ATI SM 3.0: Mobility, ATI questions - Pain, Hygiene, Tissue Integrity, Personal hygiene, ATI HIPAA Module, ATI SM: Comprehensive physical assessment of an Adult With complete verified solutions latest updated version

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?

A. "Lean on the crutches to support your body weight when standing."

B. "Fully extend your arms when holding onto the hand grips."

C. "Hold the crutches on your unaffected side when preparing to sit in a chair."

D. "Hold the crutches 9 inches in front of and to the side of each foot."

C. "Hold the crutches on your unaffected side when preparing to sit in a chair."

Rationale: The crutches should be held on the unaffected side when preparing to sit in a chair.

Incorrect rationale:

- crutches should be fitted so the client's arms are flexed ~ 30° at elbows when holding onto hand grips.

- crutches should be held 6 inches in front of & to side of each foot to assist w/ balance

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

A. Move their leg behind their body.

B. Move their leg forward and up.

C. Move their leg medially toward their other leg.

D. Turn their foot and leg away from their other leg.

A. Move their leg behind their body.

Rationale: This movement demonstrates hyperextension of the hip.

B. flexion

C. adduction

D. external rotation

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?

A. Place the stockings on the client after the client ambulates to the restroom.

B. Ensure the client's toes are visible after placing the stockings on the client.

C. After applying the stockings, place two fingers between the client's leg and stocking to check the fit.

D. Measure the client's calf circumference and leg length from heel to knee.

D. Measure the client's calf circumference and leg length from heel to knee.

Rationale: To ensure proper fit, the nurse should measure the widest part of the client's calf as well as the length of client's leg from heel to knee. Antiembolic stockings that are too large will not apply the pressure needed to prevent DVT. Antiembolic stockings that are too small could impair circulation in the client's legs.

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

A. Wrap both arms around the client's arms and shoulders.

B. Move both feet together when the client begins to fall.

C. Protect the client's extremities while lowering them to the floor.

D. Extend one leg and allow the client to slide down the leg to the floor.

D. Extend one leg and allow the client to slide down the leg to the floor.

Rationale: This action helps prevent injury to the client. As the client gets close to the floor, the nurse should bend both legs to continue supporting the client.

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique?

A. Positioning the chair slightly behind the nurse so that the seat faces the client's bed

B. Placing the client's left leg in front of the right leg just prior to the transfer

C. Aligning the nurse's knees with the client's knees just before the transfer

D. Grasping the client under the axillae to assist them to their feet

C. Aligning the nurse's knees with the client's knees just before the transfer.

Rationale: This is a correct strategy that helps the nurse safely stabilize the client while moving to a standing position.

A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?

A. Adducting the arm so that it lies next to the client's side

B. Flexing the shoulder by raising the arm from a side position to a 180° angle

C. Abducting the arm to a 90° angle from the side of the body

D. Circumducting the shoulder in a 180° half circle

B. Flexing the shoulder by raising the arm from a side position to a 180° angle

Rationale: This demonstrates full ROM of shoulder. The client's fingers should be pointing directly upward.

circumduct = 360* circle

A nurse is observing an assistive personnel (AP) who is using a mechanical lift w/ a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?

A. Places a removable cover over the sling

B. Leaves the bed in the lowest position throughout the procedure

C. Locks the hydraulic valve before attaching the sling to the lift

D. Raises the head of the bed to a sitting position just before transfer

B. Leaves the bed in the lowest position throughout the procedure

Rationale: The bed should be raised to a comfortable working position in order to prevent injury to nursing staff and to properly position the lift under the client's bed.

A charge nurse is reviewing factors that can affect the clients perception of pain with the newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply.)

Stress.

Culture.

Social support.

Disease severity.

A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the clients need for how long?

20 minutes.

A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by staff member indicates an understanding of the information? (Select all that apply.)

"A clients religious beliefs might affect the way they respond to pain".

"The clients past pain experiences are not related to their current pain and pain management".

