ATI Fundamentals Nursing- Ch. 27

Question 1

A nurse is instructing a newly licensed nurse about choosing a site to measure a client’s temperature. Sort the following clients with the correct temperature site: Oral or Rectal

A. A client who breathes through the mouth
B. A client who has a low platelet count
C. A client who has facial trauma
D. A client who has hemorrhoids

Answer 1

Oral: B, D.
Rectal: A, C.

Question 2

A nurse is caring for a client who has an oral temperature of 38.6C (101.5 F), heart rate 114/min, and respiratory rate 22/min. Which of the following interventions should the nurse take? (Select all that apply)

A. Obtain culture specimens before initiating antimicrobials.
B. Restrict the client’s oral fluid intake.
C. Encourage the client to rest and limit activity.
D. Allow the client to shiver to dispel excess heat.
E. Assist the client with oral hygiene frequently.

Answer 2

A: Obtain culture specimens before initiating antimicrobials.
C: Encourage the client to rest and limit activity.
E: Assist the client with oral hygiene frequently.

Question 3

The image below shows information regarding nursing interventions for hypothermia. Match the object to the correct description.

A. Monitor
B. Blanket
C. Defibrillator
D. Baby with hat

1. Provide a warm environmental temperature, heated humidified oxygen, warming blanket, and/ or warmed oral or IV fluids.
2. Keep the head covered.
3. Provide continuous cardiac monitoring.
4. Have emergency resuscitation equipment on standby.

Answer 3

A,3; B,1; C,4; D,2

Question 4

A nurse determine a client’s radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client’s pulse deficit?

Answer 4

When analyzing cues, the nurse should determine that the pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusion heartbeats that do not transmit pulsations to peripheral pulse points. Therefore, 84-68= 16.

Question 5

A nurse is instructing as assistive personnel (AP) how to measure a client’s respiratory rate. Which of the following statements should the nurse include? (Select all that apply.)

A. “Place he client in semi-Fowler’s position.”
B. “Have the client rest an arm across the abdomen.”
C. “Observe one full respiratory cycle before counting the rate.”
D. “Count the rate for 30 sec if it is irregular.”
E. “Inform the client you are counting their respiratory rate.”

Answer 5

A: “Place he client in semi-Fowler’s position.”
B: “Have the client rest an arm across the abdomen.”
C: “Observe one full respiratory cycle before counting the rate.”

Question 6

A nurse is caring for a client who has a fractured femur and a blood pressure of 140/94 mm Hg. Which of the following actions should the nurse take first?

A. Request a prescription for an antihypertensive medication.
B. Ask the client if they are having pain.
C. Instruct the client above a low-sodium diet.
D. Return in 30 min to recheck the client’s blood pressure.

Answer 6

B: Ask the client if they are having pain.