ATI Learning System RN 3.0
Fundamentals 1 Quiz Already Passed
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 ✔✔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. ✔✔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. ✔✔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.
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for
the procedure, which of the following actions should the nurse take first?
, - Explain the x-ray procedure to the client.
- Help the client into a wheelchair before the transporter arrives.
- Ask if the client has any questions.
- Identify the client using two identifiers. ✔✔Identify the client using two identifiers.
The nurse should apply the safety and risk reduction priority-setting framework. This framework
assigns priority to the factor or situation posing the greatest safety risk to the client. When there
are several risks to client safety, the one posing the greatest threat is the highest priority. The
nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing
knowledge to identify which risk poses the greatest threat to the client. Once the client's identity
is determined, the nurse can then proceed with the other options. This action is the priority action
because it provides for the safety of the client. It is a nursing responsibility to be certain that each
client receives only what has been prescribed. The nurse must assure that the correct client is
being transported for a chest x-ray.
A nurse is caring for a child who is postoperative following a tonsillecto my. Which of the
following actions should the nurse take?
- Encourage the child to cough frequently to clear congestion from anesthesia.
- Place a heating pad at the child's neck for comfort.
- Administer analgesics to the child on a routine schedule throughout the day and night.
- Provide the child with ice cream when oral intake is initiated. ✔✔Administer analgesics to the
child on a routine schedule throughout the day and night.
To soothe the client's throat following a tonsillectomy, the nurse should administer pain
medication routinely around the clock. The nurse can provide the medication rectally or
intravenously to avoid the oral route.
Fundamentals 1 Quiz Already Passed
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 ✔✔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. ✔✔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. ✔✔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.
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for
the procedure, which of the following actions should the nurse take first?
, - Explain the x-ray procedure to the client.
- Help the client into a wheelchair before the transporter arrives.
- Ask if the client has any questions.
- Identify the client using two identifiers. ✔✔Identify the client using two identifiers.
The nurse should apply the safety and risk reduction priority-setting framework. This framework
assigns priority to the factor or situation posing the greatest safety risk to the client. When there
are several risks to client safety, the one posing the greatest threat is the highest priority. The
nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing
knowledge to identify which risk poses the greatest threat to the client. Once the client's identity
is determined, the nurse can then proceed with the other options. This action is the priority action
because it provides for the safety of the client. It is a nursing responsibility to be certain that each
client receives only what has been prescribed. The nurse must assure that the correct client is
being transported for a chest x-ray.
A nurse is caring for a child who is postoperative following a tonsillecto my. Which of the
following actions should the nurse take?
- Encourage the child to cough frequently to clear congestion from anesthesia.
- Place a heating pad at the child's neck for comfort.
- Administer analgesics to the child on a routine schedule throughout the day and night.
- Provide the child with ice cream when oral intake is initiated. ✔✔Administer analgesics to the
child on a routine schedule throughout the day and night.
To soothe the client's throat following a tonsillectomy, the nurse should administer pain
medication routinely around the clock. The nurse can provide the medication rectally or
intravenously to avoid the oral route.
