a nurse is preparing to perform a routine abdominal assessment what action should the nurse take first
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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 providing discharge teaching for a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?

Correct answer: A

Rationale: Corrected Rationale: The nurse should instruct the client to use pursed-lip breathing during activities to help improve oxygenation. Pursed-lip breathing can keep the airways open longer, facilitating better oxygen exchange and making it easier to exhale carbon dioxide. Choice B is incorrect as physical activity, within the client's limitations, is beneficial for maintaining overall health. Choice C is incorrect as weight-bearing exercises are important for bone health but not directly related to improving oxygenation in COPD. Choice D is incorrect as using a humidifier while sleeping can help with moisture in the airways but does not directly impact oxygenation in COPD.

3. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to discontinue the infusion. The symptoms described - pain, redness, and warmth along the vein - are indicative of phlebitis, which is inflammation of the vein. Continuing the infusion can lead to further complications. Flushing the IV line, elevating the limb, or applying a cold compress do not address the underlying issue of phlebitis and may not be sufficient to resolve the problem. Therefore, the priority action is to discontinue the infusion to prevent worsening of the condition.

4. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. Which food should the nurse instruct the client to avoid?

Correct answer: B

Rationale: Correct! Orange slices should be avoided by clients on a mechanical soft diet as they can be difficult to chew and swallow. Steamed carrots, mashed potatoes, and baked chicken are suitable choices for a mechanical soft diet, as they are softer in texture and easier to consume without posing a risk of choking or swallowing difficulties.

5. A nurse is providing discharge teaching to a client with a prescription for home oxygen therapy. What information should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fire hazards as oxygen supports combustion. Choices A, B, and D are incorrect. Increasing the oxygen flow rate without healthcare provider's instructions can be dangerous. Oxygen should not be turned off when not in use as prescribed by the healthcare provider, and storing oxygen tubing near heat sources poses a risk of fire.

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