a nurse is preparing to perform a routine abdominal assessment what action should the nurse take first
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A healthcare provider is preparing to perform a routine abdominal assessment. What action should the healthcare provider take first?

Correct answer: A

Rationale: The correct first action in a routine abdominal assessment is to inspect the abdomen. This allows the healthcare provider to visually assess for any visible abnormalities such as scars, distention, or masses. Auscultating bowel sounds comes after inspection as the second step to assess bowel motility. Palpation and percussion follow in the sequence of a comprehensive abdominal assessment. Therefore, inspecting the abdomen is the priority to gather initial information before proceeding with further assessment techniques.

2. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?

Correct answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention is a sign of catheter occlusion because it indicates a failure to drain urine properly. Bladder spasms (Choice A) are more commonly associated with bladder irritability rather than catheter occlusion. Frequent urination (Choice C) is unlikely in a client with an indwelling catheter as the urine should be draining continuously. Hematuria (Choice D) refers to blood in the urine and is not typically a direct sign of catheter occlusion.

3. A nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?

Correct answer: B

Rationale: The correct answer is B: Increased hematocrit. Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. When there is a decrease in fluid volume in the body, the blood becomes more concentrated, leading to an increase in hematocrit levels. Choices A, C, and D are incorrect because decreased BUN levels, increased white blood cell count, and decreased hematocrit are not indicative of fluid volume deficit.

4. A nurse is caring for a client who is postoperative following cataract surgery. The client reports that they do not want to wear their eye shield. What should the nurse do?

Correct answer: B

Rationale: The correct answer is B: Explain the importance of wearing the eye shield. It is important for the nurse to educate the client on the reasons why wearing the eye shield is crucial post cataract surgery, such as protecting the eye from injury and promoting proper healing. This empowers the client with knowledge and helps them make an informed decision. Choice A is incorrect because the nurse should provide necessary information to ensure the client's safety. Choice C is incorrect as removing the eye shield without proper justification can compromise the client's recovery. Choice D is also incorrect as discussing concerns should come after the client is educated on the importance of the eye shield.

5. A nurse is caring for a client who has experienced a seizure. What should the nurse do immediately after the seizure?

Correct answer: C

Rationale: After a client experiences a seizure, the nurse should immediately turn the client on their side. This action helps maintain an open airway and prevents aspiration, as it allows any secretions or vomitus to drain from the mouth. Administering oxygen can be necessary if the client is hypoxic, but turning the client on their side takes precedence to prevent complications. While documenting the seizure activity is important for the client's medical record, ensuring the client's immediate safety by positioning them correctly is the priority. Reassuring the client should follow after ensuring their physical safety.

Similar Questions

When providing discharge teaching to a client prescribed home oxygen therapy, what information should the nurse include?
A client has a new prescription for a metered-dose inhaler (MDI). What instruction should the nurse include?
A healthcare professional is teaching a group of assistive personnel about the expected integumentary changes in older adults. Which change should the healthcare professional include?
A client has a new prescription for a cane. What instruction should the nurse include?
A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses