ATI questions
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include? (select all that apply) -More difficulty seeing due to a greater sensitivity to glare -Decreased cough reflex -decreased bladder capacity -decreased systolic BP -dehydration of intervebretal discs
-More difficulty seeing due to a greater sensitivity to glare -Decreased cough reflex -decreased bladder capacity -dehydration of intervebretal discs
how many ounces are in a cup?
8 oz
A nurse assumes a variety of roles while working with PT. Which of the following describes the nursing role of protecting the client and supporting the PT's decisions? A. Advocate B. Caregiver C. Manager D. Educator
A
A nurse inserting an NG tube asks the PT to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by.. A. closing off the glottis. B. preventing curling of the tube in the mouth. C. allowing the patient to breathe through her mouth. D. opening the lower esophageal sphincter.
A
A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this PT is to use proper body mechanics at all times. Which of the following findings indicates that the PT is meeting this goal? A. The client faces the direction of movement when sliding an object across the floor. B. When pushing an object, the client moves his front foot backward. C. When moving an object to one side, the client puts his weight on his heels. D. The client stands with his feet close together when lifting an object.
A
A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. repeat auscultation after asking the client to breathe deeply and cough. B. Instruct the client to limit fluid intake to less than 2000 mL/day. C. Prepare to administer antibiotics. D. Place the client on bed rest in semi folwer's position.
A
A nurse is caring for a PT who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying the initial placement? A. X-ray examination of the chest and abdomen B. Auscultation of injected air C. pH measurement of gastric aspirate D. Color of gastric contents
A
A nurse is caring for a PT who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A. Apply a moisture barrier ointment to the client's skin. B. Clean the client's skin and perineum with hot water after each episode of incontinence. C. Check the client's skin every 8 hr for signs of breakdown. D. Request a prescription for the insertion of an indwelling urinary catheter.
A
A nurse is caring for a PT who is immobile. Which of the following actions is the priority for the nurse to include in the PT's plan of care? A. auscultate breath sounds every 2 hours. B. perform ROM at least 2-3 times a day. C. Make sure the client has an intake of 2000 to 3000 mL/day. D. Apply antiembolic stockings.
A
A nurse is caring for a client who has HTN and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of the therapeutic communication response of reflection? A. "You seem upset about taking your blood pressure medication." B. "Why do you feel afraid to take your medication?" C. "You won't get better until you take your medication?" D. "Did your symptoms occur before or after you took the medication?"
A
A nurse is delivering an enteral feeding to a PT who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the PT asks the nurse why the water is necessary. Which of the following responses should the nurse make? A. "water helps clear the tube so it doesn't get clogged." B. "flushing helps make sure the tube stays in place" C. "This will help you get enough fluids" D. "Adding water makes the formula less concentrated".
A
A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? A. Inspect the oropharynx with a penlight and a tongue blade. B. Obtain an x-ray examination of the chest and abdomen. C. Tape the tube securely in place with a tube holder device. D. Aspirate gastric contents.
A
A nurse is planning care for a PT who is on bed rest. Which of the following interventions should the nurse plan to implement? A. encourage PT to perform antiembolic exercises every 2 hours. B. Instruct the PT to cough and deep breathe every 4 hours C. restrict the client's food intake. D. reposition the PT every 4 hours.
A
A nurse is planning care for an older adult PT who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed. B. Apply cornstarch to keep sensitive skin areas dry. C. Massage the skin over the client's bony prominences. D. Elevate the head of the bed no more than 45°.
A
A nurse is providing discharge teaching for a PT who is postoperative following a simple mastectomy. The PT is about to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? A. Do not apply heat to the area of irradiation. B. Do not wash the area of irradiation. C. Use an antibiotic ointment to treat skin breakdown. D. Lubricate the skin lubricated with hypoallergenic lotion.
A
After completing a procedure that required donning personal protective equipment consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? A. The gloves B. The gown C. The face shield D. The N95 respirator
A
An older adult PT in a long-term care facility is receiving intermittent enteral feedings in his room. His affect is flat, and the nurse suspects that he is feeling isolated. Which of the following interventions is appropriate for this PT? A. Encourage him to go to the dining room at meal times to talk with other patients. B. Suggest that he watch television while his feedings are being administered. C. Remind him that he can have visitors after his feeding administration times. D. Ask the facility chaplain to speak with the patient.
