ATI Learning System RN 3.0 Fundamentals 1 Quiz (Questions and Answers With Rationale

ATI Learning System RN 3.0 Fundamentals 1 Quiz (Questions and Answers With Rationale ATI Learning System RN 3.0 Fundamentals 1 Quiz (Questions and Answers With Rationale 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 diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? - Audible click - Murmur - Third heart sound - Pericardial friction rub {{Correct Ans- Pericardial friction rub: A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? - Auscultate for the blood pressure at the dorsalis pedis artery. - Measure the blood pressure with the client sitting on the side of the bed. - Place the cuff 7.6 cm (3 in) above the popliteal artery. - Place the bladder of the cuff over the posterior aspect of the thigh. {{Correct Ans- Place the bladder of the cuff over the posterior aspect of the thigh. This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurse. Which of the following actions should the charge nurse teach as the first response to CPR? - Call for assistance. - Begin chest compressions. - Confirm unresponsiveness. - Give rescue breaths. {{Correct Ans- Confirm unresponsiveness. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.