ATI- Test A1

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. Decreased BP B. Calf swelling C. Bladder distention D. Diminished bowel sound

B. Swelling, redness and tenderness of calf

What is an important electrolyte to measure for when giving IV fluid?

Sodium

Role ambiguity

when role expectations are not clearly understood

Inserting a NG tube

-High fowler position -Sip water -Gagging might occur

Cane use

-Parallel to greater trochanter -6-12 inches forward in front when walking -Move weaker leg with cane -Hold on stronger side of body

Droplet precautions

-Rubella -Meningococcal pneumonia -Stretpococcal pharyngitis Larger than 5

NG tube feedings

-Wipe the top of the formula with alcohol to disinfect -Keep head of the bed at 30 degrees at least -Make should formula is room temp -Rinse the feeding bag with warm water to reduce risk of bacteria

Urine Specific Gravity

1.010 - 1.030 (higher = more dehydrated)

Nursing Process

ADPIE Assessment Diagnosis Planning Implementation Evaluation

Feverfew

Alternative therapy for wound healing

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A. Fluid intake of 3,000 mL per day B. A bowel movement every other day C. Lower-extremity pulse strength of 2+ D. Erythema on pressure points

D. Signs of a pressure ulcer/skin breakdown -bowel movements should be more than 3 a week to be normal

Sick role

Individual experiencing an alteration in health

N95 respirator

Mask with small, tightly woven pores that protects the wearer from airborne infection.

A nurse is caring for a client who has TB. Which of the following actions should the nurse take? (Select all) A. Wear gloves when assisting the client with oral care. B. Place the client in a room with negative-pressure airflow. C. Use antimicrobial sanitizer for hand hygiene. D. Limit each visitor to 2-hr increments. E. Wear a surgical mask when providing client care.

A. B. C. -No limit, must wear mask -N95 mask

Sound: Narrowed arterial lumen

Blowing sounds

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure hat the medication reaches the inner ear? A. Move the client's auricle down and back toward her head. B. Pack a small piece of cotton deep into the client's ear canal. C. Press gently on the tragus of the client's ear. D. Tilt the client's head backward for 5 min.

C. -Move auricle upward and backward -Inserting anything could damage the ear -Lie on side for 2-5 minutes

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. Move hazardous objects away from the client. B. Ask the client to describe how she felt prior to the fall. C. Notify the provider. D. Check the client for injuries.

D. ASSESS client Assess Diagnosis Plan Implement Evaluate

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following should. The sound indicates which of the following? A. Impaired ventricular contraction B. Asynchronous closure of the aortic and pulmonic valves C. Distended jugular veins D. Narrowed arterial lumen

D. Blowing sounds

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? A. Feverfew B. Biofeedback C. Aloe D. Acupuncture

D. Could open the skin surface and lead to increase risk of further infection

Sound: Impaired ventricular contraction

Extra heart sound S3, S4

Sound: Distended jugular veins

No sound

Feverfew should not be given to pt who are prescribed

Warfarin or other blood thinners

How much fluid should be consumed daily?

2,500- 3,000 mL

Role conflict

Develops when a person must assume opposing roles with incompatible expectations

Sound: Asynchronous closure of the aortic and pulmonic valve

Two S2, "splitting"

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? 1. Position the chair of the left side of the bed 2. Use the stand-and-pivot technique to move the client to the chair 3. Ask the client if he can bear weight 4. Have the client sit and dangle his feet at the bedside

3. 1. 4. 2.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all) A. Visual acuity B. Visual fields C. Lacrimal apparatus D. Pupil clarity E. Appearance of bulbar conjunctivae

A. B. D. -Lacrimal apparatus just makes tears, -Bulbar conjunctivae is just for infection

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed postural hypotension? A. Decreased BP B. Calf swelling C. Bladder distention D. Diminished bowel sound

A. Drop in blood pressure when moving from lying to a sitting position

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? A. Flush the tube with 15 mL of sterile water. B. Push the syringe plunger gently when feeling resistance. C. Draw up medications together in the syringe. D. Dissolve each medication in 5 mL of sterile water.

