ATI Fundamentals CMS 2023
Study online at https://quizlet.com/_jnk0bn
1. a nurse is assessing the heart sounds of a client who has developed
chest pain that becomes worse with inspiration. the nurse auscultates a
high-pitched scratching sound during both systole and diastole with the di-
aphragm of the stethoscope positioned at the left sternal border. which heart
sounds should the nurse document?: pericardial friction rub
2. a nurse is obtaining the blood pressure in a clients lower extremity. which
action should the nurse take?: place the bladder of the cuff over the posterior aspect of the thigh
3. a charge nurse is teaching adult CPR to a group of new nurses. which actions
should the charge nurse teach as the first response in CPR?: confirm unresponsiveness
4. a nurse is caring for a client who requires a chest xray. prior to the client
being transported for the procedure, which actions should the nurse take
first?: identify the client using two identifiers
5. a nurse is caring for a child who is postop following a tonsillectomy. which
actions should the nurse take?: administer analgesics to the child on a routine schedule throughout
the day and night
6. a nurse is providing teaching to a client who has heart failure about how
to reduce his daily intake of sodium. which factors is the most important in
determining the clients ability to learn new dietary habits?: the involvement of the client
in planning the change
7. a charge nurse is observing a new nurse perform tracheostomy care for a
client. which actions by the new nurse requires intervention?: obtaining cotton balls
for the trach care
8. a nurse is preparing to perform mouth care for an unresponsive client.
which actions should the nurse plan to take?: raise the level of the bed
9. a nurse is witnessing a client sign an informed consent form for surgery.
which describes what the nurse is affirming by this action?: the signature on the preop
consent form is the clients
10. a nurse is preparing to provide tracheostomy care for a client. which actions
should the nurse take first?: perform hand hygiene
11. a nurse is caring for an older adult client who becomes agitated when the
nurse requests that the clients dentures be removed prior to surgery. which
responses should the nurse make?: what worries you about being without your teeth?
, ATI Fundamentals CMS 2023
Study online at https://quizlet.com/_jnk0bn
12. a nurse in an oncology clinic is assessing a client who is undergoing treat-
ment for ovarian cancer. which assessment statements by the client indicates
she is experiencing psychological distress?: i keep having nightmares about my upcoming
surgery
13. a nurse on a med surg unit is caring for a client. which actions should the
nurse take first when using the nursing process?: obtain client information
14. a nurse is caring for an older adult client who is violent and attempting
to disconnect her IV lines. the provider prescribes soft wrist restraints. which
actions should the nurse take while the client is in restraints?: remove the restraints
one at a time
15. a nurse is planning care for a client who reports abdominal pain. an assess-
ment by the nurse reveals the client has a temp of 102.6, HR of 105, a soft
nontender abdomen, and menses overdue by 2 days. which findings should
be the nurses priority?: temperature
16. a nurse is inserting an IV catheter for a client that results in a blood spill on
her gloved hand. the client has no documented bloodstream infection. which
action should the nurse take?: carefully remove the gloves and follow with hand hygiene
17. a nurse is caring for a client who is post op and has paralytic ileum. which
abdominal assessments should the nurse expect?: absent bowel sounds with distention
18. a nurse is caring for a client who has type 1 diabetes and is resistant to
learning self-injection of insulin. which statements should the nurse make?: tell
me what i can do to help you overcome your fear of giving yourself injections
19. a nurse is recieving a client from the PACU who is post op following abdom-
inal surgery. which actions should the nurse make to transfer the client from
the stretcher to the bed?: lock the wheels on the bed and stretcher
20. a nurse is caring for a client who is in the terminal stage of cancer. which
actions should the nurse take when she observes the client crying?: sit and hold
the clients hand
21. a nurse in the ED is assessing a client who reports diarrhea and decreased
urination for 4 days. which actions should the nurse take to assess the clients
skin turgor?: grasp a skinfold on chest under clavicle, release, and note whether it springs back