A
The best way to determine the depth of a PT's respiration is to... A. observe the degree of chest-wall movement during inspiration and expiration. B. count how many breathing cycles you observe per minute. C. notice whether or not expiration takes longer than inspiration. D. measure the precise amount of air the patient takes in and breathes out.
A
To prevent a common complication of continuous enteral tube feedings, the nurse should A. limit the time the formula hangs to 4 hr. B. chill the formula prior to administration. C. deliver the formula at a brisk rate. D. allow the feeding bag to empty before refilling it.
A
Which of the following actions is appropriate for a nurse who has witnessed a breach of a PT's privacy in a primary care provider's office? A. Complete a health information privacy complaint form and submit it to the appropriate agency. B. Anonymously notify the proper governmental agency. C. Notify the patient and provide her with a health information privacy complaint form to submit to the appropriate agency. D. Inform the primary care provider that a formal complaint will be submitted if another breach is committed.
A
Which of the following is an advantage for using alcohol based gel? A. Its use takes less time than washing with soap and water does. B. It removes gross contamination better than soap and water does. C. Its protective nature reduces the need for frequent handwashing. D. It provides adequate protection before surgical applications.
A
Which of the following methods of information exchange is in compliance with HIPAA? A. Walking rounds that involve two nurses discussing an assigned patient at his bedside in a private room B. Taped shift report during which all staff hear report on all patients on the unit C. Request by a primary care provider for patient information from the nurse assigned to that patient during an in-service D. A phone request by an employer for verification that an employee is currently being treated in the hospital
A
While performing a complete bed bath, the nurse should: A. raise the room temperature. B. completely remove the linens. C. add soap to the water in the basin before beginning the bath. D. complete the bathing for one side of the body at a time.
A
You are assessing a PT's vital signs. The PT has a temperature of 102. Which of the following do you expect to find? A. An elevated pulse rate B. A decreased blood pressure C. An elevated blood pressure D. A decreased pulse rate
A
You are measuring a PT's temperature orally. You place the covered probe A. in the posterior lingual pocket lateral to the midline. B. so that it rests on the lower lingual frenulum. C. centrally on top of the patient's tongue. D. under the tongue just beyond the patient's teeth.
A
a nurse instructs a PT to stand with his feet together and arms at his sides. The purpose of this is to test which of the following? A. Balance B. Muscle strength C. Reflexes D. Coordination
A
A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include. (select all that apply) A. place the client in semi-fowler's position B. have the PT rest an arm across the abdomen. C. observe 1 full respiratory cycle before counting the rate. D. count the rate for 30 seconds if it is irregular E. count and report any sighs the client has.
A, B, C
A nurse is instructing a PT, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include (select all that apply) A. hold the cane on the right side B. keep two points of support on the floor. C. place the can 38 cm in front of the feet before advancing. D. after advancing the cane, move the weaker leg forward. E. advance the stronger leg so that it aligns evenly with the cane.
A, B, D
A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (select all that apply) A. inspect the feet daily B. use moisturizing lotion on the feet C. wash the feet with warm water and let them air dry D. Use over the counter products to treat abrasions. E. Wear cotton socks
A, B, E
Which of the following are manifestations of a systemic infection? (select all that apply) A. fever B. malaise C. edema D. pain or tenderness E. increase in pulse and respiratory rate
A, B, E
A nurse is caring for an 82 year old PT in the emergency room who has an oral body temperature of 101, pulse rate is 114/min, and RR 22/min. He is restless and his skin is warm. Which of the following should the nurse do? (select all that apply) A. obtain culture specimens before initiating antimicrobials. B. restrict client's fluid intake C. encourage the client to rest and limit activity. D. allow the client to shiver to dispel heat. E. assist the client with oral hygiene frequently.
