ATI EXAM EXIT

A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following lab results as an indication that the client has fluid volume excess?

A BUN of 8 mg/dl is below the expected reference range of 10 to 20mg/dl. With fluid volume excess, the nurse should expect the client's BUN to be below the expected reference range due to hemodilution.

Assign to AP

A client who has a history of congestive heart failure (stable) A young adult client who is 1 day postoperative following an appendectomy. A client who is 2 days postoperative following a laparoscopic cholecystectomy

A nurse is reviewing the vital signs of four clients. Which of the following findings requires further data collection by the nurse?

A client who has a pulse rate of 110/min The client's heart rate is above the expected range of 60 to 100/min.

Delegating tasks to AP

Accompanying a client who has depression to occupational therapy Checking the position of a client who is in soft wrist restraints Sitting with a client who has alcohol use disorder who last drink was 4 days ago

A nurse is caring for an older adult client who has dysphagia and left-sides weakness following a stroke. Which of the following actions should the nurse take?

Add thickener to fluids.

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

Administer an analgesic 30 min before starting the procedure.

NSAIDS, acetaminophen, ibuprofen

Check CBC, liver functions, ---AST, ALT; kidney functions—BUN, creatinine

Steps Prior to Blood Transfusion

Check and document the client's vital signs is correct. Verify that the blood type and Rh of the packed RBCs are checked by two nurses is correct. Provide the RN with IV tubing that has a filter is correct

Providing hygiene care for a client who is immobilized

Check the bed linens when removing them for personal items Keep the bath water's temp between 110F and 115F Shave the client's hair in the direction of the hair growth

Cholesterol-lowering statins

Cholesterol, HDL, LDL, triglycerides, AST, ALT, CPK

A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury?

Internally rotate the client's hips by using a trochanter roll. The nurse should place trochanter rolls at the proximal end of each of the client's legs to maintain a neutral or internal rotation of the client's hips and to prevent external rotation of the hips, which can cause injury when the client is supine.

right sided heart failure

Jugular vein distention, generalized edema, hepatomegaly, ascites.

Cortisone, Corticosteroids

K+, CBC, serum glucose

Interventions for risk of falls

Keep a night light in room lock the wheels on beds and wheelchairs during transfers Place the bedside table within the client's reach

Chronic kidney disease.

Limit foods high in potassium such as orange juice and bananas.

MRSA

Methicillin-Resistant Staphylococcus Aureus; an infectious disease caused by a pathogen that is resistant to many antibiotics such as penicillin

surgery for bowel obstruction. NG tube in place

Perform leg exercises every 2 hr encourage hourly use of an incentive spirometer while awake document the color, consistency, and amount of nasogastric drainage

Left sided heart failure

SOB, fatigue, crackles in the lungs, pallor, weak pulses, cool extremities

Anticonvulsants

Specific drug serum levels, CBC, AST, ALT, bilirubin, BUN, Creatinine

A nurse identifies an extravasation of vesicant solution (a medication that injures tissues if it leaks from a vein) at a client's peripheral IV catheter's insertion site

Stop the infusion disconnect the catheter from the tubing Attach a 3 - 5 ml syringe to the catheter Aspirate any IV solution from the catheter

Teaching for a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

Take temperature once a day. to identify if a temperature is present due to the client's altered immune system.

Treatment options for psoriasis

Tar preparations corticosteroids UV light

A nurse is providing would care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention?

The nurse should identify a pressure injury and other wounds with edges that are not approximated as healing by secondary intention.

Preparing to administer enteral feeding via NG tube

Verify tube placement Check the residual feeding contents Administer feeding Evaluate client's tolerance to the feeding

Alcohol withdrawal delirium

Visual hallucinations tremors

Antibiotics

WBC count, liver function, renal function, C&S

Risks for postpartum hemorrhage

What is precipitous labor? You may be wondering what, exactly, is precipitous labor? Basically, it's the experience of being in labor and then giving birth less than 3 hours after regular contractions start

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

When ascending stairs, the client should first advance the unaffected leg. (UP to Heaven)

WBC lab values

5,000-10,000

Teaching to a client about advance directives

enteral feeding tubes cardiopulmonary resuscitation durable power of attorney

MMR vaccine

first dose: 12-15 months second dose: 4-6 years

M.I

Nausea Tachycardia Diaphoresis

Depressive disorder group therapy

Decreasing feelings of isolation gaining support and encouragement from other group members

Stage III pressure ulcer

Full-thickness tissue loss with no bone, tendon, or muscle visible

Mild preeclampsia

Perform daily fetal movements counts

Billirubin

greater than 15 is jaundice

Sterile procedure

remove the bottle cap place the bottle cap inside up on clean surface pick up the bottle with the label facing his palm pour 1 to 2ml into a receptacle

Levothyroxine

separate calcium carbonate by 4 hr

Metabolic alkalosis

slow and shallow respirations, dizziness, paresthesias, lightheadedness, cardiac dysrhymias, hyperactive reflexes, hypertonic muscles

Echinacea

stimulates the immune system

air NPH, air regular

withdraw regular, withdraw nph

clear liquid diet

- liquids that leave little residue - examples: clear fruit juices, gelatin, broth

Iron Preparations

CBC, Hgb & Hct

Antihypertensives

Check CBC, electrolytes, BP

Autism Spectrum Disorder

Delayed language development Spins a toy repetitively Ritualistic behavior

Clients with OCD

Difficulty relaxing rule-conscious behavior perfectionist behavior

Care of client after lumbar puncture

Encourage fluid intake monitor the puncture site for a hematoma

Lamotrigine

Withhold and Notify prescriber if skin rash occurs

Adverse effect of clopidogrel

black stools can indicate GI bleeding

A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching?

