 3 hours following an appendectomy
Explanation The radial site is appropriate for assessing the pulse rate in a 19-year old patient with a hand laceration to be sutured because it is easily accessible and provides an accurate representation of the heart rate. Similarly, it is also appropriate for a 26-year old patient who has been stable for 3 hours following an appendectomy as they are not in a critical condition and the radial site can be easily accessed.
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43.
A nurse is checking the vital signs of a 92-year old patient. The patient's radial pulse has an irregular beat about every 5th or 6th beat. The rate is 92/min. The patient is asymptomatic. What should be the first intervention?
A.
Report the findings to the physician immediately.
B.
Obtain an electrocardiogram
C.
Check an apical pulse for 60 seconds and note any pulse deficits
D.
Place the patient on telemetry
Correct Answer
C. Check an apical pulse for 60 seconds and note any pulse deficits
Explanation This radial pulse does not require immediate medical treatment; therefore, the nurse should next measure the client's apical pulse to assess the client's status further. The nurse should then report the findings to the provider, who will then decide if the client requires telemetry and an electrocardiogram
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44.
Which of the following are appropriate when assessing a client's respiration? Select all that apply:
A.
Count the respiratory rate for 1 minute
B.
Place the client on semi-Fowler's position
C.
Count the respiratory rate simultaneously with the pulse
D.
Position the stethoscope on the anterior chest
E.
Observe one full respiratory cycle before counting the rate
Correct Answer(s)
B. Place the client on semi-Fowler's position E. Observe one full respiratory cycle before counting the rate
Explanation The best position for the client during respiratory assessment is semi-Fowler's with the chest visible. Observing for one full respiratory cycle before starting to count assists in obtaining an accurate count. If the rate is regular, count for 30 seconds and multiply by 2. Count the rate for 1 full minute if irregular, faster than 20 / min or slower than 12 /min. It is difficult to measure either the respiratory rate or the pulse accurately if counted simultaneously. The respiratory rate is not auscultated with a stethoscope
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45.
Which of the following increases respiratory rate? Select all that apply:
A.
Brisk walk on treadmill
B.
Sickle cell disease
C.
Smoking
D.
Acute gall bladder attack
E.
Mountain hiking
Correct Answer(s)
A. Brisk walk on treadmill B. Sickle cell disease C. Smoking D. Acute gall bladder attack E. Mountain hiking
Explanation All of the options listed can increase respiratory rate. Brisk walk on a treadmill, mountain hiking, and acute gall bladder attack can lead to an increase in respiratory rate due to increased physical activity or pain. Sickle cell disease can cause a decrease in oxygen levels, leading to compensatory increase in respiratory rate. Smoking can irritate the airways and cause shortness of breath, resulting in an increased respiratory rate.
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46.
Which of the following decreases respiratory rate? Select all that apply:
A.
Morphine
B.
Caffeine
C.
Jogging in the park
D.
General anesthesia during surgery
E.
Smoking
Correct Answer(s)
A. MorpHine D. General anesthesia during surgery
Explanation Morphine is a potent analgesic and sedative that can decrease respiratory rate by depressing the central nervous system. General anesthesia during surgery also decreases respiratory rate as it involves the use of medications that suppress the respiratory drive. Caffeine, jogging in the park, and smoking, on the other hand, do not decrease respiratory rate. Caffeine is a stimulant that can actually increase respiratory rate, while jogging in the park and smoking may have variable effects on respiratory rate but are generally not known to decrease it.
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47.
Which of the following increases blood pressure? Select all that apply
A.
Cocaine
B.
Brisk walk on a treadmill
C.
Antihypertensive
D.
Acute gallbladder attack
E.
Postoperative pain
Correct Answer(s)
A. Cocaine D. Acute gallbladder attack E. Postoperative pain
Explanation Cocaine is a stimulant drug that increases blood pressure by constricting blood vessels and stimulating the release of adrenaline. An acute gallbladder attack can cause an increase in blood pressure due to the intense pain and stress on the body. Postoperative pain can also lead to an increase in blood pressure as a result of the body's response to pain and stress. Antihypertensive medications, on the other hand, are used to lower blood pressure, so they do not increase it. A brisk walk on a treadmill can temporarily raise blood pressure during exercise, but it is not a long-term increase.
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48.
Which of the following decreases blood pressure? Select all that apply:
A.
Cocaine
B.
Brisk walk on a treadmill
C.
Antihypertensive
D.
Acute gallbladder attack
E.
Postoperative pain
Correct Answer(s)
B. Brisk walk on a treadmill C. Antihypertensive
Explanation Both a brisk walk on a treadmill and antihypertensive medications can decrease blood pressure. Exercise, such as walking, helps to improve cardiovascular health and can lower blood pressure. Antihypertensive medications are specifically designed to lower blood pressure and are commonly prescribed to individuals with hypertension.
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49.
A nurse is checking the vital signs of a newly admitted patient who has a femur fracture. The patient's blood pressure is 140/94 mm Hg. The client denies any history of hypertension. What should the nurse do next?
A.
Ask the patient if she is having pain
B.
Report the elevated BP to the physician
C.
Return within 30 minutes to check the blood pressure
D.
Check orthostatic blood pressure
Correct Answer
A. Ask the patient if she is having pain
Explanation The patient has a broken femur and her blood pressure is elevated due to pain. The nurse should ask if she is having pain and continue a full pain assessment. If the patient's BP is still elevated after pain intervention. the nurse should report this finding to the physician. This client needs further assessment at this time, so returning in 30 minutes is not appropriate. There is no indication for orthostatic pressure, and it might be difficult to have the client sit or stand with a fractured femur
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50.
Which of the following is an effective technique to use when interviewing a client?
A.
Start interview with nonthreatening topics
B.
Use only non-directive questions
C.
Have the client fill out a printed history form
D.
Ask questions word for word from the history form
Correct Answer
A. Start interview with nonthreatening topics
Explanation A nonthreatening topic will establish rapport and trust between client and nurse. Nondirective questions may make the client feel comfortable, but may allow the client to avoid discussing important details. Having the client fill out a history form and asking questions word for word may discourage the establishment of a therapeutic relationship with client.
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