1100 test 3 ATI

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D. the flap farthest from the body

A client who had abdominal surgery 24 hours ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? select all that apply a. cover the area with saline soaked sterile dressings b. apply abdominal binder snugly around the abdomen c. use sterile gauze to apply gentle pressure to the exposed tissue d. position the client supine with the hips and knees bent e. offer the client a warm beverage (herbal tea)

a. cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene d. this position minimizes pressure on the abdominal area

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. which of the following findings should the nurse expect? select all that apply. a. increase in incisional pain b. fever and chills c. reddened wound edges d. increase in serosanguineous drainage e. decrease in thirst

a. increase in incisional pain b. fever and chills c. reddened or inflamed wound edges

a nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? select all that apply. a. stage 3 pressure injury b. sutured surgical incision c. casted bone fracture d. laceration sealed with adhesive e. open burn area

a. open pressure injuries heal secondary intention, which is the process for wounds that have tissue loss and widely separated edges e. open burn areas heal by secondary intention

a nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (select all that apply) a. planning and evaluating control and prevention strategies b. determining public health priorities c. ensuring proper medical treatment d. identifying endemic disease e. monitoring for common-source outbreaks

a. planning and evaluating control and prevention strategies b. determining public health priorities c. ensuring proper medical treatment e. monitoring for common-source outbreaks

A nurse receiving a providers prescription by telephone for morphine for a client who is reporting moderate to severe pain. which of the following actions are appropriate? select all that apply a. repeat the details of the prescription back to the provider b. have another nurse listen to the telephone prescription c. obtain the providers signature on the prescription within 24 hours d. decline the verbal prescription because it is not an emergency situation e. tell the charge nurse that the provider has prescribed morphine by telephone

a. repeat the details of the prescription back to the provider b. have another nurse listen to the telephone prescription c. obtain the providers signature on the prescription within 24 hours

a nurse is caring for a client who is at risk for developing pressure injury. which of the following interventions should the nurse use to help maintain the integrity of the clients skin? select all that apply a. keep the head of the bed elevated 30 degrees b. massage the clients bony prominences frequently c. apply cornstarch liberally to the skin after bathing d. have the client sit on a gel cushion when in a chair e. reposition the client at least every 3 hours while in bed

a. slightly elevate the head of the bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels d. have client sit on a gel, air or foam cushion to redistribute weight away from ischial areas

which of the following actions should the nurse take when demonstrating an empathic presence to a client? select all that apply a. use an open posture b. write down what the client says to avoid forgetting details c. establish and maintain eye contact d. nod in agreement with the client throughout the conversation e. sit facing the client

a. use an open posture c. establish and maintain eye contact e. sit facing the client

A nurse is caring for a client who report difficulty hearing. which of the following assessment findings indicate a sensorineural hearing loss in the left ear? select all that apply a. Weber test showing lateralization to the right ear. b. light reflex at 10 oclock in the left ear c. indications of obstruction in the left ear canal d. Rinne test showing less time for air and bone conduction e. Rinne test showing air conduction lass than bone conduction in the left ear

a. with sensorineural hearing loss, the Weber test demonstrates lateralization to the unaffected ear d. with sensorineural hearing loss in the left ear, length of time is decreased for both air and bone conduction

A nurse is caring for a client who is 2 days postoperative following appendectomy and has type I diabetes mellitus. their Hgb is 12 g/dl and bmi is 17.1. the incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? select all that apply a. extremes in age b. chronic illness c. low hemoglobin d. malnutrition d. poor wound care

b. chronic illness - diabetes c. low hemoglobin - Hgb is essential for oxygen delivery to heal tissues. the clients Hgb level is low d. malnutrition - the clients bmi indicates they are underweight and therefore malnourished

which of the following strategies should a nurse use to establish a helping relationship with a client? a. make sure the communication is equally distributed between the nurses and clients desires b. encourage the client to communicate their thoughts and feelings. c. give the nurse client communication not time limits d. allow communication to occur spontaneously throughout the nurse client relationship

b. encourage the client to communicate their thoughts and feelings.

