ATI Learning System RN: Fundamentals
1, 2, and Final (Answered) Graded A+
terminal illness and questions directed to nurse about religion and death
encourage the patient to express feeling about death and dying
-therapeutic technique of reflection
first priority action when performing tracheostomy care
1. perform hand hygiene
-The nurse should also- don sterile gloves, open all sterile supplies and solutions, and
stabilize the tracheostomy tube but they all will come after hand hygiene in order to
prevent contamination of the trach tube
what should a nurse's priority action be when they notice a patient's pulse is
irregular?
auscultate the apical pulse and listen for 1 minute to obtain and accurate rate and
document the irregularity in the chart
-check peripheral pulses bilaterally to determine equality of blood perfusion
-check pedal pulses to determine circulation in pts lower extremities
-a doppler ultrasound should be used when a pt has a nonpalpable pulse/ very difficult
to palpate
first nursing action when receiving a new patient
1. obtain the pts information
-other steps that follow this include: identify goals of care, document nursing findings,
evaluate effectiveness of care
transferring a patient from a stretcher to a bed following an abdominal surgery
lock the wheels of the stretcher and the bed
-pt should cross their arms over the chest to prevent injury
-stretcher should be no more than 1.3 cm above the height of bed
-logroll technique used to prevent injury of pts requiring immobilization of neck, back,
spine
priority nursing action for a patient admitted with decreased circulation of the left
leg
evaluate pedal pulses
-nurse should also obtain a medical history, assess vitals and assess for leg pain but
these aren't the first priority
abdominal assessment of a patient postoperative with a paralytic ileum
absent bowel sounds w/ distention
-paralytic ileus is an immobile bowel w/ absent bowel sounds, abdominal distention,
decreased peristalsis, no flatulence or stool
,teaching for an older adult who has constipation
sit on the toilet for 30 minutes after eating a meal
-increased peristalsis occurs after eating, sitting on the toilet for 30 min after eating is
recommended bowel retraining to treat constipation
-consume a minimum of 1500 mL of water
increase intake of coarse-fiber and whole grains, not refined-fiber
-do not use daily softeners because it hinders bowel retraining process
patient who has chest pain that worsens upon inspiration and a high-pitched
scratching sounds is auscultated during systole and diastole by the nurse with
the diaphragm of the stethoscope positioned at the left sternal border. What heart
sound should the nurse document?
pericardial friction rub
-pericardial friction rub high-pitched scratching, grating, squeaking leathery sound heard
best w/ the diaphragm of the stethoscope at the left sternal border
-common manifestation of pericardial inflammation; can be heard w/ ineffective
pericarditis w/ MI, following cardiac surgery or trauma, or some autoimmune disorders
such as rheumatic fever
-typically has signs of chest pain that increases w/ inspiration or coughing and is
relieved by sitting up or leaning forward
-audible click, occurs in pts after prosthetic valve replacement surgery
-murmur = swishing, whistling sound, hear best w/ bell of stethoscope
-third heart sound = low-pitched sound after 2nd heart sound caused by rapid
ventricular filling during diastole, best heard at mitral area w/ pt on L side; commonly
heard in pts w/ HD and indicative of HF
a nurse demonstrates postop breathing and coughing excises to a patient having
an emergency surgery for appendicitis. What statement indicates the patient has
a lack of readiness to learn?
pt reports severe pain
-pt w/ pain is unable to concentrate and perform exercises
-Pt asking to repeat the instructions, how often to perform the exercises, and stating that
it will probably be painful to perform them. Are all statements that show a readiness to
learn
F1
nurse teaching a group of older adults about the expected changes of aging. what
statement indicates an understanding of the teaching?
"I should expect my heart rate to take longer to return to normal after exercise as I get
older."
-d/t decreased cardiac output which causes an increased pulse rate during exercise
-Bladder capacity decreases w/ age but urinary incontinence is not an expected finding
of aging
-Have an increase of ear wax buildup which may increase incidence problems w/
, hearing loss
-Decreased gastric emptying is an expected finding
what statement should a nurse make when a patient with DM1 is resistant to
learning self-injection of insulin?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
-therapeutic, pt able to express feelings
A patient is scheduled for an arthroplasty in the next month and may need a
blood transfusion. The patient expresses concern about the risk of developing an
infection from the transfusion. What statement should the nurse make to the
patient?
"donate autologous blood before the surgery"
-collection and reinfusion of the pts own blood, blood is drawn 3-5 weeks prior to
surgery; safest form of blood tranfusions
-taking epoetin prior to surgery can boost HCT levels but is inappropriate if their levels
are w/in normal and this might not eliminate need for transfusion
-taking iron supplement can boost hemoglobin levels but inappropriate if levels are w/in
range and may not eliminate need for transfusion
-blood donated from family member doesn't eliminate a possible infection from
transfusion
What action by a newly licensed nurse during tracheostomy care requires
intervention?
obtaining cotton balls for tracheostomy care
-cotton balls can be aspirated possible causing tracheal abscess
-high-strength peroxide solution is used to clean inner cannula
-trach care is sterile procedure and sterile gloves are needed
-pipe cleaners, small sterile brush can be used to remove thick/crusty secretions from
inner cannula
a nurse observes and AP using a small B/P cuff on an obese patient. What
explanation should the nurse give the AP?
"using a cuff that is too small will result in an inaccurately high reading."
-a cuff that's too small for an obese pt will not result in an inaudible reading or an
accurate reading
-a B/P cuff should take up no more than 40% the circumference of the pts arm
correct sequence of steps for an abdominal assessment
1. inspection
2. auscultation
3. percussion
4. palpation
-prevents alerting the bowel sounds and causing false results
a nurse is assessing a patient who is to undergo treatment for ovarian cancer.
what statement indicated the patient is experiencing psychological distress?