"Pain control might be harder to achieve if the nurse and client speak different primary languages".

A nurse is caring for an older adult client who has a cognitive impairment and it's postoperative period which of the following action should the nurse take?

Evaluate the client for pain by observing their behavior.

A nurse is discussing transcutaneous electrical nerve stimulation (TENS) Treatment with the client who has chronic lower back pain. Which of the following statements should the nurse include? (Select all that apply.)

"You can be taught how to use TENS therapy at home".

" The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas".

"We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy".

A nurse is monitoring a client who is two hours postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid induced Ventilatory Impairment (OIVI)? (Select all that apply.)

Respiratory rate.

Capnography (measuring carbon dioxide).

Oxygen saturation.

A nurse is caring for a client who has a prescription for Hydro morphine 1 to 2 mg IM every four hours as needed for pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken Hydro morphine before. Which of the following action should the nurse plan to take?

Administer 1 mg IM (The nurse should administer the lowest dose)

A nurse is caring for a client who has severe pain and repeatedly asked for pain medication. The nurses busy and forget to assess the client pain and administer prescribe pain medication. Which of the following in the nurse be charged with?

Negligence ( Failure to perform in a manner that are reasonable person would).

A nurse is caring for a group of clients on the pediatric unit. For which of the following client should the nurse use the FLACC pain scale to determine their pain level? (Select all that apply.)

A three year old toddler who has a fractured femur.

A 14- year old client who has severe cognitive and developmental delays.

A five year old preschooler who is experiencing pain during a sickle cell crisis.

A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every four hours PRN. Which of the following statement by the client indicates an understanding of the instructions?

"I will keep the morphine bottle in a locked cabinet in my kitchen."

A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greater risk for respiratory depression?

A client who had surgery three hours ago and is receiving IV Hydromorphine PRN

A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increase level of discomfort? (Select all that apply.)

Grimacing.

Restlessness.

Increase diaphoresis (sweating).

A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor vehicle crash. And which way should the nurse categorize the clients pain?

Chronic pain.

A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine pump. Which of the following medication should the nurse insurer is available in case the client develops respiratory depression?

Naloxone

A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse made

"Justice allows the client the opportunity to be treated fairly."

A nurse is reviewing a prescription with a client who reports difficulty managing a chronic pain. Which of the following statements should the nurse include

"You should write down the pain interventions you use in your pain rating before and after."

A nurse is planning to teach coworkers about the legal and ethical principles years with pain management. Which of the following examples to the nurse include as an example of autonomy?

A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.

A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain?

The client is diaphoretic. (Sweating).

A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (Select all that apply.)

Face.

Legs.

Consolability.

A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following action should the nurse plan to take to evaluate the patient's pain control? (Select all that apply.)

Consider each clients cultural preferences.

Determine the effectiveness of non-pharmacological strategies.

Use a pain scale specific to each clients cognitive abilities.

A nurse is discussing end of life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of- life pain management? (Select all that apply.)

Fear of addiction.

Believe that pain is an expected part of their illness.

In adequate pain assessment.

A nurse is evaluating group of clients are experiencing pain. Which of the following client should the nurse identifies experiencing neuropathic pain

A client who has diabetes Molite us and reports bilateral burning for pain without signs of injury.

A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hours as needed for pain rating 7 to 10 on a 0 to 10 scale. 15 minutes after receiving the dose, the client reports to the nurse their pain is still a seven and has not changed. Which of the following action should the nurse take?

Offer to assist the client with non-pharmacological relief strategies.

A nurse is providing end-of-life care for a client who is unresponsive and near death. The clients family asked the nurse about managing the clients pain. Which of the following statements should the nurse make to the clients family?

"Your family member has the right to receive effective pain management."

A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (Select all that apply.)

Muscular pain.

Menstrual discomfort.

Back ache.

A nurse is discussing cutaneous stimulation with the client who has back pain. Which of the following most methods should the nurse include? (Select all that apply.)