A, C, E
A nurse is preparing to insert an NG tube for a PT who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (select all that apply). A. review a signal the PT can use if feeling any distress. B. lay a towel across the PT chest. C. administer oral pain medication. D. obtain a dobhoff tube for insertion. E. have a petroleum-based lubricant available.
A,B
A nurse is performing mouth care for a client who is unconscious. which of the following should the nurse do? A. turn the PT head to the side B. place two fingers in the clients mouth to open. C. brush the client's teeth once per day D. inject a mouth rinse.
A. turn the PT head to the side
A nurse is caring for a PT within the intimate zone of the client's personal space. The nurse should perform which of the following activities in this space? (select all the apply) Auscultating heart sounds Teaching about a medication Changing a dressing Discussing intake and output Talking with the client's partner
AUSCULTATING HEART SOUNDS CHANGING A DRESSING
A PT recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A. Allow the patient to suck on ice chips. B. Provide frequent mouth care. C. Apply petroleum jelly to the patient's naris. D. Offer throat lozenges for the patient to use.
B
A PT with a gastric ileus post operatively requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes is appropriate for the PT? A. Nasogastric tube B. Nasointestinal tube C. Percutaneous endoscopic gastrostomy tube D. Percutaneous endoscopic jejunostomy tube
B
A nurse is admitting a PT who has a wound infected with vancomycin-resistant enterococci. Which of the following types of precautions should the nurse plan to initiate? A. Droplet B. Contact C. Airborne D.Protective
B
A nurse is caring for a PT who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. auscultate breath sounds B. stop the feeding C. obtain a chest x-ray D. initiate oxygen therapy
B
A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? A. 6.0 B. 4.0 C. 7.0 D. 8.0
B
A nurse is caring for a hospitalized PT who is performing active ROM exercises. Which of the following body movements would indicate to the nurse the PT has full range of motion of the Shoulder? A. Adducting the arm so that it lies next to the patient's side B. Flexing the shoulder by raising the arm from a side position to a 180° angle C. Abducting the arm to a 90° angle from the side of the body D. Circumducting the shoulder in a 180° half circle
B
A nurse is caring for an older adult PT who was alert and oriented at admission, but not seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the PT's safety needs? A. Call the family and ask them to stay with the client. B. Move the client to a room closer to the nurses' station. C. Apply wrist and leg restraints to the client. D. Administer medication to sedate the client.
B
A nurse is discussing the use of a computer to document in the client's health record with newly licensed nurse. Which of the following comments by the new nurse indicates an understanding of the teaching? A. "I should share my computer password with the nurse orienting me." B. "I should remain aware of my surroundings when documenting on the computer." C. "I can step away from the computer for a short time if I am logged on and no one is around." D. "I can review the health records of other clients on the unit not assigned to me."
B
A nurse is evaluating teaching on a PT who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? A. "This device will keep me from getting sores on my skin". B. "This thing will keep the blood pumping through my leg" C. "With this thing on, my leg muscles wont get weak. D. "This device is going to keep my joints in good shape."
B
A nurse is observing a PT's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication? A. Nonverbal communication conveys less truth than what the client states verbally. B. The client's sociocultural background influences nonverbal communication. C. Nonverbal communication is a poor reflection of what the client feels. D. The client enacts nonverbal communication consciously.
B
A nurse is preparing to administer a cleansing enema to a PT. Which of the following actions should the nurse take? A. Keep the container of solution at a level to maintain client comfort. B. Hold the container of solution 30 cm (12 in) above the anus. C. Hold the container of solution level with the client's upper hip. D. Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus
B
A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. pull down and out at the back of the upper denture to remove B. brush the dentures with a toothbrush and denture cleaner C. rinse the dentures with hot water D. place the dentures in a clean and dry container.
B
A nurse is providing teaching to a PT who is receiving intermittent nasogastric feedings. Which of the following should the nurse instruct the PT to report immediately? A. A feeling of fullness B. Persistent coughing C. Discomfort in the naris D. Post feeding belching
B
A nurse notices an AP preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take? A. Allow the AP to deliver the food tray to the client. B. Call the dietary department and ask for a kosher tray. C. Replace the nonfat milk with apple juice. D. Explain to the client that he needs the protein in the milk and the beef.