1, 2, and Final (Answered) Graded A+
terminal illness and questions directed to nurse about religion and death
encourage the patient to express feeling about death and dying
-therapeutic technique of reflection
first priority action when performing tracheostomy care
1. perform hand hygiene
-The nurse should also- don sterile gloves, open all sterile supplies and solutions, and
stabilize the tracheostomy tube but they all will come after hand hygiene in order to
prevent contamination of the trach tube
what should a nurse's priority action be when they notice a patient's pulse is
irregular?
auscultate the apical pulse and listen for 1 minute to obtain and accurate rate and
document the irregularity in the chart
-check peripheral pulses bilaterally to determine equality of blood perfusion
-check pedal pulses to determine circulation in pts lower extremities
-a doppler ultrasound should be used when a pt has a nonpalpable pulse/ very difficult
to palpate
first nursing action when receiving a new patient
1. obtain the pts information
-other steps that follow this include: identify goals of care, document nursing findings,
evaluate effectiveness of care
transferring a patient from a stretcher to a bed following an abdominal surgery
lock the wheels of the stretcher and the bed
-pt should cross their arms over the chest to prevent injury
-stretcher should be no more than 1.3 cm above the height of bed
-logroll technique used to prevent injury of pts requiring immobilization of neck, back,
spine
priority nursing action for a patient admitted with decreased circulation of the left
leg
evaluate pedal pulses
-nurse should also obtain a medical history, assess vitals and assess for leg pain but
these aren't the first priority
abdominal assessment of a patient postoperative with a paralytic ileum
absent bowel sounds w/ distention
-paralytic ileus is an immobile bowel w/ absent bowel sounds, abdominal distention,
decreased peristalsis, no flatulence or stool
,teaching for an older adult who has constipation
sit on the toilet for 30 minutes after eating a meal
-increased peristalsis occurs after eating, sitting on the toilet for 30 min after eating is
recommended bowel retraining to treat constipation
-consume a minimum of 1500 mL of water
increase intake of coarse-fiber and whole grains, not refined-fiber
-do not use daily softeners because it hinders bowel retraining process
patient who has chest pain that worsens upon inspiration and a high-pitched
scratching sounds is auscultated during systole and diastole by the nurse with
the diaphragm of the stethoscope positioned at the left sternal border. What heart
sound should the nurse document?
pericardial friction rub
-pericardial friction rub high-pitched scratching, grating, squeaking leathery sound heard
best w/ the diaphragm of the stethoscope at the left sternal border
-common manifestation of pericardial inflammation; can be heard w/ ineffective
pericarditis w/ MI, following cardiac surgery or trauma, or some autoimmune disorders
such as rheumatic fever
-typically has signs of chest pain that increases w/ inspiration or coughing and is
relieved by sitting up or leaning forward
-audible click, occurs in pts after prosthetic valve replacement surgery
-murmur = swishing, whistling sound, hear best w/ bell of stethoscope
-third heart sound = low-pitched sound after 2nd heart sound caused by rapid
ventricular filling during diastole, best heard at mitral area w/ pt on L side; commonly
heard in pts w/ HD and indicative of HF
a nurse demonstrates postop breathing and coughing excises to a patient having
an emergency surgery for appendicitis. What statement indicates the patient has
a lack of readiness to learn?
pt reports severe pain
-pt w/ pain is unable to concentrate and perform exercises
-Pt asking to repeat the instructions, how often to perform the exercises, and stating that
it will probably be painful to perform them. Are all statements that show a readiness to
learn
F1
nurse teaching a group of older adults about the expected changes of aging. what
statement indicates an understanding of the teaching?
"I should expect my heart rate to take longer to return to normal after exercise as I get
older."
-d/t decreased cardiac output which causes an increased pulse rate during exercise
-Bladder capacity decreases w/ age but urinary incontinence is not an expected finding
of aging
-Have an increase of ear wax buildup which may increase incidence problems w/
, hearing loss
-Decreased gastric emptying is an expected finding
what statement should a nurse make when a patient with DM1 is resistant to
learning self-injection of insulin?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
-therapeutic, pt able to express feelings
A patient is scheduled for an arthroplasty in the next month and may need a
blood transfusion. The patient expresses concern about the risk of developing an
infection from the transfusion. What statement should the nurse make to the
patient?
"donate autologous blood before the surgery"
-collection and reinfusion of the pts own blood, blood is drawn 3-5 weeks prior to
surgery; safest form of blood tranfusions
-taking epoetin prior to surgery can boost HCT levels but is inappropriate if their levels
are w/in normal and this might not eliminate need for transfusion
-taking iron supplement can boost hemoglobin levels but inappropriate if levels are w/in
range and may not eliminate need for transfusion
-blood donated from family member doesn't eliminate a possible infection from
transfusion
What action by a newly licensed nurse during tracheostomy care requires
intervention?
obtaining cotton balls for tracheostomy care
-cotton balls can be aspirated possible causing tracheal abscess
-high-strength peroxide solution is used to clean inner cannula
-trach care is sterile procedure and sterile gloves are needed
-pipe cleaners, small sterile brush can be used to remove thick/crusty secretions from
inner cannula
a nurse observes and AP using a small B/P cuff on an obese patient. What
explanation should the nurse give the AP?
"using a cuff that is too small will result in an inaccurately high reading."
-a cuff that's too small for an obese pt will not result in an inaudible reading or an
accurate reading
-a B/P cuff should take up no more than 40% the circumference of the pts arm
correct sequence of steps for an abdominal assessment
1. inspection
2. auscultation
3. percussion
4. palpation
-prevents alerting the bowel sounds and causing false results
a nurse is assessing a patient who is to undergo treatment for ovarian cancer.
what statement indicated the patient is experiencing psychological distress?
