ATI Fundamentals 2 Quiz

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? A: use the pain scale to determine the clients pain level B: discuss the adverse effects of pain medication with the client C: obtain the clients vital signs D: check the clients allergies

Use the pain scale to determine the client's pain level. -The first action the nurse should take is to begin pain management by asking the client to describe her pain and to rate it on the pain scale.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The clients surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A: apply a fecal collection system B: apply a barrier cream C: cleanse and dry the area D: check the clients perineum

Check the client's perineum -before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client status, she must first collect adequate data from the client.

A nurse is collecting a urine specimen for a culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? a: place and oxygen mask on the client b: check the client's pulse c: determine whether the client is able to breathe. d: wrap arms around the client from behind.

Determine whether the client is able to breathe. -If the client is unable to move air in or out, severe airway obstruction is present. As long there is good air exchange and she can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition.

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? a: encourage the client to drink fluids before swallowing food b: offer the client tart or sour foods first c: tilt the client's head backward when swallowing d: turn on the television

Offer the client tart or sour foods first. -The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A: instruct the client to defecate into the toilet bowl B: transfer the specimen to a sterile container C: refrigerate the collected specimen D: place the stool specimen collection container in a biohazard bag

Place the stool specimen collection container in a biohazard bag.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the clients weight? A : calibrate the scales weekly B: use a different scale each time C: weigh the client on arising D: weigh the client without clothing

Weigh the client on arising -The client should be weighed on arising each day, after avoiding, and before breakfast. An accurate weight requires the client to be weighed wearing the same garments, and on the same carefully calibrated scale

A nurse is planning care for a client who has a prescription for a collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A: collect the specimen upon arising in the morning B: force fluids during the day and collect the specimen in the evening C: collect the specimen after antibiotics have been started D: collect 2 ML of sputum before sending the specimen to the laboratory

Collect the specimen upon arising in the morning -The nurse should plan to collect the sputum specimen when the client arises in the morning because the client is able to more easily cough up the secretions that have accumulated during the night. Generally the deepest specimens are obtained early in the morning.

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?

The side hip between the iliac crest and anterior iliac spine

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? a: Roll the stocking partially down if too long b: Remove the stocking once per day. c: Bunch and pull the stocking half way up the calf. d: Turn the stocking inside out up to the heel before applying.

Turn the stocking inside out up to the heel before applying. -The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following intervention should the nurse include in the plan of care? A: renew the prescription for the use of restraints within 24 hours B: secure the restraint with the buckle side next to the clients skin C: ensure 4 fingers can be inserted under the secured restraint D: remove the restraint every 3 hours

Renew the prescription for the use of restraints within 24 hours -The nurse should plan to renew the prescription for the restraints within 24 hours, and only after the provider has a valuated the client.

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A: start chest compressions B: provide breaths with a manual resuscitation bag C: administer oxygen D: establish an airway

Start chest compressions. give priority to the factor or situation posing the greatest safety risk.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the client's head of bed 45 degrees before the feeding. Rationale: the nurse should do this to prevent aspiration

A nurse is planning care of a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. -The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe his own exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. Oxygen is a gas which can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.

A nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past two hours. Which of the following actions should the nurse take first? A : check to determine if the catheter tubing is kinked B: palpate the bladder C: obtain a prescription to irrigate the catheter with 0.9% sodium chloride D: encourage the client to drink more fluids

Check to determine if the catheter tubing is kinked -The first action should be to inspect the tubing carefully, straightening out any kinks, and making certain that there are no dependent loops. A common reason a tube is not draining is that there is a kink in the tubing or that the client is lying on it.

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A: lateral thigh B: lower abdomen C: mid abdominal region D: medial thigh

Lower abdomen -The nurse should secure the catheter tubing to the clients upper thigh or lower abdomen by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra.

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open

A nurse is preparing to administer eyedrops to a client following surgery. Which of the following actions should the nurse take when installing the eyedrops? A : drop the eye medication into the lower conjunctival sac B: apply gentle pressure in the outer opening of the eye for two minutes C: hold the eyedropper 0.5 cm from the cornea D: instruct the client to close eyes tightly after administration

Drop the eye medication into the lower conjunctival sac -The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.

A nurse is preparing to assist with ambulation of an older adult client who was on bedrest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A: use a gait belt during ambulation B: ensure the client is wearing socks before ambulating C: instruct the client to sit on the edge of the bed for 15 seconds before ambulating D: walk 2 feet behind the client during ambulation

Use a gait belt during ambulation -The nurse shared use a gait belt to keep the client center of gravity midline and decrease the risk of a fall. The nurse should ensure the client is wearing nonskid shoes or slippers when ambulating. The nurse should encourage the client to dangle her legs on the edge of the bed for 60 seconds before attempting to ambulate.

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water

A nurse is caring for a client who had a mastectomy and has a self section drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?

