ATI Foundations 1st Sem

A nurse is caring for a client who has an NG tube that is irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance

0.9% sodium chloride is an isotonic solution that would be least likely to cause electrolyte imbalance.

restraints should have _________extra space

2 finger width

The nurse should remove each restraint one at a time every to allow the client to perform range-of-motion exercises and the nurse to perform neurovascular checks.

2 hr

The client should keep his elbows__________when ambulating with a walker

20-30 degrees

Nurse should use ______________________mL syringe to irrigate wounds

30-60

The nurse should adjust the suction pressure between

80 and 120 mm Hg to prevent hypoxemia and trauma to the mucosa

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.

phenol solution does not kill

C. Diff

What should indicate to a nurse the need to suction a client's tracheostomy?

Irritability, a sign that indicates the client has decreased oxygen to the tissues and the nurse should suction his tracheostomy.

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following should the nurse suggest to promote neck rotation?

Move her head from side to side

Patient having problems urinating...

Pour warm water on perineal

Expected findings of colostomy replacement

Protrusion of stoma from the abdomen Stoma mucosa bleeds when touched Red peristomal skin under the adhesive

Most important kind of pain statement to record?

Quality of pain and how it feels

A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next?

The greatest risk to the client is further injury. The next action the nurse should take is to apply a warm compress over the IV site to decrease edema and client discomfort.

Weber's test

The nurse should apply a vibrating tuning fork to the client's head to identify sound lateralization when assessing hearing.

A nurse is caring for a client with an order for 5 units of Regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously. List the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

The nurse should first inject air into the vial of NPH without touching the solution in order to withdraw the desired amount of medication later. The nurse should next inject air into the vial of Regular insulin, and then withdraw the appropriate amount of medication. Next the nurse should place the needle into the NPH insulin vial and withdrawthe correct amount of medication. The nurse should follow these steps to prevent contaminating the Regular insulin with NPH insulin.

to test cranial nerve V.

The nurse should touch the client's face with a cotton ball

A high-density lipoprotein level above 60 mg/dL indicates

a desirable level of protection against coronary artery disease.

A client who has C. difficile does not require

a room with a negative air-flow system

The nurse should instruct the client to place both when using a sliding board

across the chest to prevent injury to the extremities

Romberg's test assesses for

alterations in balance therefore, the nurse should have the client stand with arms at the sides and feet together to observe for swaying and a loss of balance.

Clients who have dysphagia tend to have incomplete emptying of the food from their mouth. This can lead to

collections or "pockets" of food left in the mouth, which they tuck in front of the buccal surfaces of the gums.

Always dispose excess_______

controlled substances

non-isotonic liquids, i.e. sterile and tap water lead to

electrolyte imbalances

Aserum albumin level below 3 g/dL indicates

protein deficiency, putting the client at risk for pressure ulcer formation and poor wound healing.

The nurse should preoxygenate the client w/

100% oxygen before suctioning to prevent hypoxemia.

A female client who has thoracic muscle movement when breathing is

an expected assessment finding.

When assessing an older adult client's abdomen, the nurse should

auscaltate bowel sounds before performing palpation in order to not change the character of the sounds.

Impaired ventricular function produces

extra heart sounds, S3 or S4.

Nurse should have client _____________ neck when using a slide board to avoid head/neck injury

flex neck

The nurse should select a suction catheter that is

half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

Arterial bruits are

"blowing" sounds resulting from blood flowing through occluded or narrowed arteries.

Asynchronous closure of the aortic and pulmonic valves is known as

"splitting" of S2, so the nurse should hear two "dub" sounds during auscultation.

The Norton scale measures

pressure ulcer risk based on physical condition, mental condition, activity, mobility, and incontinence. A score of 16 or less indicates pressure ulcer risk.

The client should apply the heating pad periodically and for no more than ________ at a time to prevent reflex vasoconstriction.

30-45 min

The nurse should place the stethoscope at the point of maximal impulse, which is

5th intercosntal space at midclavicular line left of sternum

A male client who has diaphragmatic breathing is

An expected assessment finding.

alcohol-based hand sanitizer does not kill

C. difficile spores.

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the client and his family?