TENS therapy.

Massage.

Cold therapy.

Acupuncture.

A nurse is evaluating the clients pain level using the PQRST pneumonic. Which of the following question should the nurse asked her about the letter R?

"Can you point to where you're having your pain?"

A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which of the following statements should the nurse include?

"The skin contains Langerhans cells that kill pathogens."

A nurse is discussing health promotion programs with a client. Which of the following information should the nurse include?

Health promotion programs emphasize behavior changes in relation to prevention of illness.

A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse take

Discuss with the client their individual perspective on health and illness.

A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include?

The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health.

A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client?

Washing the client in bed is less effective than taking a shower.

A nurse is teaching the importance of handwashing to a client. Which of the following statements should the nurse make about hand hygiene in a health care setting?

"Effective handwashing can decrease hospital infection rates."

A nurse is reviewing handwashing skills with a newly licensed nurse. In which order should the nurse plan to perform this task using soap and water? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Wet hands with warm water is the first step.

Apply the amount of soap recommended by the manufacture

Rub hands together vigorously for at least 15 seconds is the third step.

Rinse hands with water

Use a disposable towel to dry

Use a towel to turn off the faucet

A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include? (Select all that apply.)

A fluoride mouthwash should be used to promote oral health.

The teeth should be brushed twice daily for 2 min.

Poor oral hygiene can lead to gingivitis.

Use a soft-bristled toothbrush for brushing the teeth.

A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion?

Enamel protects the teeth from pathogens.

A nurse is performing nail hygiene on a client. Which of the following actions should the nurse take?

Trim the nails straight across.

A nurse is reviewing the anatomy of the skin with a newly licensed nurse. Which of the following information should the nurse include as a characteristic of the epidermis?

The epidermis consists of squamous epithelial cells.

A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (Select all that apply.)

The nurse's hands become visibly soiled.

The nurse removes the meal tray of a client who has infectious diarrhea.

The nurse empties the urinal of a client who has Clostridium difficile.

A nurse is performing foot care for a client. Which of the following actions should the nurse take?

Use a towel to completely dry between the toes.

A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client?

The nurse should have the client remove clothing from the unaffected side first.

A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make?

"Give the client choices regarding their bathing preferences to encourage them to bathe."

A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include?

The cuticle of the nail forms a barrier to prevent infections.

A nurse is reviewing information about performing oral hygiene with an assistive personnel (AP). Which of the following information should the nurse include?

"Clean the tongue with the toothbrush or tongue scraper during oral hygiene."

A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skin care for the client?

Urinary incontinence can cause a yeast infection.

A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include?

"The mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body."

A nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions should the nurse take?

Assist the client as needed to ensure proper hygiene is performed.

A nurse is caring for a 6-month-old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity?

Dermatitis

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown?

Flex the client's knees while in bed.

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown?

"You should shift your weight off your buttocks at intervals throughout the day."

A nurse is teaching an assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?

"The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use?

A transparent film

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?

"This type of healing begins in the wound bed with the generation of granulation tissue."

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?

Clean the wound with 0.9% sodium chloride.

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?

A client who has a Braden Scale score of 9

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound?

Hydrogel

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster?

The dermis contains blood vessels that help nourish the epidermis.

A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicates an understanding of an alginate dressing?

"This type of dressing will need a secondary dressing for reinforcement."

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information?

"I should report pain at my wound site."

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?

A bright pink incision site that is absent of exudate

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?

"I should increase my protein intake."

A nurse is planning care for an older adult client who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown?

Tilt the client on their side at 30°.

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which of the following actions should the nurse take?

Cover the client's wound with a sterile saline dressing.

A wound, ostomy, and continence nurse (WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?

"Pressure injury documentation includes the location, stage, measurements, and condition of the wound bed and any drainage present."

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity?

The AP places the client in high-Fowler's position.

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?

Increased blood glucose

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?