Collapse the device of air after emptying

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the clients diet? A: vitamin C and zinc B: vitamin D C: vitamin K and iron D: calcium

A. Vitamin C and zinc The client's body needs both vitamin C and zinc to help fight infection. The client should receive a multivitamin, and a mineral supplement of both. Vitamin E is also needed to aid skin healing

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take?

Don clean gloves to remove the old dressing

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?

Granulation tissue fills the wound during healing

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? A colon applies sterile gloves to open catheter package B: wipes the labia minora in and Antero posterior direction C: spreads the labia with the dominant hand D: uses one cotton ball to wipe the right and the left labia majora

Wipes the labia minora in an Antero posterior direction

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A: provide the client with a glass of water B: assist the client to a sitting position C: explain the procedure to the client D: measure the length of tubing to be inserted

Explain the procedure to the client -informing the client about the procedure reduces fear and assess in gaining the clients cooperation, which is important for NG tube insertion and is the priority nursing intervention

A nurse is caring for a toddler at a well child visit when the mother calls to the nurse, "help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A : flushing of the skin B: inability of the toddler to cry or speak C: presence of nausea and mild emesis D: capillary refill time 1.5 seconds

Inability of the toddler to cry or speak -when the client has no sound passing through the vocal cords, the nurse should identify a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea

A nurse is caring for a client who has a hearing impairment. Which of the following intervention should the nurse use when speaking with the client? A: speak directly into the clients impaired ear B: exaggerates lip movements C: speak loudly D: face the client when speaking

Face the client when speaking -The nurse should always directly face the client who has a hearing impairment and stand or sit at the same level to maximize communication. Many clients who are hearing impaired combine lip reading with their residual hearing when communicating.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? A : exhale slowly to reach goal volume B: hold breath for five seconds after goal volume is reached C: continue to deep breathe between each cycle D: limit repeat pattern of breathing to 5 breaths

Hold breath for 5 seconds after goal volume is reached -The nurse should instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia. The client should breathe normally for short periods of time between each cycle of breaths. Instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake.

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her post operative diet prescription reads: clear liquids; advanced diet as tolerated. Which of the following responses should the nurse make? A: lunch trays should be here within the hour B: I am going to listen to your abdomen C: I'll get you some water to drink D: I would wait a bit, or you could feel sick

I am going to listen to your abdomen -A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the clients abdomen to determine the presence of bowel sounds before clear liquids can be administered

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A: lubricate up to 3.2 cm of the tip of the rectal tube B: position the client on his right side C: insert the tip of the tubing 8 cm (3.1 in) D: hold the enema container 61 cm (24 in) above the rectum

Insert the tip of the tubing 8 cm (3.1 in) -The nurse should insert the tip of the tubing 7 to 10 cm (3-4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa. The client should be on their left side in the Sims position to allow the solution to flow downward into the sigmoid: and rectum and promote retention of the enema.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A: maintain suction while removing the NG tube B: instill 100 ML of air into the NG tube before removal C: pinch the NG tube while removing the tube D: instruct the client to breathe in and out during the removal of the NG tube

Pinch the NG tube while removing the tube -The nurse should pinch the NG tube while removing to decrease the risk of aspiration of any gastric contents. The nurse should instill 50 ML of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration. The nurse should instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis and decrease the risk of aspiration.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A: pulse suction catheter back 1 cm if the client starts coughing B: allow 30 seconds between suctioning passes C: hyperventilate the client with 50% oxygen for 30 seconds D: perform a maximum of four passes with the suction catheter

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing -this will remove the catheter from the mucosal wall of the trachea prior to suctioning. The nurse should allow at least one minute between sectioning passes to prevent hypoxia and to hyperventilate the client. The nurse should hyperventilate the client with 100% oxygen for at least two minutes before suctioning to decrease hypoxia. The nurse should perform a maximum of three passes with the suction catheter because sectioning can cause hypoxia and induce dysrhythmia.

A nurse is changing the dressings for a client who is 3 days post operative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A: sanguinous exudate B: serious exudate C: serosanguinous exudate D: purulent exudate

Purulent exudate -thick yellow, green and brown drainage usually indicates wound sloughing or infection.

A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A: redness at the IV catheter entry site B: a palpable cord is felt along the vein used for the infusion C: taught skin around the IV catheter site that is cool to the touch D: bleeding at the IV insertion site

Taut skin around the IV catheter site that is cool to the touch -The client who has taut skin around the IV catheter site that is cool to the touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress, or a cold compress according to the type of infiltration.

A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

"What do you think caused the onset of your pain?" -The nurse is using an open ended question that allows the client to respond with a wide range of information by using more than one or two words.

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? A: place the soiled linens on the chair while making the bed B: hold the linens away from the body and clothing C: placed the linens on the floor until able to place it in a linen bag D: shake the clean linens to unfold

Hold the linens away from the body and clothing -The linen should be held away from the body and clothing to prevent soiling or the transfer of micro organisms. The micro organisms present on the nurses clothing can expose other clients to micro organisms.