A. Flush the feeding tube with 15-30 mL of sterile water before and between each medication; after flush with 30-60 mL of sterile water -Dissolve each medication in at least 30 mL of warm, sterile water -No resistance

A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A. Wrap monitoring cords with stockinette and tape them in place. B. Ensure sterilization of nondisposable items with ethylene oxide. C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. D. Wear hypoallergenic latex gloves that contain powder.

A. Prevent contact with cords/devices that have latex -Use a stopcock for injecting medication -Powder has latex protein

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? A. Cleanse the wound from the center outward. B. Wear sterile gloves when removing the old dressing. C. Warm the irrigation solution to 40.5° C (105° F). D. Use a 20-mL syringe to irrigate the wound.

A. Prevent introduction of infection from the outer skin surface -Warm to body temperature -30-60 mL syringe

A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? A. Semi-Fowlers B. Trendelenburg C. Side-lying D. Supine

A. semi/high

Biofeedback

Alternative therapy for stroke recover, smoking cessation, headache disorders -Mind-Body technique

The 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 identify as infection? A. Warmth B. Purulent exudate C. Skin blanching D. Bleeding

B.

The nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? A. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over." B. "I'll check the wires and cables on my TV to make sure they are in good working order." C. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." D. "I'll use a woolen blanket if I get chilly while I'm using my oxygen."

B. -No smoking around at all -Keep tank upright -Use a cotton blanket

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A. Monitor serum electrolyte levels. B. Auscultate lung sounds. C. Monitor blood pressure readings. D. Measure urine output.

B. ABC

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A. Wipe the top of the formula can with alcohol. B. Tell the client to keep the head of the bed elevated at least 30°. C. Make sure the enteral formula is at room temperature. D. Rinse the feeding bag with water between feedings.

B. Airway, breathing, circulation approach PRIORITY = ABC

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? A. Administer a pain medication to the client. B. Determine the reasons why the client is refusing to use the incentive spirometer. C. Request that a respiratory therapist discuss the technique for incentive spirometry. D. Document the client's refusal to participate in health restorative activities.

B. Assess the client first always ADPIE

A nurse in a long-term care facility is planning to preform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? A. "At what temperature do you prefer your bath water?" B. "Are you able to help with your hygiene care?" C. "When do you usually bathe, in the morning or in the evening?" D. "Do you prefer a bath or a shower?"

B. Assess the clients ability to assist with hygiene care -other help promote comfort and independence

A charge nurse is discussing the responsibility of nurses caring for clients who have a C. diff infection. Which of the following information should the nurse include in the teaching? A. Clean contaminated surfaces in the client's room with a phenol solution. B. Have family members wear a gown and gloves when visiting. C. Use alcohol-based hand sanitizer when leaving the client's room. D. Assign the client to a room with a negative air-flow system.

B. Prevent the transmission -Phenol solution kills bacteria and fungi, but not C. diff spores -Wash hands with soap and water -Private room

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A. Shave excess hair from the insertion site. B. Place the client's arm in a dependent position. C. Insert the catheter at a 45° angle. D. Initiate IV therapy in the veins of the hand.

B. Will cause veins to dilate due to gravity -Clip excess hair, no shaving to prevent cuts -10-30 degree angle

A nurse if caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine." B. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." C. "I have a specimen in the bathroom from about 30 minutes ago." D. "I drink a lot, so I will fill up the bottle and complete the test quickly."

B. discard the first voiding and save all the others -Keep on ice/Refrigerator -collection takes over a full 24 hr

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? A. Increase the humidity in the client's room. B. Suction the client's airway. C. Assist the client to an upright position. D. Administer a bronchodilator.