B
A nurse who is admitting a PT who has a fractured femur obtains a blood pressure reading of 140/94. The client denies any history of hypertension. Which of the following actions should the nurse take first? A. request a prescription for an antihypertensive medication. B. ask the PT if they are having any pain C. request a prescription for an antianxiety medication D. return in 30 minutes to recheck the blood pressure.
B
After assisting a PT in removing his shoes and underwear, you notice what appears to be soil or grime on your hands. You... A. cleanse your hands with an alcohol-based gel. B. wash your hands with soap and water. C. brush off the soil against a cloth surface. D. use a wet paper towel to remove the soil.
B
Nurses on a clinical unit wish to research the incidence of falls among PTs following joint replacement surgery. Which of the following should they do to ensure the study complies with the HIPAA privacy rules? A. Contact the medical record department to obtain permission to access patients' charts. B. Submit their proposal to the institutional review board for review and describe how they will de-identify patient information. C. Notify the patients that they will be included in the study and should submit a written request if they choose not to participate. D. Obtain permission from the risk management department to gain access to incident reports that were filed due to patient falls.
B
The difference between a PT systolic and diastolic blood pressure is called... A. an auscultatory gap. B. the pulse pressure. C. a diurnal variation. D. the pulse deficit
B
The patient has a large family and they have been calling frequently asking about her status. How should you respond to a phone call from the patient's sister? The patient has only given her spouse permission to receive her healthcare information. A. Tell her sister that the patient is resting comfortably. B. Tell her sister that she must speak to the patient's spouse to obtain information. C. Tell her sister that you are not at liberty to give out any information.
B
Which of the following formulas is appropriate to administer to a PT who has a dysfunctional GI tract? A. Modular B. Elemental C. Polymeric D. Specialty
B
You are caring for a patient diagnosed with mycoplasma pneumonia. Droplet precautions have been instituted, so you must: A. wear a respirator. B. protect your eyes. C. use an air filter. D. wear shoe covers.
B
You are washing your hands with nonantimicrobial soap and water prior to repositioning a PT in bed. During the handwashing procedure, it is important to: A. make sure that the water is hot. B. continue for at least 15 seconds. C. use a liquid soap preparation. D. remove rings and watches first.
B
when assessing a PT respiratory rate, it is recommended that the PT... A. lie flat in bed with his/her head on a pillow. B. have the head of the bed elevated 45 to 60°. C. continue to go about his/her usual activities. D. take several deep breaths prior to the assessment.
B
when checking for nasogastric tube placement, the nurse should conduct which of the following procedures? A. Instill 20 mL of air into the tube and listen for a whooshing sound. B. Aspirate stomach contents and check the pH. C. Aspirate stomach contents and check their color. D. Auscultate lung sounds.
B
a nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (select all that apply) A. instruct PT not to perform the Valsalva maneuver B. apply elastic stockings. C. review laboratory values for total protein level. D. place pillows under the client's knees and lower extremities E. assist the client to change positions often.
B, E
A PT smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. WHich of the following actions is the nurse's priority? A. Close the fire doors on the unit. B. Activate the fire alarm. C. Move any clients in the immediate vicinity. D. Use a fire extinguisher to put out the fire.
C
A nurse in a clinic is interviewing a PT who will undergo diagnostic testing. The nurse should ask the PT about potential allergies in what phase of the nursing process? A. planning B. evaluation C. assessment D. Implementation
C
A nurse in the emergency department is caring for a PT who has a knee injury. The PT will be discharged and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include when discharging this PT? A. Lean on the crutches to support body weight when standing. B. Fully extend arms when holding onto the hand grips. C. Hold the crutches on the unaffected side when preparing to sit in a chair. D. Hold the crutches 9 to 12 inches in front of and to the side of each foot.