Study online at https://quizlet.com/_jnk0bn
1. a nurse is assessing the heart sounds of a client who has developed
chest pain that becomes worse with inspiration. the nurse auscultates a
high-pitched scratching sound during both systole and diastole with the di-
aphragm of the stethoscope positioned at the left sternal border. which heart
sounds should the nurse document?: pericardial friction rub
2. a nurse is obtaining the blood pressure in a clients lower extremity. which
action should the nurse take?: place the bladder of the cuff over the posterior aspect of the thigh
3. a charge nurse is teaching adult CPR to a group of new nurses. which actions
should the charge nurse teach as the first response in CPR?: confirm unresponsiveness
4. a nurse is caring for a client who requires a chest xray. prior to the client
being transported for the procedure, which actions should the nurse take
first?: identify the client using two identifiers
5. a nurse is caring for a child who is postop following a tonsillectomy. which
actions should the nurse take?: administer analgesics to the child on a routine schedule throughout
the day and night
6. a nurse is providing teaching to a client who has heart failure about how
to reduce his daily intake of sodium. which factors is the most important in
determining the clients ability to learn new dietary habits?: the involvement of the client
in planning the change
7. a charge nurse is observing a new nurse perform tracheostomy care for a
client. which actions by the new nurse requires intervention?: obtaining cotton balls
for the trach care
8. a nurse is preparing to perform mouth care for an unresponsive client.
which actions should the nurse plan to take?: raise the level of the bed
9. a nurse is witnessing a client sign an informed consent form for surgery.
which describes what the nurse is affirming by this action?: the signature on the preop
consent form is the clients
10. a nurse is preparing to provide tracheostomy care for a client. which actions
should the nurse take first?: perform hand hygiene
11. a nurse is caring for an older adult client who becomes agitated when the
nurse requests that the clients dentures be removed prior to surgery. which
responses should the nurse make?: what worries you about being without your teeth?
, ATI Fundamentals CMS 2023
Study online at https://quizlet.com/_jnk0bn
12. a nurse in an oncology clinic is assessing a client who is undergoing treat-
ment for ovarian cancer. which assessment statements by the client indicates
she is experiencing psychological distress?: i keep having nightmares about my upcoming
surgery
13. a nurse on a med surg unit is caring for a client. which actions should the
nurse take first when using the nursing process?: obtain client information
14. a nurse is caring for an older adult client who is violent and attempting
to disconnect her IV lines. the provider prescribes soft wrist restraints. which
actions should the nurse take while the client is in restraints?: remove the restraints
one at a time
15. a nurse is planning care for a client who reports abdominal pain. an assess-
ment by the nurse reveals the client has a temp of 102.6, HR of 105, a soft
nontender abdomen, and menses overdue by 2 days. which findings should
be the nurses priority?: temperature
16. a nurse is inserting an IV catheter for a client that results in a blood spill on
her gloved hand. the client has no documented bloodstream infection. which
action should the nurse take?: carefully remove the gloves and follow with hand hygiene
17. a nurse is caring for a client who is post op and has paralytic ileum. which
abdominal assessments should the nurse expect?: absent bowel sounds with distention
18. a nurse is caring for a client who has type 1 diabetes and is resistant to
learning self-injection of insulin. which statements should the nurse make?: tell
me what i can do to help you overcome your fear of giving yourself injections
19. a nurse is recieving a client from the PACU who is post op following abdom-
inal surgery. which actions should the nurse make to transfer the client from
the stretcher to the bed?: lock the wheels on the bed and stretcher
20. a nurse is caring for a client who is in the terminal stage of cancer. which
actions should the nurse take when she observes the client crying?: sit and hold
the clients hand
21. a nurse in the ED is assessing a client who reports diarrhea and decreased
urination for 4 days. which actions should the nurse take to assess the clients
skin turgor?: grasp a skinfold on chest under clavicle, release, and note whether it springs back