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

b. the nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. c. the procedure is delayed 1 hour because the provider receives an emergency call d. the nurse turns to speak to someone who enters through the door behind the nurse

a nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). which of the following instructions should the nurse include when discussing hand washing? select all that apply. a. apply 3 to 5 ml of liquid soap to dry hands b. wash the hands with soap and water for at least 15 seconds c. rinse the hands with hot water d. use a clean paper towel to turn off hand faucets e. allow the hands to air dry after washing

b. wash the hand with soap and water for at least 15 seconds d. use a clean paper towel to turn of hand faucets

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. which of the following interventions should the nurse include? select all that apply. a. place the client in a room that has negative air pressure of at least six exchanges per hour. b. wear a mask when providing care within 3 ft. of the client c. place a surgical mask on the client if transportation to another department is unavoidable d. use sterile gloves when handling soiled linens e. wear a gown when performing care that might result in contamination from secretions

b. wear a mask within 3 feet of a client c. place a surgical mask on the client if transportation to another department is unavoidable e. wear a gown if the nurses clothing or skin might be contaminated with body secretions or excretions

a nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. which of the following statements should the nurse make? select all that apply a. "you will do great. you just have to get used to it" b. "why are you worried about going home" c. "your daily routines will be different when you get home" d."tell me about the support system you have after you leave the hospital" e. "it sounds like you are not sure how having a colostomy will affect swimming"

c. "your daily routines will be different when you get home" d."tell me about the support system you have after you leave the hospital" e. "it sounds like you are not sure how having a colostomy will affect swimming"

when entering a clients room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. which of the following actions should the nurse take when preparing a sterile field.? a. keep the sterile field at least 6 ft. away from the clients bedside b. instruct the client to refrain from coughing and sneezing during the dressing change. c. place a mask on the client to limit the spread of micro-organisms into the surgical wound. d. keep a box of facial tissues nearby for the client to use during the dressing change.

c. place a mask on the client to limit the spread of micro-organisms into the surgical wound

A nurse is caring for a client who had an amphetamine toxicity and has sensory overload. which of the following interventions should the nurse implement?

c. provide the client with a private room to decrease stimulation

A nurse is preparing information for a change of shift report. which of the following information should the nurse include in the report. a. input and output for the shift b. blood pressure from the from the previous day c. bone scan scheduled for today d. medication routine from the medication administration record

c. the bone scan is important because the nurse might have to modify the clients care to accommodate leaving the unit

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. which of the following objects can the nurse touch without breaching sterile technique? select all that apply a. a bottle containing a sterile solution b. the edge of the sterile drape at the base of the field. c. the inner wrapping of an item on the sterile field. d. an irrigation syringe on the sterile field e. one gloved hand with the other gloved hand

c. the inner wrapping of an item on the sterile field d. an irrigation syringe on the sterile field e. one sterile gloved hand may touch the other sterile gloved hand because both are sterile

A nurse is caring for client who has had a cough for 3 weeks and is beginning to cough up blood. the client has manifestations of which of the following conditions? a. allergic reaction b. ringworm c. systemic lupus erythematosus d. tuberculosis

d. a cough for 3 weeks and beginning to cough up blood are manifestations of tuberculosis

A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. " i use a damp cloth to clean the outside part of my hearing aids" b. " i clean the ear molds of my hearing aids with rubbing alcohol" c. " i keep the volume of my hearing aids turned up so i can hear better" d. " i take the batteries out of my hearing aids when i take them off at night"

d. to conserve battery power, the client should turn off the hearing aids and remove the batteries when not in use

A nurse manager is discussing the HIPAA privacy rule with a group of newly hired nurses during orientation. which of the following information should the nurse manager include? select all that apply. a. a single electronic records password is provided for nurses on the same unit b. family members should provide a code prior to receiving client health information c. communication of client information can occur at the nurses station d. a client can request a copy of their medical record e. a nurse can photocopy a clients medical record for transfer to another facility

b. family members should provide a code prior to receiving client health information c. communication of client information can occur at the nurses station d. a client can request a copy of their medical record e. a nurse can photocopy a clients medical record for transfer to another facility

A nurse is caring for a client who had a stroke and aphasia. which of the following interventions should the nurse use to promote communication with this client? select all that apply. a. speak at a higher volume to the client b. make sure only one person speaks at a time c. avoid discouraging the client by indicating that they cannot be understood d. allow plenty of time for the client to respond e. use brief sentences with simple words.

b. make sure only one person speaks at a time d. allow plenty of time for the client to respond e. use brief sentences with simple words.

