ATI EXAM

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

****The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment. ***ALWAYS ASSESS THE CLIENT; WHICH MEANS FINDING OUT WHY!!!!

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

***Abdominal cramping -This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.

A nurse is preparing to delegate client care tasks to an tech. Which of the following tasks should the nurse delegate?

*Ambulating a client who is postoperative -Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

*Apply intermittent suction when withdrawing the catheter -Nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

Answer: "You should receive a pneumococcal vacine when you are 65 y/o" *The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.

Nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of info is the priority for the nurse to provide?

Breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

Nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend?

Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

*Check the client for injuries ***The first action the nurse should take when using the nursing process is to assess the client for injuries. ***ASSESSING THE CLIENT

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Answer: Rapid heart rate *Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

*Calf swelling -Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?

*I will hire someone to trim the tree that hangs low over the stairs on my front porch

Nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

*Mole with an asymmetrical appearance -An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

A nurse is caring for a client who is receiving fluid through an IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?

*Skin blanching -Skin blanching, edema, and coolness at the IV site indicate infiltration.

Nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airwayy. Which of the following actions should the nurse take?

*The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was sucessful?

Answer: *Decrease in heart rate -Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. **Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. **Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease. **Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

***Answer: It might help me to listen to music while im laying in bed -Listening to music is an effective nonpharmacological intervention for the management of mild pain.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel?

-Assist client w/ a partial bed bath -Measure the client's BP after nurse administers antihypertensive med -Use a communication board to ask what the client wants for lunc

5 steps of mixing regular insulin and NPH

1) The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. 2) Next, the nurse should inject air into the vial of regular insulin and 3) withdraw the correct amount of the regular insulin. 4) the nurse should insert the needle into the NPH insulin vial and 5) withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

LONG TERM CARE FACILITY death

1)The first step is to obtain the death pronouncement from the provider. 2)Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. 3) After cleansing 4) The nurse should ask the family members if they wish to view the body. 5) Finally, the nurse should place a name tag on the body before transfer.

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Answer: Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm -The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading Incorrect: -The nurse should place the stethoscope at the point of maximal impulse, which is at the fifth intercostal space at the midclavicular line left of the sternum.

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurses make?

Answer: I am available to talk if you should change your mind. ***When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

Answer: They indicate the form of treatment a client is willing to accept in the event of a serious illness -Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as a proper safety protocol?

The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them. *The client should store extra oxygen tanks in an upright position to maintain safety. *The client or caregiver should inspect oxygen equipment daily.

A middle adult client tells the nurse, " I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people" -According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

***Administer pain medication 45 min before changing the client's dressing -The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include int he plan of care to assist the client with feeding?

***Arrange food in a consistent pattern on the client's plate -Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse on a med surg unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

***PAD THE CLIENT'S WRIST BEFORE APPLYING THE RESTRAINTS -The use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

***Wear a gown when caring for the client -The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces. ***DIARRHEA IS CONTACT PRECAUTIONS AND GOWN NEEDS TO BE WORN

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

*8 oz of ice chips -The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

A nurse is caring for a group of clients on a med surg unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

*A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. -Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

*Administer the medication into the abdomen -The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. ***CLIENT SHOULD NOT ASPIRATE FOR BLOOD ***CLIENT SHOULD NOT INSTRUCT CLIENT TO MASSAGE THE SITE BC IT CAN CAUSE TISSUE DAMAGE AND BRUISING

Nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

*Assess the client for orthostatic hypotension -The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse is caring for a client who has an indwelling urine catheter. Which of the following findings indicates that the catheter requires irrigation?

*Bladder scan shows 525 mL of urine. -A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

*Cleanse the wound from the center outward -The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

A nurse enter's a client's room and finds her on the floor. THe client's roomate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

*Client found lying on the floor -The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconcilliation?

*Compare the client's home medications w/ the provider's prescriptions -The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A nurse is admitting a client who has an abdominal wound w/ a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

*Contact precautions -Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

*Distended neck veins -Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

Nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

*Droplet -Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis.

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precaution should the nurse initiate?

