a nurse is preparing to perform an abdominal assessment on a client which action should the nurse take first
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is preparing to perform an abdominal assessment on a client. Which action should the nurse take first?

Correct answer: C

Rationale: The correct answer is to auscultate before palpation. This ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen is a valid step but not the first. Percussing and palpating should come after auscultation to prevent altering bowel sounds or causing discomfort to the client.

2. A healthcare provider is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the provider identify as examples of cultural variables?

Correct answer: B

Rationale: The correct answer is B: Eye contact, personal space, and touch are cultural variables that can influence healthcare interactions. These factors vary across cultures and can impact how individuals perceive communication and interactions. Choices A, C, and D include elements that are not specifically cultural variables affecting communication and interactions in the same way as eye contact, personal space, and touch.

3. A nurse is caring for a client who is experiencing fluid volume deficit (FVD). What clinical finding should the nurse expect?

Correct answer: B

Rationale: Increased heart rate is a common sign of fluid volume deficit (FVD) as the body compensates for decreased fluid levels. When a client is experiencing FVD, the body tries to maintain perfusion to vital organs by increasing the heart rate. This compensatory mechanism helps to improve cardiac output and maintain blood pressure. Choices A, C, and D are incorrect because in FVD, hematocrit may be increased due to hemoconcentration, blood pressure tends to decrease as a compensatory response to FVD, and respiratory rate is usually unaffected or may increase due to attempts to maintain oxygenation.

4. A client with diabetes mellitus is being taught about foot care by a nurse. Which statement indicates understanding?

Correct answer: B

Rationale: The correct answer is B. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it helps prevent injuries to the feet, reducing the risk of infection. Choices A, C, and D are incorrect. Soaking feet in hot water daily can lead to dryness and skin damage, applying lotion between toes can create a moist environment promoting fungal growth, and cutting nails in a rounded shape can increase the risk of ingrown nails.

5. A nurse is preparing to administer medications to a client through a nasogastric (NG) tube. Which action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when administering medications through an NG tube is to dissolve each medication separately and flush with water between medications. This practice helps prevent interactions between medications and ensures that each medication is delivered effectively. Option A is incorrect as mixing all medications together can lead to chemical interactions or alter the effectiveness of the medications. Option B is incorrect because flushing the NG tube with air is not recommended and may cause harm. Option D is incorrect as administering all medications at the same time does not allow for proper absorption and interaction control.

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