1100 Exam One (ATI)
A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make?
"Remove nail polish on your fingernails if it is chipped."
A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first?
- develop a plan of care.
A nurse is performing a general client survey and finds that the client has a body mass index of 23. Which of the following should the nurse document?
-BMI is in expected limits
What other common findings might be expected with an elderly patient?
-Presbycusis: age related hearing loss -presbyopia: farsightedness due to loss of elasticity of the lens of the eye.
A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first?
-The right lower quadrant.
A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect?
-a brief thump felt near the 4th or 5th intercostal space near the midclavicular line.
The nurse should begin an examination by inspecting the clients body for what?
-symmetry -common findings -uncommon finding
Whistling sound when breathing
-wheezing
What is kyphosis?
A noticeable hunchback curvature of the spine. -common result of osteoporosis, and vertebral fractures
A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves?
After changing a dressing on the client and before documenting findings on a computer
A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission?
Airborne
A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask?
Airborne
Where would you palpate for the point of maximal impulse?
Apical pulse -over the fifth intercostal space near left midclavicular line.
A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?
Apply chlorhexidine and ethanol to the hands.
A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger?
Bacteria
nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics
Balance
A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests?
C-reactive protein
A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions?
Contact
A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection?
Convalescence
A nurse is performing a respiratory assessment on a client. The nurse ausculates a wet, popping sound upon inspiration of the clients breathing period the nurse should identify this observation as which of the following findings?
Crackles
A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the clients foot, between the tendons of the great toe and of those of the toe next to it, in order to palpate which of the following pulses?
Dorsalis pedis
A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?
Droplet
A nurse is planning to admit a client who has respiratory syncytial virus. Which of the following precautions should the nurse plan to implement
Droplet
A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first?
Gloves
A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?
Gloves should be removed from the inside out.
What is the chain of infection?
How bacteria, viruses, fungi, parasites,and prions move from place to place. -contact, droplet, and airborne. -portal of entry -Susceptible host -infectious agent -reservoir -Portal of exit
A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first?
Inspection
A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging?
Kyphosis
A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take?
Open the first flap on the sterile package away from their body
A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?
Place the client in a private room
A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?
Prodromal
A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. What findings should the nurse document?
Rebound tenderness
A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?
Report needlestick injuries to the nursing supervisor
A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent?
Reservoir
What is Rhonchi? how can you clear it?
Rhonchi is the noise lungs make when air travels through backed up mucus -tell you patient top inhale deep and cough.
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use?
Soap and water
When performing an assessment what is the way of movement?
Start in right lower quadrant, than right upper, left upper, last lower left quadrant.
What is a sharp pitched sound when breathing? normally cause by a blockage in the upper airways
Stridors
A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection?
Susceptible host
What is the only part of the body nurses assess differently than inspect, palpate, percuss, auscultate.
The abdominal area. -inspect, auscultate, percuss, palpate.
A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve I is intact?
The client can identify as minty scent -cranial nerve 1 is the olfactory nerve
A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include?
The door to the AIIR should remain closed
What is the system that Recognizes harmful stimuli by pattern receptors (located on the surface of cells) Activation of the inflammatory pathway Release of inflammatory markers Recruitment of inflammatory cells
The inflammatory Response
A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle?
Try to use alternatives before inserting indwelling urinary catheters.
A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Turns off the faucet with a towel
What are the stages of an infection
incubation, prodromal, acute illness, decline, convalescence
Types of infection
local, systemic, acute, chronic