"We will keep her room cool to help her breathe better"

Multiple skin lesions from a varicella zoster infection.

(HEPA) filter mask

Cushing's syndrome

Buffalo hump purple striations moon face

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

Compare the client's pedal pulses bilaterally every 4 hr. The nurse should compare the pedal pulses bilaterally every 4 hours to check for adequate circulation for a client who has elastic bandages on their lower extremities.

Total parenteral nutrition (TPN)

Contains high concentration of dextrose and minerals, placing the client at riskfor hyperglycemia or fluid and electrolyte imbalance. monitor blood glucose. Complication of TPN: Polyuria

Complications of immobility

Contractures of extremeties Crackles in the lungs pressure ulcers

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit?

Cool extremities Orthostatic hypotension Flat neck

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?

Draining urine from the tubing before ambulation will prevent back flow of urine into the bladder.

Findings to report for croup

Drooling; can indicate epiglottis, which requires immediate attention

A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect?

Dysnea, barrel chest, clubbing of the fingers, shallow respirations.

A nurse is assisting with the care a client immediately following a lumbar puncture. Which of the following actions should the nurse take?

Encourage fluid intake Monitor the puncture site for a hematoma

Crutches

First move right crutch about 10 to 15 inch. move theft foot foward to the level of the left crutch. instruct client to move the left crutch forward move right foot forward

REMOVING PPE

Gloves Goggles Gown Mask

Mental status examination (MSE)

Grooming long-term memory Affect

diverticulitis

High fiber such as chicken or broccoli, high residue diet and avoid small seeds or husks

Acute kidney injury

Hyperkalemia, hypermagnesemia

Sterile field for the insertion of a urinary catheter

Perform hand hygiene Place the sterile package on the work surface Open the outermost flap of the package away from the body Open the side flaps of the package Open the innermost flap of the package Use the inner surface of the package as a sterile field

Inserting large bore catheter into a large vein = Central Line

Place tube in a basin of warm water Measure how far to insert the tube Lubricate the tip of the tube Insert the tube Obtain an x-ray

A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?

Re-establish communication. Left-hemisphere is dominant for language.

Seizure steps

Remain with client and call for help Position the client safely in a lateral or side lying position Check the client from head to toe for injuries once the seizure is over. Orient and reassure client once they are awake.

Steps of staple removal

Remove the wound dressing Clean the skin along the sides of the incision Remove every other staple

A nurse is preparing to transfer a client from an acute care facility to a long-term facility. Which of the following information should the nurse plan to include in the transfer report.

Resolved health conditions. The nurse should report both unresolved and resolved health conditions to promote continuity of care.

PH 7.22 paCo2 68 mm hg base excess -2 PaCo2 78 mm hg O2 sat 80% bicarb 28 meq/L

Respiratory acidosis, ph 7.22 acidotic paCo2 elevated

Infant who has a prescription for home oxygen and pulse oximetry monitoring.

Rotate probe every 3 to 4 hours Notify if SaO2 readings over 95%

Hypoglycemics & Insulin

Serum glucose, finger-stick glucose

A nurse is collecting data from an older client. Which of the following findings should the nurse report to the provider?

The client reports urinary incontinence.

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel *(AP)

The nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgement and is within the AP's range of function.

Postoperative following a laryngectomy

To aid in swallowing food, tip the chin before swallowing Swallow twice after each bite

A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. which of the following actions should the nurse take?

Verify that the suction regular is on.

Urine output

at least 30mL per hour

Helping to manage the client's pain

consider the client's individual expression of pain 0-10 monitor

Hydroxyzine

decreasing anxiety controlling emesis (nausea & vomiting) Reducing the amount of narcotics needed for pain relief. (increases effects of narcotic meds)

Ginger root, garlic, and ginko biloba.

increased effects of oral anticoagulants

Fiber

kidney beans strawberries whole wheat bread

Rule of Nines

left arm: 9% 1/2 of right arm: 4.5% Front torso: 18% back: 18% leg: 18% each perineum: 1%

Capillary refill

less than 2 seconds

Metabolic acidosis

low pH, low HCO3, normal PaCO2 Hyperventilation

diabetes mellitus

monitor for hypotension

History of stroke

observe for symmetry of the client's soft palate and uvula. Pt is at risk for aspiration and choking.