C. -Start with the least invasive tactic

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A. Lock the remaining medication in the controlled substances cabinet. B. Dispose of the vial with the remaining medication in a sharps container. C. Ask another nurse to observe the medication wastage. D. Notify the pharmacy when wasting the medication.

C. A second nurse must witness the disposal of any portion of a dose of a controlled substance

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? A. Protective environment B. Droplet precautions C. Contact precautions D. Airborne precautions

C. All caregivers should wear gown and gloves when in contact with client

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress? A. Role conflict B. Sick role C. Role overload D. Role ambiguity

C. Having too many responsibilities

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed urinary retention? A. Decreased BP B. Calf swelling C. Bladder distention D. Diminished bowel sound

C. Loss of muscle tone in the bladder causes

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? A. "They permit a client to withhold medical information from health care personnel." B. "They allow health care personnel in the emergency department to stabilize a client's condition." C. "They allow the court to overrule an adult client's refusal of medical treatment." D. "They indicate the form of treatment a client is willing to accept in the event of a serious illness."

D.

A nurse is caring for a client who has limited mobility in how lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A. Place the client in high-Fowler's position. B. Massage reddened areas with unscented lotion. C. Increase the client's intake of carbohydrates. D. Have the client use a trapeze bar when changing position.

D. Avoids friction and shearing when moving -Massaging can cause breakdown -Increase protein

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. The top of the cane is parallel to the client's waist. B. When walking, the client moves the cane 46 cm (18 in) forward. C. The client moves her stronger limb forward with the cane. D. The client holds the cane on the stronger side of her body.

D. Hold the cane on the stronger side to increase support -Top of cane should be parallel to client's greater trochanter -6-12 inches at a time in front -Move weaker leg with cane

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair to prevent self-injury, which of the following actions should the nurse take when lifting this object? A. Use his back muscles for lifting. B. Keep his feet close together. C. Bend at the waist. D. Stand close to the cabinet when lifting it.

D. Keep object close to center of gravity, decreases horizontal reaching -Use arm and leg muscles rather than back -Feet wide apart for broad base of support -Bend at the knees

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Riding a bike B. Performing isometric exercises C. Engaging in high-impact aerobics D. Walking briskly

D. Pt needs weight-bearing exercises -High-impact will damage bone

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Focus teaching on what the client will need to do in the future to manage his illness. B. Discuss the risk factors for colon cancer. C. Provide the client with written information about the phases of loss and grief. D. Reassure the client that this is an expected response to grief.

D. Support the pt -Not a good state to teach -Listen

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? A. Blood pressure 144/82 mm Hg B. Neck vein distention C. Urine specific gravity 1.010 D. Rapid heart rate

D. Tachycardia indicates fluid-volume deficit -Neck vein distention= excess fluid/volume -1.030 or higher for urine specific gravity

A nurse if preparing a heparin infusion for a client who was hospitalized with DVT. The order reads 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

Desired X Amount/ Have= X mL 800 X 250mL/ 25,000 units = 8 mL

Pain Assessment

PQRST- Provocative or palliative (aggravating factors), Quality (feeling) Region (location, radiation), Severity (scale/how bad) Timing (when/how long)

Isometric exercise

exercise in which muscle tension occurs without a significant change in muscle length Ex. Flexing

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? A. The dose B. The medication C. The route D. The frequency

A. There are no units given

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? A. Apply the stockings so the creases are on the front side of the leg. B. Apply the stockings while the client's legs are in a dependent position. C. Remove the stockings while the client is sitting in a reclining chair. D. Remove the stockings at least once per shift.

D. Check circulation and skin integrity -No creases or wrinkles -Apply in the morning while pt is still in bed -Avoid crossing legs

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? A. Allow extra time for the client to respond to questions. B. Expect the client to have difficulty understanding the information. C. Avoid references to the client's past experiences. D. Keep the learning session private and one-on-one.