*Droplet -Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

*During the admission process -Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

*Erythema on pressure points -Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

*Evacuate the client -According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area. -the second action in response to a fire is to activate the alarm. -the third action in response to a fire is to contain the fire by closing all the doors and windows in the area. The nurse should also turn off oxygen and electrical equipment in the area of the fire. -the fourth action in response to a fire is to attempt to extinguish the fire.

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

*Flush the tube with 15 mL of sterile water -The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

*Gently shake the container of medication prior to administration -The nurse should gently shake the liquid medication to ensure that the medication is mixed.

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

*Have the client stand with their arms at their sides and their feet together -A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

Nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

*Have the client take sips of water to promote insertion of the NG tube into the esophagus Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

*Have the client use a trapeze bar when changing position -By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

*Hydrocolloid -Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

*I flushed what i urinated at 7 am and have saved all urine since -For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

Nurse is preparing to adminsiter enoxaparin subq to a client. Which of the following actions should the nurse take?

*Insert the needle at a 45°-90° angle for a subq injection ***Do not pull the client's skin laterally or downward prior to administration; THAT IS IM INJECTION

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

*Is your pain sharp or dull? -Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?

*Make sure two fingers can fit under the sleeves

Nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client?

*N95 respirator -The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.

Charge nurse is observing a newly licensed nurse preparing a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

*Newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field -The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

Nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following action should the nurse plan to take?

*Place the client's arm in a dependent position -The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. DONT!!!! -Initiate IV therapy in the veins of the hand -The nurse should avoid using the fragile veins of an older adult's hands because the loss of subcutaneous tissue can allow those veins to roll away from the needle. Also, having an IV catheter in the client's hand can interfere with the client's performance of activities of daily living and can diminish an older adult's sense of independence and mobility.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

*Practice sessions -Practice sessions require psychomotor skills when learning.

A nurse is adminstering an otic medication to an older adult client. Which of the following action should the nurse take to ensure that the med reaches the inner ear?

*Press gently on the tragus of the ear

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "what would happen if i arrived at the ER and i had difficulty breathing? Which of the following responses should the nurse make?

*we would give you oxygen through a tube in your nose -Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

*Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. *Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. *Visual acuity is correct. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

*Reassure the client that this is an expected response to grief

A nurse is reviewing EBP principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

*Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min -Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2). *Incorrect: -The reservoir bag should inflate by one-third to one-half with inspiration. If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale. -Evidence-based practice supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen. -The nurse should regulate the oxygen flow rate by aligning the rate on the flow meter with the middle of the silver ball inside the meter.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

*Subtract the amouont of irrigant used from client's urine output -The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following action should the nurse take first?

*Tell the client to keep the head of the bed elevated at least 30° -The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

*The client's caregiver washes out the feeding bag w/ warm water once every 24 hour. -Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination.

Nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

*The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

*Use a bed exit alarm system -The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

Nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

*Use tracheostomy covers when outdoors -Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles. *NEVER REMOVE OUTER CANNULA FOR ROUTINE CLEANING; OUTER CANNULA STABILIZES THE AIRWAY, therefore client should never remove it for cleaning

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

*When descending stairs, I will first shift my weight to my right leg -To descend stairs, the client should first shift his body weight to his right, unaffected leg.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?

*Witness the client's signature on the consent form -The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure.

A nurse has inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

*X-ray shows the end of the tube above the pylorus -An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

*the pain is like a dull ache in my stomach -The client is describing the quality of the pain, which is how the pain feels in the client's own words.

Nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Answer: AUSCULTATE LUNG SOUNDS ***The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath. ***PRIORITY IS BREATHING

A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting

D

A nurse is revieing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

POtassium 5.4 mEq/L -Value is above expected range of 3.5-5 mEq/L

A nurse is caring for a client who has a tuberculosis. Which of the following actions should the nurse take?

Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions.Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth.Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room.Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions.Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.

Nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hour. Which of the following actions should the nurse take first?

The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed.

A nurse has accepte a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this med?

The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg. **0.3 mg