a nurse is performing an abdominal assessment on a client what action should the nurse take first
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. When performing an abdominal assessment on a client, what action should the nurse take first?

Correct answer: B

Rationale: The correct answer is to auscultate bowel sounds. This action should be taken first because it ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen (choice C) may provide visual cues but does not address functional assessment. Palpating the abdomen (choice A) should follow auscultation to prevent altering bowel sounds. Percussing the abdomen (choice D) is typically done after auscultation and palpation.

2. A client with diabetes mellitus is being taught about foot care. What statement by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Wearing slippers or shoes at all times when out of bed is crucial for clients with diabetes mellitus to protect their feet from injury. Option A is incorrect as soaking feet in warm water can lead to dry skin, making it more susceptible to injuries. Option C is incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Option D is incorrect as cutting toenails straight across is a good practice but is not directly related to preventing foot injuries in clients with diabetes.

3. 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.

4. 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.

5. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?

Correct answer: B

Rationale: An immunization functions as part of acquired immunity. Acquired immunity involves the production of antibodies after immunization, which helps protect against future infections. Natural immunity is not induced by immunization but is present from birth. Passive immunity is temporary and acquired through the transfer of pre-formed antibodies. Cell-mediated immunity is a type of immune response that involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen.

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