Fundamentals ATI

A nurse is caring for a client who is postoperative and requires the use of a sequential compression device (SCD). Which of the following actions should the nurse take?

Place an SCD sleeve under each leg with the opening at the knee. MY ANSWER The nurse should place an SCD sleeve under each leg, with the opening at the level of the knee, and then wrap the sleeve around the leg so that it is secure.

A nurse is preparing to measure a client's BP. Which of the following actions should the nurse take?

Position the client's arm at the level of the client's heart. If the client's arm is above heart level, the blood pressure reading will be falsely low. If the client's arm is below heart level, the blood pressure reading will be falsely high.

A nurse is reinforcing teaching about using crutches with a cient who has a fractured left ankle. which of the following client statements indicates an understanding of the instructions?

"I'll bend my elbows to about 25 degrees when I walk with my crutches." The client should have 20° to 30° of flexion at the elbows when using their crutches. The nurse should verify that the client understands the correct amount of elbow flexion to have when using crutches. -client should wear rubber-sole shoes to reduce the risk for slipping or skidding. -client should shift their weight to their right leg and then advance the crutches and their left leg down to the next step. Then, they should transfer their weight to the crutches and move their right leg down to the step that their left leg and the crutches are on.

A nurse is reinforcing teaching to a client about guaiac fecal occult blood testing. Which of the following statements should the nurse include?

"Perform three separate tests using three separate stool specimens." The nurse should reinforce and provide the client with three separate test cards to obtain three separate stool specimens. Each of the test cards are sent to a laboratory for the provider to determine the presence of blood.

A nurse is contributing to the plan of care for a client who has urinary and fecal incontinence. which of the following interventions should the nurse implement to help maintain the clients skin integrity

Apply a moisture barrier ointment after each incontinence episode. After cleansing the skin of urine and feces, the nurse should apply a barrier ointment to help protect the skin from the damaging effects of excessive moisture and bacteria, especially if the client has diarrhea. -keep the head of the client's bed elevated to 30° with the client in a slight lateral position to minimize pressure on bony prominences. -Soap can have a drying effect on the skin, especially if the nurse does not rinse it off thoroughly. The nurse should use a no-rinse perineal cleanser or one with nonionic surfactants to remove urine and feces from the client's skin.

A nurse is collecting data from a client for a comprehensive physical exam. The nurse should use the bell of the stethoscope to auscultate for which of the following alterations?

Bruits The nurse should auscultate for bruits (blowing or swishing vascular sounds) with the bell of the stethoscope. Incorrect: Borborygmi The nurse should auscultate for borborygmi (growling bowel sounds) with the diaphragm of the stethoscope. Crackles The nurse should auscultate for crackles (high-pitched, interrupted breath sounds) with the diaphragm of the stethoscope. Rhonchi The nurse should auscultate for rhonchi (low-pitched, rumbling breath sounds) with the diaphragm of the stethoscope.

A nurse is planning to remove sutures from a clients incision. Which of the following actions should the nurse take?

Clip the suture on one side and pull out on the other side. The nurse should clip the suture on one side of the incision and pull out the suture on the other side of the incision. This technique prevents microorganism and debris from contaminating the underlying tissue.

A nurse discovers they have administered a multivitamin tot he wrong client. What action does she take?

Complete an incident report about the medication error. An incident report is required whenever there is an event outside the usual routine, such as a medication error, a client or visitor injury, an omission of a prescribed therapy, or a needlestick injury. The nurse should follow the facility's protocol for a medication error, including observing the client, completing an incident report, and reporting the occurrence to the charge nurse or supervisor and the client's provider.

A nurse is caring for a client who has hypokalemia. Which of the following findings should the nurse expect?

Decreased bowel sounds The nurse should auscultate the abdomen and expect decreased bowel sounds due to decreased smooth muscle contractility when the client has a decreased serum potassium level.

A nurse is caring for a client who has an ng tube in place. which of the following actions should the nurse take to verify the placement of the client's ng tube

Test the pH of gastric aspirate. MY ANSWER Prior to administering an enteral feeding, the nurse should aspirate 5 mL of gastric contents through the tube and then test the aspirate's pH. A pH between 0 and 4 indicates gastric placement. A pH higher than 6 indicates that the distal end of the tube is in the intestines or in the pulmonary system.

Preventative care Primary level of prevention secondary Tertiary level of prevention Restorative

immunizations and education for minimizing risk factors for illness ex hospital conducting a community blood pressure screening in its lobby hospital based care in the emergency department or clinical unit Third in order the intensive care unit, oncology, treatment center and burn center cardiac rehabilitation and home health care