"Your staples will be removed in about 2 weeks."

A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"The skin assists in the regulation of body temperature."

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

"Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take?

Empty and measure the drainage.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?

A client who is incontinent and is taking a prescribed diuretic.

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?

Dehiscence

A nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious which of the following statements by the newly licensed nurse indicates an understanding of the teaching

Ill swab the clients mouth with chlorhexidine

A nurse is planning morning hygiene care for a postoperative client. Which of the following actions should the nurse take?

Ask the client in what order they typically perform their morning routine.

A nurse is preparing to assist the client with a tub bath. Identify the sequence of steps the nurse should take.

1. gather all necessary supplies

2. Place of rubber mat on the tub floor

3. assist the client into the bathroom

4. Instructed client on using safety bars when getting in and out of the tub

5.Instruct the client to remain in the tub for no longer than 20 minutes

A nurse is performing a complete bed bath for a client which of the following actions should the nurse take

Raise the room temperature

A nurse is preparing to provide oral care for a client who is an NPO. The client tells the nurse, I don't need oral care because I haven't eaten anything. Which of the following responses should the nurse make?

Oral care is still important even though you're not eating

A nurse is observing an assistant personnel AP make a clients bed while the client is out of the room. Which of the following actions by the AP indicates an understanding of the procedure?

The AP raises the clients clean blanket and spread.

A nurse in a long-term care facility is caring for a client who is on bedrest and requires frequent linen changing. Which of the following should the nurse identify as a priority rationale for frequent linen changes?

Moisture from excessive diaphoresis can cause skin breakdown

A nurse is assisting a client with personal hygiene care which of the following actions should the nurse take to reduce the risk of infection

Clean the least soiled areas prior to cleaning the most soiled areas

Which of the following actions should a nurse take after witnessing a breach of a client's confidentiality in a provider's office?

1. Complete a health information privacy complaint form.

2. Anonymously notify the proper governmental agency.

3. Notify the client and ask them to complete a health information privacy complaint form.

4. Inform the provider that a formal complaint will be submitted if another breach is committed.

1

It is the nurse's responsibility to submit complaints to the proper agency regarding a breach of client confidentiality.

A nurse in the emergency department is caring for a client following a motor vehicle crash. The client is unresponsive and the client's spouse is not present at the facility. Which of the following actions should the nurse take to assist with obtaining consent for the client' surgery?

1. Ask the facility's Privacy Officer to witness the informed consent document.

2. .Inform the client's friends that are present about the surgery and obtain group consent.

3. Ask the nursing supervisor to provide implied emergency consent.

4. Inform the provider of the spouse's contact information so consent can be obtained over the telephone.

D

Because the client is not cognitively or physically able to provide consent, it is within HIPAA guidelines to discuss the client's condition with a spouse, close relative, or friend. Informed consent guidelines mandate obtaining consent from the client's closest adult relative in an emergency situation because it is deemed in the best interest of the client.

A group of nurses on a clinical unit are planning to research the incidence of falls among client following joint replacement surgery. Which of the following actions should the nurses take to ensure the study complies with the HIPAA Privacy Rule?

1. Contact the medical record department to obtain permission to access clients' charts.

2. Submit their proposal to the institutional review board for review and describe how they will de-identify client information.

3. Notify the clients who will be included in the study to submit a written request if they choose not to participate.

4. Obtain permission from the risk management department to gain access to incident reports that were filed due to client falls.

2

Research using client records can be done if client information is de-identified. It is the responsibility of institutional review boards to determine if a study meets this criterion.

A newly hired nurse is reviewing information about the HIPAA Privacy Rule during facility orientation. Which of the following statements by the nurse indicates an understanding of the Privacy Rule?

1. "Clients do not have the right to read their charts."

2. "I can read the charts of other clients on my floor."

3. "I will expect a list of clients and their admitting diagnoses to be posted on my unit."

4. "I can give information about a client over the phone if the client gives permission."

