ATI Learning System RN 3.0 Fundamentals 2 Quiz

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? - Irrigate the tubing with sterile normal water once each shift. - Cleanse the opening with soap and water after emptying. - Maintain the tubing above the level of the surgical incision. - Collapse the device of air after emptying.

Collapse the device of air after emptying.

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? - Place an oxygen mask on the client. - Check the client's pulse. - Determine whether the client is able to breathe. - Wrap arms around the client from behind.

Determine whether the client is able to breathe.

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? - Don clean gloves to remove the old dressing. - Loosen the dressing by pulling the tape away from the wound. - Remove the entire old dressing at once. - Open sterile supplies after applying sterile gloves.

Don clean gloves to remove the old dressing.

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? - Hold the irrigator 1.25 cm (0.5 in) above the eye. - Direct the irrigation solution upward toward the upper eyelid. - Exert pressure on the bony prominences when holding the eyelids open. - Direct the irrigation from the outer canthus to the inner canthus of the eye.

Exert pressure on the bony prominences when holding the eyelids open. The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? - Calibrate the scales weekly. - Use a different scale each time. - Weigh the client on arising. - Weigh the client without clothing.

Weigh the client on arising.

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? - Roll the stocking partially down if too long. - Remove the stocking once per day. - Bunch and pull the stocking halfway up the calf. - Turn the stocking inside out up to the heel before applying.

- Turn the stocking inside out up to the heel before applying. The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles.

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? - A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask - A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula - A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar - A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse when speaking with the client? - Speak directly into the client's impaired ear. - Exaggerate lip movements. - Speak loudly. - Face the client when speaking.

Face the client when speaking. The nurse should always directly face the client who has a hearing impairment and stand or sit at the same level to maximize communication. Many clients who are hearing impaired combine lip reading with their residual hearing when communicating.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? - Exhale slowly to reach goal volume. - Hold breath for 5 seconds after goal volume is reached. - Continue to deep breathe between each cycle. - Limit repeat pattern of breathing to 5 breaths.

Hold breath for 5 seconds after goal volume is reached. The nurse should instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia.

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? - Flushing of the skin - Inability of the toddler to cry or speak - Presence of nausea and mild emesis - Capillary refill time 1.5 sec

Inability of the toddler to cry or speak When the client has no sound passing through the vocal cords, the nurse should identify a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? - Maintain suction while removing the NG tube. - Instill 100 mL of air into the NG tube before removal. - Pinch the NG tube while removing the tube. - Instruct the client to breathe in and out during the removal of the NG tube.

Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? - Remove the sleeve of the gown from the arm without the IV line. - Slow the infusion using the roller clamp. - Disconnect the IV line from the pump. - Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown.

Remove the sleeve of the gown from the arm without the IV line. According to evidence-based practice, the nurse should first remove the gown from the client's arm without the IV line. Beginning this process will enable the nurse to move the gown fully off the client and last stop the system to remove the gown off the line, resulting in minimal interruption of the IV flow.

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? - Vitamin C and zinc - Vitamin D - Vitamin K and iron - Calcium

vitamin C and zinc The client's body needs both vitamin C and zinc to help fight a wound infection. The client should receive a multivitamin, and a mineral supplement of both. In addition, vitamin E supplements also are needed to aid in skin and wound healing.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? - Apply a fecal collection system. - Apply a barrier cream. - Cleanse and dry the area. - Check the client's perineum.

Check the client's perineum. Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation.

A nurse is performing a straight catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining a sterile technique? - Applies sterile gloves to open catheter package - Wipes the labia minora in an anteroposterior direction - Spreads the labia with the dominant hand - Uses one cotton ball to wipe the right and left labia majora

Wipes the labia minora in an anteroposterior direction The nurse should wipe anteroposterior both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.