Check the cord routinely for frays or tearing is correct. Safe use of the oxygen concentrator includes assessing the electrical appropriate function of the device; therefore, the nurse should instruct the client to routinely check the cord condition. Keep the unit at least 4 feet away from a heat source is incorrect. Safe use of home oxygen equipment includes keeping the unit at least 8 feet away from a heat source. Consider purchasing a generator for power backup is correct.Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of the required oxygen; therefore the nurse should instruct the client to consider use of a generator or other backup power source. Monitor for signs of hypoxia is correct.The client can still experience hypoxia due to worsening condition; therefore, the nurse should instruct the client and family to monitor for indications of hypoxia and notify the provider. Select clothing and bedding made of synthetic materials is incorrect.Safe use of oxygen therapy includes choosing clothing and bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to select materials made from cotton.

For a 24 hr urine, client should _________the first voiding and ____________

Discard, savel all subsequent voids

The Braden scale measures

pressure ulcer risk based on sensory perception, moisture, activity, mobility, nutrition, friction, and shear. A score below 18 indicates pressure ulcer risk.

The client's output should

Equal daily fluid intake

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

Inserting the catheter up to the hub reduces the risk of contamination along the length of the catheter.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply).

Place the client in a negative pressure room is correct. The nurse should place the client in a negative pressure room 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 with oral care to meet the requirements of standard precautions. Limit each visitor to 2 hr increments is incorrect.The nurse does not need to limit visitors. Wear a surgical mask when providing client care is incorrect.The nurse should wear a N95 respirator to meet the requirements of airborne precautions. Use antimicrobial sanitizer for hand hygiene is correct.The nurse can use antimicrobial sanitizer for hand hygiene when caring for a client who has tuberculosis.

The nurse should use a ___________ tie to secure the restraints to the bed.

quick-release

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

Skin blanching indicates infiltration at the IV site.

A nurse is caring for a client who is postoperative following colostomy placement. Which of the following findings should the nurse report to the provider?

Stoma appears purple under colon The stoma should appear red and moist. The provider should be notified if the stoma appears dark in color, which is an indication of impaired circulation.

A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following factors is most important for the nurse to consider before delegating care?

The most important factor the nurse should consider is the facility's job description for the AP because it provides specific information about what tasks are within the scope of practice for the AP.

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

The nurse should clean the wound from the center outwards to prevent introduction of microorganisms from the outer skin surface.

A nurse is implementing a plan of care for an older adult client who is at risk for falls. Which of the following is an appropriate nursing action?

The nurse should toilet the client every 1 to 3 hr to reduce the risk of falls due to the client ambulating to the bathroom without assistance.

A nurse is caring for a client who has left-sided paralysis after a cerebrovascular accident. The client is unable to bear his own weight. Which of the following actions is an appropriate method to move the client from his bed to his wheelchair?

The safest ergonomic method of moving the client from the bed to the wheelchair is using a hydraulic device. Use of a hydraulic device requires two staff members.

Positioning the client with the head of the bed raised approximately 30°

allows for maximum expansion of the lungs. Good foR INCENTIVE SPIROMETRY

An infant who has an irregular breathing pattern is

an expected assessment finding

Cleansing agent for IV catheter insertion should be

chlorhexidine or povidone-iodine, per facility protocol

An adolescent who has visible accessory muscle movement when breathing is

demonstrating labored breathing.

A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the client's diet?

he nurse should suggest the client eat avocados, which are an excellent dietary source of potassium.

Flexion of the neck is

moving the chin downward so that it rests on the chest.

Hyperextension of the neck is

moving the head backward as far as possible.

Lateral flexion of the neck is

moving the head sideways toward the shoulder as far as possible.

The nurse should position the bed so that it is _____________________when using a sliding board

slightly higher than the stretcher

The nurse should lubricate the end of the suction catheter with

sterile water or normal saline to decrease trauma to the mucosa.

The nurse should not use "q.d.", "sub q", "SQ", or "qhs" because

they are error-prone abbreviations