A. -Assess the client's cognition and ability to learn and teach accordingly; verify understanding of teachings -Helpful to have another household member in on the teaching session to reinforce information later -Connect past information to make similarities

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? A. Use progressive relaxation techniques at bedtime. B. Reflect on the day's activities before going to bed. C. Exercise 1 hr before going to bed. D. Drink a cup of hot cocoa before bedtime.

A. -Reflecting can cause stress -2 hr before exercise can effect sleep

A nurse is planning care to improve self-feeding for a client who has dysphagia. Which of the following interventions should the nurse include in the plan of care? A. Use a clock pattern to describe food on the client's plate. B. Thicken liquids on the client's tray. C. Provide small-handle utensils for the client. D. Tell the client which food she should eat first.

B. Facilitate swallowing without choking

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer SQ. Determine the correct order of steps for this procedure. 1. Inject 5 units of air into the bottle of regular insulin 2. Withdraw the correct dose of NPH insulin from the bottle 3. Inject 10 units of air into the bottle of NPH insulin 4. Withdraw the correct dose of regular insulin from the bottle

3. 1. 4. 2. Inject Cloudy, Inject Clear, Draw up Clear, Draw up Cloudy

A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? A. Use a clock pattern to describe food on the client's plate. B. Thicken liquids on the client's tray. C. Provide small-handle utensils for the client. D. Tell the client which food she should eat first.

A. Promote independence within the pt

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. "Delete the space between the numerical dose and the unit of measure." B. "Use the complete name of the medication magnesium sulfate." C. "Use the abbreviation SC when indicting an injection." D. B"Write the letter U when noting the dosage of insulin."

B. Do not confuse with other medications -Include a space between dose and unit -Need to write units for insulin

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. Apply suction to the NG tube prior to insertion. B. Have the client take sips of water to promote insertion of the NG tube into the esophagus. C. Remove the NG tube if the client begins to gag or choke. D. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube.

B. -Do not suction until it is in place -High-fowlers position with head of the bed at 90 degrees

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A. 0.30 mg B. .3 mg C. 0.3 mg D. 3/10 mg

C. Think significant numbers

The 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 identify as infiltration? A. Warmth B. Purulent exudate C. Skin blanching D. Bleeding

C. Edema and coolness

Airborne precautions

-TB -Measles -Chicken pox Smaller than 5 ; must have negative air flow in room

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? A. Fried egg B. Bananas C. Tomato juice D. Pancake

A.

The 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 identify as phlebitis? A. Warmth B. Purulent exudate C. Skin blanching D. Bleeding

A.

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I can concentrate best in the morning." B. "You will have to talk to my wife about this." C. "I'm wondering why I need to learn this." D. "It is difficult to read the instructions because my glasses are at home."

A. He is ready to learn and gives information on when it would be best to learn the information

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? A. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology. B. A nurse tied a client's restraint straps to the moveable part of the bed frame. C. A nurse administers a medication to a client 30 min before the dose is due. D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

D. -Can give meds 1-2 hr before or after if it is not time sensitive -Put restraint on moveable to prevent injury

A HCP is caring for a middle adult client who states, "The Dr. says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the HCP make? A."Beginning at age 60, you should have a colonoscopy." B."I'll get a blood sample from you and send it for a screening test." C."The recommendation is to have a sigmoidoscopy every 10 years." D."You should have a fecal occult blood test every year."

D. -Colon cancer risk begins at 50 -Colonoscopy every 10 yrs -Sigmoidoscopy every 5 yrs

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A. Verify the dosage by measuring the liquid before administering it. B. Place the client in a semi-Fowler's position prior to medication administration. C. Gently shake the container of medication prior to administration. D. Transfer the medication to a medicine cup.

C. Make sure the liquid is mixed -Do not transfer prepackage -HIGH fowlers position

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A. "I notice that the pain gets worse after I eat." B. "I'm having mild pain." C. "The pain is like a dull ache in my stomach." D. "The pain makes me feel nauseous."

C. Quality of pain is described as how the pain feels