C
A nurse is about to transfer to a chair a PT who has a weak left leg. Which of the following actions by the nurse demonstrates correct transfer technique? A. Positioning the chair slightly behind the nurse so that the seat faces the patient's bed B. Placing the patient's left leg in front of her right leg just prior to the transfer C. Aligning the nurse's knees with the patient's knees just before the transfer D. Grasping the patient under the axilla to assist her to her feet
C
A nurse is assessing a PT's ability to ambulate with crutches using a 3 point gait. WHich of the following actions should the nurse identify as a risk to the client's safety? The client pushes downward on the handgrips. The client stands in a tripod position prior to walking. The client places partial weight on the affected leg. The client keeps the elbows in a flexed position.
C
A nurse is caring for a PT is using active listening skills. Which of the following actions should the nurse take? A. Sit side-by-side with the client. B. Have a pen and paper handy. C. Use intermittent eye contact. D. Lean back in the chair.
C
A nurse is caring for a PT who is recieving oxygen therapy via nasal cannula. The nurse explains to the PT that this method of oxygen delivery does which of the following? A. Delivers a constant rate of a specific concentration of oxygen B. Delivers a high concentration of oxygen C. Delivers a low concentration of oxygen D. Restricts the client's ability to eat, speak, or drink
C
A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understand when dicharge planning should be implemented? A. "I will begin 48 hr before the client's discharge" B. "I will begin once the client's discharge order is written." C. "I will begin upon the client's admission to the facility." D. "I will begin once the client's insurance company approves discharge coverage."
C
A nurse is instructing an AP about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? A. let the client rest for 5 minutes before you measure her blood pressure. B. count the client's radial pulse for 30 seconds and multiply it by 2 C. do not measure the client's temperature rectally D. do not let the client know you are counting her respirations.
C
A nurse is preparing to instill an enteral feeding for a PT who has an NG tube. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. check how long the feeding container has been open B. confirm that the client doesn't have diarrhea. C. verify the placement of the NG tube D. make sure the client is alert and oriented.
C
A nurse is teaching a PT who has type 1 diabetes mellitus about foot care. Which of the following statements by the PT indicates an understand of the teaching? A. "I'll wear sandals in warm weather." B. "I'll put lotion between my toes after drying my feet." C. "I'll check my feet every day for sores and bruises." D. "I'll soak my feet in cool water every night before I go to bed."
C
A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which of the following PT? A. A 6-year-old child who drank a toxic substance B. A 60-year-old patient admitted with gastrointestinal hemorrhage C. A 40-year-old patient with a postoperative bowel obstruction D. A 20-year-old patient with malabsorption syndrome
C
A parents calls a pediatrician's office to make an appointment for her school-age child. The nurse should instruct the parent to call the previous pediatrician's office and request that.. A. the records be photocopied and sent to the new pediatrician's office. B. the original records be sent to the new pediatrician's office. C. a form authorizing release of copies of the records be sent to her to sign and return. D. a form authorizing release of the records be sent to the new pediatrician to sign and return.
C
During report, a nurse is informed that a PT has a nasogastric tube connected to a continuous suction. The nurse should recognize that this PT must have which of the following types of tube? A. Levin B. Sengstaken-Blakemore C. Salem sump D. Ewald
C
Nasogastric tube feedings are an approapriate choice for a PT who... A. has a paralytic ileus. B. has recently experienced facial trauma. C. is postoperative following laryngectomy. D. has pancreatitis.
C
Standard precautions mandate: A. rinsing gloves that become visibly soiled during use. B. using antimicrobial soap for routine handwashing. C. disinfecting hands immediately after removing gloves. D. keeping gloves on when touching environmental surfaces.
C
Which product can affect the permeability of gloves? A. Antimicrobial soap and water B. Alcohol-based antiseptic gel C. Petroleum-based hand lotion D. Water-based hand lotion
C
You are about to irrigate a patient's open wound. Besides gloves, which other item of personal protective equipment must you wear? A. A sterile gown B. Goggles C. A face shield D. An N95 respirator
C
You have assessed a 45 year old PT's vital signs. Which of the following assessment values requires immediate attention? A. An oral temperature of 100° F (37.8° C) B. A blood pressure of 148/88 mm Hg C. A respiratory rate of 30/min D. A radial pulse rate of 45 beats per 30 seconds
C
a PT feels his privacy has been violated and wants to file a formal complaint. Through which of the following agencies should the nurse instruct the patient to file the complaint? A. Occupational Safety and Health Administration (OSHA) B. Joint Commission C. Office of Civil Rights (OCR) D. Privacy and Civil Liberties Office
C
A NURSE IS ADMITTING A PT WHO HAS A PARTIAL HEARING LOSS. WHICH OF THE FOLLOWING IS THE PRIORITY ACTION BY THE NURSE? A. Speak using his usual tone of voice. B. Stand directly in front of the client. C. Rephrase statements the client does not hear. D. Determine if the client uses hearing aids.
