ATI RN
Fundamental Of Nursing Nclex Practice Questions Questions
Question 1 of 5
A nurse obtained a client's pulse and found the rate to be above normal. The nurse documents this finding as:
Correct Answer: D
Rationale: When a nurse finds a client's pulse rate to be above normal, it is documented as tachycardia. Tachycardia specifically refers to an elevated heart rate, while tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is an irregular heartbeat. Therefore, the correct term to describe an above-normal pulse rate is tachycardia.
Question 2 of 5
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
Correct Answer: D
Rationale: In cases where the oral route is not recommended due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate, and arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.
Question 3 of 5
A client who is unconscious needs frequent mouth care. When performing mouth care, what is the best position for the client?
Correct Answer: B
Rationale: When providing mouth care to an unconscious client, the side-lying position is the best choice. This position helps prevent aspiration by allowing any fluids to drain out of the mouth easily, reducing the risk of choking or aspiration pneumonia. Placing the client in a side-lying position also promotes comfort and safety during the procedure.
Question 4 of 5
During a client's first hospitalization, which of the following actions ensures the safety of the client?
Correct Answer: A
Rationale: During a client's first hospitalization, it is essential to keep unnecessary furniture out of the way to prevent obstacles and ensure a safe environment. This action helps reduce the risk of accidents or falls, promoting the client's safety and well-being. Keeping the lights on at all times may not be necessary and can disrupt the client's rest. Keeping side rails up at all times can restrict the client's movement and independence unnecessarily. Keeping all equipment out of view may hinder the healthcare team's ability to monitor and access necessary tools for providing care.
Question 5 of 5
After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client's vital signs. What phase of the nursing process is being implemented by the nurse?
Correct Answer: A
Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process.