4

Information about a client can be given over the phone if the client has granted permission for that person to receive information. Many facilities have implemented an access code system that requires the person asking for information to provide the code.

A client tells a nurse that they feel their privacy has been violated and wants to file a formal complaint with someone other than the medical facility. Through which of the following agencies should the nurse instruct the client to file the complaint?

1. Occupational Safety and Health Administration (OSHA)

2. The Joint Commission

3. Office for Civil Rights (OCR)

4. Privacy and Civil Liberties Office

3

The OCR investigates complaints by clients and other involved individuals related to the HIPAA Privacy Rule. If the client wants to file a complaint to someone in the medical facility, the nurse should arrange for the client to talk to the facility's Privacy Officer.

Which of the following methods of information exchange can occur without client authorization?

1. Walking rounds that involve two nurses discussing an assigned client at the client's bedside in a private room

2. Recording shift report on a device for all oncoming staff to access information about all clients on the unit

3. Talking about a client's information during a staff in-service with all levels of unit staff present

4. Providing an employer with confirmation that their employee is currently being treated in the facility

1

This practice is acceptable if the two nurses are both assigned to this client and no one else is in the room. It is within the client's rights to hear information about their own care and treatment.

A nurse is teaching a newly licensed nurse about using a computer to document a client's health record. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

1. "I should share my computer password with the nurse orienting me."

2. "I should remain aware of my surroundings when documenting on the computer."

3. "I can step away from the computer for a short time if I am logged on and no one is around."

4. "I can review the health records of other clients on the unit not assigned to me."

2

The nurse should protect the screen from being visible to others. Maintaining an awareness of who is near the computer and able to see the screen promotes confidentiality and compliance with HIPAA regulations.

A nurse in a pediatrician's office is speaking on the telephone with the guardian of a school-age child who will become a new client at the office. The nurse should instruct the guardian to call the child's previous provider's office to request while of the following?

1. The guardian be allowed to take the child's medical records and make photocopies for the new pediatrician's office

2. The child's original medical records be given to the new pediatrician's office

3. A form authorizing release of copies of the child's medical records to be signed by the guardian

4. A form authorizing release of the child's medical records to be signed by the new pediatrician and sent back to the previous provider

3

A written authorization by the responsible party, in this case the guardian, must be provided to the previous provider's office prior to making copies of the health care records available to the new pediatrician.

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first?

Right lower quadrant

EXPL: Evidence-based practice indicates that the first area the nurse should auscultate for active bowel sounds is over the right lower quadrant of the client's abdomen. The right lower quadrant is located to the right of the umbilicus and contains the ileocecal valve. This is where the small intestine connects to the large intestine, and it is normally very active with bowel sounds. For an average adult, the nurse should expect to hear 5 to 30 bowel sounds per minute.

A nurse is performing a general client survey and finds that the client has a BMI of 23. What should the nurse document?

The client has a BMI within the expected reference range

EXPL: BMI is a measurement of an adult's body fat based on height and weight. The expected reference range for a BMI is between 18.5 and 24.9, which indicates a normal body weight. Therefore, the nurse should document that the client has a BMI within the expected reference range for a client who has a BMI of 23.

A nurse is assessing a client's cranial nerves. What following client actions is an indication that cranial nerve I is intact?

The client can identify a minty scent

EXPL: Cranial nerve I, the olfactory nerve, controls the sense of smell. To test this nerve's function, the nurse should ask the client to identify a nonirritating aroma, such as mint or coffee.

A nurse is preparing to perform a comprehensive physical assessment on a client. What actions should the nurse plan to take first?

Develop a plan of care

EXPL: The first action the nurse should take using the nursing process is to assess the client and develop a plan of care. The nursing process follows the steps of assessment, analysis, planning, implementation, and evaluation.

A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client's foot, between the tendons of the greater toe and those of the toe next to it, in order to palpate which of the following pulses?

Dorsalis pedis