D
A PT is brought to the emergency department after a motor-vehicle crash. She is unresponsive due to a head injury. Permission for stabilization of a cervical injury was obtained over the phone from her husband, who is currently overseas. Which of the following should the assigned nurse document to verify HIPPA guidelines were maintained? A. Document that the primary care provider informed the patient of her condition and the need for surgery. B. Document the patient's condition and surgeon's rationale for taking her to surgery. C. Document the patient's physical condition and avoid addressing the conversation the primary care provider had with the husband. D. Document the patient's condition and that consent was obtained after the primary care provider discussed the proposed surgery with the husband.
D
A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection? A. Massage the reddened areas of the patient's skin B. wash the eyes from outer canthus to inner canthus C. Wash the PT from the shoulder down to the fingertips with smooth, short strokes. D. Cleanse the least-soiled areas prior to cleaning the most-soiled areas.
D
A nurse is caring for a PT who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded? A. Active bowel sounds B. Passing flatus C. Increase in gastric secretions D. Patient's report of nausea
D
A nurse is caring for a PT who has expressive aphasia following a cerebrovascular accident. Which of the following parameters should the nurse use first in order to assess the PT's pain level? A. pulse and blood pressure findings B. behavioral indicators and effect C. scheduled treatments and client illness D. a self-report pain rating scale
D
A nurse is caring for a PT who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? A. Trochanter roll B. Sheepskin heel pad C. Abduction pillow D. Footboard
D
A nurse is caring for a PT who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hours. which of the following actions should the nurse take as directed by the plan of care? A. Ask the client to move her arms and legs while applying slight resistance. B. Move the client's limbs through their complete range of motion. C. Have the client move each limb independently through its complete range of motion. D. Instruct the client to tighten muscle groups for a short period, and then relax.
D
A nurse is caring for a PT who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen? A. Use a sterile swab to obtain the specimen. B. Place the specimen in a sterile container. C. Label the paper bag in which specimen container is placed. D. Send specimen container immediately to the lab.
D
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? A. allergic reaction B. ringworm C. systemic lupus erythematosus D. herpes zoster
D
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes, The PT is experiencing which of the following stages of infections? A. prodromal B. incubation C. convalescence D. illness
D
A nurse is orienting to his new place of employment. Information is being provided regarding HIPAA's privacy rule. Which of the following comments by the nurse indicates an accurate understanding of these standards? A. "Patients do not have the right to read their charts." B. "I can read the charts of other patients on my floor." C. "I will expect a list of patients and their room numbers to be posted on my unit." D. "I can give information about a patient over the phone if the patient gives his permission."
D
A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints? A. The provider must renew a restraint prescription every 8 hr. B. The client must understand the need for the restraints. C. The restraints should promote the client's safety and prevent injuries. D. The nurse has already considered alternatives to restraints.
D
A nurse is teaching a PT who is obese and has an obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following PT statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." B. "I'll sleep better if I take a sleeping pill at night." C. "I'll get a humidifier to run at my bedside at night." D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
D
A nurse is teaching a PT's older adult son about how to position the PT when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? A. "I will allow him to be in the position where he is most comfortable during the feeding." B. "I will elevate the head of the bed 10 degrees during the feeding." C. "I will turn him on his left side during the feeding." D. "I will have him sit in his chair during the feeding."
D
A nurse observes an AP make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task? A. The AP records the task when it is completed. B. The AP wears sterile gloves while making the bed. C. The AP makes a mitered corner with the blanket and spread. D. The AP reuses the patient's blanket and spread.
