ATI Fundamentals 2 quiz

A nurse is planning care for a client who has a prescription for 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 lab

A. Collect the specimen upon arising in the morning This is because the client is able to more easily cough up secretions that have accumulated during the night.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull 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 4 passes with the suction catheter

A. Pull suction catheter back 1 cm if the client starts coughing This will remove the catheter from the mucosal wall of the trachea prior to suctioning

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest 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 3 feet behind the client during ambulation

A. Use a gait belt during ambulation This keeps the client's center of gravity midline and decreases the risk of fall

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 client's pain level B. Discuss the adverse effects of pain medication with the client C. Obtain vital signs D. Check the client's allergies

A. Use the pain scale to determine the client's pain level This action should be done first, as it is an assessment of the client's current condition.

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 question? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. What do you think caused the onset of your pain?" D. "Changing positions makes your pain worse, right?"

C. "What do you think caused the onset of your pain?" With this answer, the nurse is using an open-ended question that allows the client to respond with a range of information by using more than one or two words. All other options are close-ended questions that generally can be answered by one or two words.

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? A. Auscultate for bowel sounds after each feeding B. Ensure the formula is cold before administering C. Elevate the client's head of bed 45 degrees before the feeding D. Flush the tubing with 15 mL of water after the enteral feeding

C. Elevate the clients head of bed 45 degrees before the feeding This prevents aspiration. 30 mL of water should be flushed through the tube after feedings to ensure patency of the feeding tube. Formula should be at room temp, and auscultation of bowel sounds should be done before the feeding to ensure the client has peristalsis bowel activity

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 D. Hold the enema container 61 cm above the rectum

C. Insert the tip of the tubing 8 cm

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

C. Pinch the NG tube while removing the tube Pinching the tube decreases the risk of aspiration of gastric contents 50 mL of air should be instilled into the tube to clear contents and decrease risk of aspiration. Suction should be disconnected before NG tube removal, as to not damage the gastrointestinal mucosa. The patient should take a deep breath and hold it during the removal of the NG tube to close off the glottis and reduce aspiration risk.

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. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

C. Taut skin around the IV catheter site that is cool to the touch 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 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? A. Abdominal Binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps Montgomery straps are the least restrictive of the choices, and least likely to cause skin irritation. Abdominal binders are good for when the patient is laying in bed, but the dressings tend to slide out from beneath it when the patient ambulates. Tape can cause skin irritation due to frequent removal.

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 clients head backward when swallowing D. Turn on the television

B. Offer teh client tart or sour foods first Patients who have 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 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 client's 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 caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance 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"

B. "I am going to listen to your abdomen" The nurse hsould auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered It is preferable to offer the client a choice of clear liquids, rather than water. Water provides hydration, but no other nutrients.

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 refil time 1.5 seconds

B. Inability of the toddler to cry or speak When the patient 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 preparing to administer an intramuscular injection to a client who is overweight. Whic of the following sites should the nurse select for the injection? A. The lower, medial quadrant of the buttock near the coccyx B. The side hip between the iliac crest and anterior iliac spine C. The tissue of the posterior upper arm D. The lower, inner thigh 4 finger widths above the patella

B. The side hip between the iliac crest and anterior iliac spine This forms the boundaries for ventrogluteal injection.

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 client's weight? A. Calibrate the scales weekly B. Use a different scale each time C. Weigh the client on arising D. Weight the client without clothing

C. Weight the client on arising The client should be weighed on arising each day, after voiding, but before breakfast. They need to be wearing the same garments, and on a carefully calibrated scale

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched B. Pink, shiny tissue with a granular appearance C. Serosanguineous drainage D. A halo of erythema on the surrounding skin

D. A halo of erythema on the surrounding skin Rings of redness might indicate underlying infection.

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 client's perineum

D. Check the client's perineum Think of care order: assessment comes before action. This is the first action that the nurse must take before they can care for a patient.

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse the device of air after emptying

D. Collapse the device of air after emptying Collapsing air is essential to this type of draining device, as the negative pressure provides enough suction to pull fluid exudate into the collection area of the device

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 incl7ude in the teaching? A. The wound edges are well-approximated B. The wound is closed at a later date C. A skin graft is placed over the wound bed D. Granulation tissue fills the wound during healing

D. Granulation tissue fills the wound during healing Beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention that should occur within 5 to 21 days. Open wounds place the client at an increased risk for wound infection.

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

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

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication in the outer third of the lower conjunctival sac B. Apply gentle pressure in teh outer opening of the eye for 2 min. C. Hold the eye dropper 0.5 cm (0.2 in) from the cornea. D. Instruct the client to close eyes tightly after administration

A. Drop the eye medication in the outer third of the lower conjunctival sac. This avoids placing the drops on the cornea and causing damage. Eye dropper should be held 1 to 2 cm from the lower conjunctival sac, to prevent contaimination of the eye dropper and to protect the cornea. The nurse should apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds to keep the medication from running out of the eye

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? A. Change the colostomy bag following breakfast B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor

B. Cleanse the skin around the stoma with warm water Because using soap can leave residue on the skin and cause poor adherence of the pouch adhesive. The pouch should be replaced every 3 to 7 days to avoid skin breakdown around the stoma

A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly insterted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower Abdomen Taping the catheter to the lower abdomen or the upper aspect of the thigh eliminates the penoscrotal angle, and prevents tissue injury. Taping a catheter to the clients lateral or medial thigh can cause discomfort and tissue injury, and taping it to the mid-abdominal region does not allow the urine to flow down into the drainage bag via gravity.

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 5 seconds after goal volume is reached C. Continue to deep breathe between each cycle D. Limit repeat pattern of breathing to 5 breaths

B. Hold breath for 5 seconds after goal volume is reached Patient should hold their 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 patient should breathe normally for short periods of time between each cycle of breaths, to reduce hyperventilation and fatigue. Patient should inhale slowly to reach goal volume, and should repeat the patterns for 10 to 20 breaths every hour while awake.

A nurse is changing the dressings for a client who is 3 days postoperative 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. Sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent exudate

D. Purulent Exudate Sanguineous = Bright red, indicates accumulation of RBCs from the plasma Serous = clear to light yellow, watery, indicates plasma Serosanguineous = plasma mixed with light bloody drainage. Pale yellow to blood-tinged, watery Perulent = thick yellow, green, or brown. Indicates wound sloughing or infection