ATI Practice B

A nurse is performing an admission assessment on a client who has chronic fatigue syndrome and is seeing a practitioner for therapeutic touch therapy. Which of the following statements should the nurse make?

"tell me about the specific symptoms this therapy relieves for you"

expected age-related changes

- flesh colored cutaneous tags (skin tags) in the axillary or neck regions - brown macules over the backs of both hands as senile lentigines (associated with sun exposure) - skin turgor should be checked on the sternum due to loss of skin elasticity

NC O2 delivery

24-44% flow rate of 1-6 L/min

chest pain, sudden dyspnea, hypotension, tachycardia, coughing, and a decreased LOC

air embolism => air gets into the vein

a nurse is caring for a client who has fecal incontinence. which of the following actions should the nurse take?

apply a moisture barrier to the client's skin => over clean, dry skin => wash the least contaminated area first (buttocks then the anus) => use cleaners with nonionic surfactants

A nurse is placing a client in the dorsal recumbent position. Which of the following actions should the nurse take?

arrange a pillow under the client's head and shoulders => back-lying position => place pillow under the client's ankles or lower legs to keep the heels off the mattress and decrease the risk for developing pressure injuries

a nurse is performing medication reconciliation with a client. what action should the nurse take first

ask the client if they take any over the counter OTC medications => assess current use of Rx and nonRx medications, vitamins, herbal supplements to obtain a complete list for comparison to the provider's admission prescriptions

a nurse is a community health center is teaching a group of clients about the use of aromatherapy. which essential oil is used to alleviate swollen joints?

chamomile => and muscle aches => sage oil minimize GI distress, to alleviate discomfort in the mouth and throat, and supplement to help treat depression => jasmine oil stimulate mood or alleviate menstrual cramps and lower back pain => lavender oil for calming effect or sedative to alleviate insomnia

how to administer medication by IV bolus through a saline lock

check for blood return before injecting the medication => confirm the catheter is in the vein to ensure medication is being injected into the bloodstream => then inject the flush (2 to 3 mL of NS) after the medication at the same rate as the medication to prevent a sudden bolus of medication and adverse effects => use the injection port of IV tubing closest to the client to allow the medication to reach the client as soon as possible

a nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. which of the following actions should the nurse take first

check the pH of the client's stomach contents => first check the pH of the aspirate by drawing up 5mL of gastric fluid => pH should be less than 5 to confirm gastric placement => then check the gastric residual volume of the tube feeding to determine the absorption of the previous feeding, draw up 30 mL of air and instill into the tubing to clear any residual matter, flush the tubing with 30 mL of water to clear the tube and ensure patency

a nurse is assessing an older client during a home visit. which finding should the nurse report to the nursing supervisor

ecchymosis on the torso in various stages of healing => possible indication of physical abuse

IV site is cool to palpation and edematous

extravasation => vesicant fluids leaks into the surrounding tissue. assess for blanched skin and pain at the IV site

a nurse is teaching a client who has a new hearing aid, which of the following statements by the client indicates to the nurse an understanding of the teaching

i will reinsert the hearing aid if i hear a whistling sound => whistling sound can indicate incorrect insertion, improper fit, or ear wax build up => initially wear the hearing aid for 15 to 20 min each day then increase the time slowly to 10 to 12 hr each day => clean the hearing aid with a soft cloth => turn the hearing aid slowly to one third to one half volume

a nurse is planning care for a client who is postoperative. which of the following interventions should the nurse include in the plan to decrease the client's risk for venous stasis?

instruct the client to elevate their legs when sitting in a chair => to prevent pooling and clotting of the blood => do NOT place a pillow under the client's knees because this can impede blood flow => encourage the client to exercise legs every 1 to 2 hr while awake to promote blood circulation

warmth, erythema, swelling, and purulent drainage at the IV site

local infection of the IV site during insertion, maintenance, or removal of the catheter

erythema, warmth, tenderness at the IV site

phlebitis => inflamed vein

a nurse is preparing to obtain a client's blood pressure. which of the following actions should the nurse plan to take?

record the diastolic number as the last sound heard => phase 5 of Korotkoff sounds => place the cuff above the antecubital space to allow room for the bell of the stethoscope => release air from cuff so the pressure decreases at a rate of 2 to 3 mmHg per second => use a blood pressure cuff with a bladder that is 40% of the client's arm circumference.