ATI pt. 2 Fundamentals (Quiz A)

what is the normal creatinine range

0.5 to 1.1 mg/dL for women 41 to 60yrs 0.5 to 1.3 mg/dL for men

what is the order for a client who dies (5)

1. obtain death pronouncement 2. remove tubes and indwelling 3. wash/cleanse body 4. ask the family members if they wish to view the body 5. place name tag on body before transfer

what angle should a peripheral IV catheter be put in for an older adult client?

10-15 (because veins are closer to the skin surface as aging diminishes subcutaneous tissue)

how many mL of fluid should a client receive daily?

2000-3000

what angle should heparin be inserted

45-90 degrees

What is petechiae?

Round pinpoint, non-raised, purplish-red spots, caused by mucosal or dermal hemorrhage; rash like; NOT skin malignancy

what dressing should a nurse use for a stage 2 pressure injury? and why

hydrocolloid because it creates a moist wound bed

What is purulent drainage?

thick, yellow, green, tan, or brown

when is it esp important to use contact precautions?

with major wound infections

what angle should a peripheral IV catheter be put in general?

10-30 degrees

normal range of sodium levels

135-145 mEq/L

normal sodium ranges

136-145 mEq/L

what is the normal BUN range?

15mg/dL

normal potassium levels

3.5 to 5 mEq/L

when walking, the client should move the cane 15 to 30 cm (_______ inches) forward

6 to 12inches

what is a papule?

A raised area of the skin that is generally smaller than 1 centimeter; NOT skin malignancy

A 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? a) position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube b) have the client take sips of water to promote insertion of the NG tube into the esophagus

B

a client who has a sodium level of 125 mEq/L would expect to have what manifestation?

abdominal cramping

where do you self-administering heparin

administer into the abdomen (5.08) 2 inches from the umbilicus with a pinch or spread of skin

what do you use for a stage 3 (or stage 4) pressure injury

alginate; it absorbs drainage and forms a soft gel when it comes in contact w drainage

when do you use protective environments/precautions?

clients who have a compromised immune system

a nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. how would you know it was successful?

decrease in heart rate (sodium chloride causes tachycardia)

place the client's arm in a ______________dependent position when inserting a peripheral IV catheter

dependant

a nurse is caring for a client who has pharyngeal diphteria. which of the following types of transmission precautions should the nurse initiate?

droplet

what does rhonchi sound like?

dry, LOW-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions

what should the nurse do to ensure medication has reached the inner ear in an older adult client?

press gently on the tragus of the client's ear

what is sick role

refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver

a nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly license nurse. which of the following actions should the nurse include?

regulate oxygen via nasal cannula at a flow rate of no more than ^ L.min

when is a transparent dressing used for? (which stage of pressure injuries)

stage 1 to prevent further friction and shearing

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 amount of irritant used from the client's urine output

what is an allogeneic stem cell transplant?

transferring stem cells from a health person (the donor) to the patient's body after high-intensity chemo or radiation

Advocacy ensures what 3 things?

safety, health, and rights (right to privacy, confidentiality, and refusal of care) = code of ethics

what does a friction rub sound like

scratching or squeaking sound that persists throughout the respiratory cycle

if a client with a terminal illness had difficulty breathing, what would the nurse do in the ED?

"we would give you oxygen through a tube in your nose"

what is heparin

Anticoagulant/blood thinner

otic means what part of the body?

ear

justice ensures ___________

fairness

what type of dressing do you use for a stage 4 or unstageable pressure injury? and why

gauze because it causes debridement and allows granulation of the wound bed

where should the client hold their cane parallel to?

greater trochanter

numbness of the extremities is a manifestation of _______________

hyperkalemia

positive Cvostek's sign is a manifestation of hypomagnesemia and ____________

hypocalcemia

what is the purpose of advance directive

includes a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness

what is aphasia?

loss of ability to understand or express speech, caused by brain damage.

a nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 mins and to report back in 1 hour. which of the following actions should the nurse take next?

notify the nurse manager (activating the chain of command ensures that the client receives timely care to prevent deterioration in physiological status)

a nurse is talking with the partner of a client who has dementia. the client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. what does the nurse identify this as?

role overload (it expresses frustration)