A nurse is caring for a client who states " i have to check with my partner and see if they think i am ready to go home" the nurse replies "how do you feel about going home today?' which clarifying technique is the nurse using to enhance communication with the client?

b. reflecting directs the focus of the conversation back to the client so they can further explore their own feelings

a nurse is evaluating a clients understanding of the use of a sequential compression device. which of the following client statements indicate client understanding? a. "this device will keep me from getting sores on my skin" b. "this device will keep the blood pumping through my leg" c. "with this device on, my leg muscles wont get weak" d. "this device is going to keep my joints in good shape"

b. sequential pressure device promote venous return in the deep veins in the legs and thus help prevent thrombus formation

A charge nurse is reviewing documentation with a group of newly licensed nurses. which of the following legal guidelines should be followed when documenting in a clients record? select all that apply a. cover errors with correction fluid and write in the correct information b. put the date and time on all entries c. document objective data, leaving out opinions d. use a many abbreviations as possible e. wait until the end of the shift to document

b. the day and time confirm the recording of the correct sequence of events c. documentation must be factual, descriptive, and objective without opinions or criticism

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. 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. a fever indicates that the infection is affecting the whole body, and therefore systemic b. malaise indicates that the infection is affecting the whole body e. and increase in pulse and respiratory rate indicates that the infection is affecting the whole body

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? a. prodromal b. incubation c. convalescence d. illness

d. the illness stage is when the client experiences manifestations specific to the infection

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 the client not to perform the valsalva maneuver b. apply elastic stockings c. review laboratory values for total protein levels d. place pillow under the clients knees and lower extremities e. assist the client to change positions often

b. apply elastic stocking e. assist the client to change positions often

a nurse is caring for a school aged child who is sitting in a chair. to facilitate communication, which of the following actions should the nurse take. a. touch the child's arm b. sit at eye level with the child c. stand facing the child d. stand with relaxed posture

b. sit at eye level with the child

A nurse is planning care for a client who is on bed rest. which of the following interventions should the nurse plan to implement a. encourage the client to perform antiembolic exercises every 2 hours b. instruct the client to cough and deep breath every 4 hours c. restrict the clients fluid intake d. reposition the client every 4 hours

a. encourage the client to perform antiembolic exercises every 2 hours to promote venous return and reduce the risk of thrombus formation

A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to further risk of ototoxicity? select all that apply a. furosemide b. ibuprofen c. cimetidine d. simvastatin e. amiodarone

a. furosemide - a loop diuretic, can cause hearing loss as well as blurred vision b. ibuprofen - a nonsteroidal anti-inflammatory agent, can cause hearing loss as well as vision loss

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. which of the following should the nurse include in the teaching. select all that apply. a. medication error b. needlesticks c. conflict with provider or nursing staff d. omission of prescription e. missed specimen collection of a prescribed laboratory test

a. medication error b. needlesticks d. omission of prescription

A nurse is instructing a client, who has an injury of the left lower extremity, about the use if 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 cane 38 cm (15in) 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 with the cane

a. the client should hold the cane on the uninjured side to provide support for the injured left leg b. the client should keep 2 points of support on the ground at all times for stability d. the client should advance the weaker leg first, followed by the stronger leg.

A nurse is caring for a client who has been sitting in a chair for 1 hour. which of the following complications is the greatest risk to the client? a. decreased subcutaneous fat b. muscle atrophy c. pressure injury d. fecal impaction

c. pressure injury