D
A patient has a healthcare-associated infection. This term means that the patient A. became infected due to compromised immunity. B. was infected during a therapeutic procedure. C. inhaled pathogens in a healthcare setting. D. acquired the infection while hospitalized.
D
As a nurse ambulates an unsteady PT, the PT become light-headed and begins to fall. Which of the following interventions by the nurse is appropriate? A. Wrap both arms around the patient's arms and shoulders. B. Move both feet together when the patient begins to fall. C. Protect the patient's extremities while lowering him to the floor. D. Extend one leg and allow the patient to slide down it.
D
Contact precautions would be mandated for a patient diagnosed with: A. hepatitis B. B. measles. C. meningitis. D. infectious diarrhea.
D
To determine how much of the length of an NG tube to insert, a nurse should measure the distance from the tip of the PT nose to the earlobe and from the earlobe to the... A. umbilicus. B. xiphoid process. C. manubrium plus 10 to 20 cm more. D. xiphoid process plus 20 to 30 cm more.
D
To prevent aspiration during the administration of an enteral tube feeding, a nurse should.. A. flush the feeding tube with 30 mL of water. B. add blue food coloring to the enteral formula. C. ensure the formula is at room temperature. D. place the patient in Fowler's position.
D
When taking a PT's blood pressure, why is it important to notice the pressure on the manometer when you hear the 4th kototkoff sound or phase? A. It corresponds to the patient's systolic pressure. B. You need it to record the second diastolic pressure. C. It is the loudest of the Korotkoff sounds. D. You might not hear a fifth Korotkoff sound.
D
When preparing to measure the vital signs of a PT, you should recognize that which of the following will affect the methods that you will use? (select all that apply) The patient is 60 pounds overweight. The patient has been nauseated for 2 days. The patient is reporting a "stuffy" nose. The patient has been fasting for blood tests. The patient is taking digoxin (Lanoxin). The patient had a mastectomy 2 years ago.
The PT is 60 pounds overweight The PT is reporting a stuffy nose The PT is taking digoxin. The PT had a mastectomy 2 years ago.
A nurse stands facing a PT to demonstrate active ROM exercises. Which of the following should the nurse do when demonstration hyperextension of the hip? A. Move the leg behind the body. B. Move the leg forward and up. C. Move the leg medially toward the other leg. D. Turn the foot and leg away from the other leg.
a
A nurse is teaching a PT's partner about how to obtain a BP reading. Which of the following by the partner indicates a need for further instruction? a. Wraps the blood pressure cuff snugly around the client's arm b. Places the client's arm above the level of the client's heart c. Checks the instrument gauge to ensure the reading starts at zero d. Centers the cuff bladder over the client's brachial artery
b
A nurse is caring for a PT in long term care facility who is receiving enteral feeding through an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding (select all that apply) A. discard any residual gastric contents. B. auscultate bowel sounds. C. assist the client to an upright position. D. test the pH of the gastric aspirate. E. warm the formula to body temperature.
b, c, d
When auscultating a PT's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the A. Atria contract vigorously. B. ventricular walls vibrate. C. semilunar valves close. D. mitral valve snaps open.
c
A nurse is assessing a PT who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (select all that apply) contractures of the extremities polyuria diarrhea crackles in the lungs pressure ulcers
contractures of the extremities crackles in the lungs pressure ulcers
When taking an adult PT's temperature rectally, it is important to... A. rotate the probe gently if you encounter any resistance. B. insert the probe so that you are aiming at the patient's pelvic area. C. dip the probe about an inch to an inch and a half into a tube of lubricant. D. insert the probe about an inch and a half into the patient's anus.
d
Standard precautions indicate that a nurse does not have to wear gloves unless
having direct contact with bodily fluids, non intact skin, or mucous membranes
A nurse is teaching a PT about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (select all that apply) sedentary lifestyle obesity aging caffeine intake secondhand smoke
sedentary lifestyle aging caffeine intake secondhand smoke
How much did this client intake? Consumed: 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The PT also recieved 400 mL of IV fluids.
1240
how many milliliters are in an ounce?
30 mL