ati fundamentals

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child infused over 24 hours. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only. Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)

29

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client?

C. Soak the inner cannula of the tracheostomy tube in normal saline The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of normal saline and hydrogen peroxide to loosen secretions. Incorrect Answers: A. Tracheostomy care for a client with a new tracheostomy should be performed using surgical asepsis, or sterile technique. B. The nurse should allow room to insert one to two fingers under the tracheostomy ties so that they are not too restrictive. D. A cut gauze pad should not be used near a tracheostomy tube because the client can aspirate loose threads. The nurse should use a commercially prepared tracheostomy dressing under the tracheostomy tube.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer: A. Pull back the suction catheter by 1 cm (0.5 in) if the client starts coughing the nurse should pull back the suction catheter 1 cm (0.5 in) when the client starts to cough or if resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning. Incorrect Answers: B. The nurse should allow at least 1 minute between suctioning passes to prevent hypoxia and to hyperventilate the client. C. The nurse should hyperventilate the client with 100% oxygen for at least 2 minutes before suctioning to decrease hypoxia. D. The nurse should perform a maximum of 3 passes with the suction catheter because suctioning can cause hypoxia and induce dysrhythmia.

A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, famotidine20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hr. What is the total intake in milliliters that the nurse should document for this client for this 12-hr period? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

125 mL x 12 hr = 1500 mL + 100 mL + (50 mL x 2 = 100 mL) + 250 mL + (30 mL x 6 = 180 mL) = 2130 mL

A nurse is reinforcing teaching with a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?

Correct Answer: A. The client holds the cane on the unaffected side. The nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability. Incorrect Answers: B. The nurse should instruct the client to walk by stepping with the affected leg before the unaffected leg to maintain stability. C. The nurse should instruct the client to place the cane at about 15 cm (6 in) from the side of the foot to provide balance and support. D. The nurse should instruct the client to hold the cane with the elbow slightly flexed to provide support and stability.

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads as follows: "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make?

Correct Answer: B. "I am going to listen to your abdomen." Clients often experience nausea and vomiting after surgery because of delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered. Incorrect Answers: A. This response is nontherapeutic because it indicates that the client's immediate needs are not important. C. When a client is ready to resume a postsurgical diet, it is preferable to offer a choice of clear liquids rather than water. Water provides hydration but no other nutrients. D. This response is nontherapeutic and offers unsolicited advice to the client. Peer Comparison

A nurse is collecting data about a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Correct Answer: B. Auscultation of the arteries for bruits with the bell of the stethoscope the bell of the stethoscope is more effective than the diaphragm in transmitting blowing or swishing sounds such as those from turbulence in blood vessels. Incorrect Answers: A. Palpating the carotid arteries simultaneously can compromise the blood flow to the brain. C. Murmurs are swishing or blowing sounds. Detecting them requires auscultation, not palpation. D. Thrills are palpable purring sensations. Detecting them requires palpation, not auscultation.

A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy?

Correct Answer: B. Screening groups of older adults in nursing care facilities for early influenza manifestations Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe. Incorrect Answers: A. Administering influenza immunizations is an example of primary prevention for people who are healthy but in danger of becoming ill. C. Educating clients about the dangers of influenza is an example of primary prevention for people who are healthy but in danger of becoming ill. D. This is an example of tertiary prevention, which tries to prevent complications and help people recover from an existing illness.

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?

Correct Answer: C. "Keep a diary of the foods your child eats each day." The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack. Incorrect Answers: A. The nurse should inform the parent that children's dietary habits can change from day to day. It is important to feed the child healthy foods and focus on the quality of food rather than the quantity of food during this time. B. The nurse should inform the client that calorie and fluid requirements decrease slightly in a preschool-aged child. The nurse should not promote an increase of calories and water in the child's diet. D. The nurse should inform the parent that excessive consumption of sweetened beverages, including fruit juices, can be associated with adverse health effects such as dental caries, obesity, and metabolic syndrome.

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?

Correct Answer: C. Exert pressure on the bony prominences when holding the eyelids open the nurse should hold the client's upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye. Incorrect Answers: A. The nurse should hold the irrigator 2.5 cm (1 in) above the eye to keep the irrigator from touching the eye and to prevent the solution from damaging the eye tissue. B. The nurse should direct the irrigation solution onto the lower conjunctival sac to avoid injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. D. The nurse should direct the irrigation solution from the inner canthus to the outer canthus of the eye to avoid injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.

A nurse is instilling antibiotic ear drops for a client who has an ear infection. Which of the following actions should the nurse take?

Correct Answer: C. Have the client lie on the side opposite the infected ear This position allows optimal access for instilling the drops. A sitting position with the client's head leaning toward the unaffected ear is also acceptable. Incorrect Answers: A. The nurse should warm the medication before instillation to avoid nerve stimulation and discomfort. B. The nurse should wear clean gloves during the instillation. D. For adults, the nurse should pull the pinna upward to straighten the ear canal. For children younger than 3 years, pulling the pinna down and back will straighten the canal.

A nurse is caring for a client who is dehydrated. Which of the following laboratory values should the nurse expect for this client?

Correct Answer: C. Hct 55% An elevated hematocrit indicates dehydration. Other manifestations include a weak pulse, tachycardia, hypotension, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output. Incorrect Answers: A. This BUN falls within the expected reference range; therefore, it does not indicate dehydration. B. This capillary refill time is within the expected reference range. With dehydration, it tends to be longer. D. This low urine specific gravity indicates over-hydration, not dehydration.

A nurse on a same-day procedure unit is caring for several clients undergoing different types of procedures. A client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)?

Correct Answer: C. Hearing aids A client who has hearing aids can undergo MRI because the hearing aids can be removed. The powerful magnetic field of the MRI system could damage the hearing aids, so they should be removed prior to the imaging. Incorrect Answers: A. A coronary artery stent is a contraindication for undergoing MRI. The powerful magnetic field of the MRI system could pull on the metal stent and dislodge it. B. An aneurysm clip is a contraindication for undergoing MRI. The powerful magnetic field of the MRI system could pull on the metal clip and dislodge it. D. An automated internal defibrillator is a contraindication for undergoing MRI. The powerful magnetic field of the MRI system could damage the defibrillator and cause it to malfunction.

A nurse in a provider's office is collecting data from an older adult client. Which of the following findings should the nurse expect?

Correct Answer: C. Increased cerumen with aging, the buildup of cerumen (ear wax) increases, and there is a loss of acuity for high-frequency sounds. Incorrect Answers: A. Older adults have a higher systolic blood pressure, narrowing of blood-vessel lumens, and weaker peripheral circulation. B. Muscle mass and strength decrease with aging, accompanied by increases in fatty tissue and degenerative joint changes. D. Pupils tend to become smaller with aging, and accommodation to near and far vision declines.

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?

Correct Answer: C. 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 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa. Incorrect Answers: A. The nurse should lubricate 5 to 8 cm (2 to 3 in) of the tip of the rectal tube before inserting to decrease the risk of irritation or injury to the mucosa. B. The nurse should position the client on the left side in the Sims' position to allow the solution to flow downward into the sigmoid colon and rectum and to promote retention of the enema. D. The nurse should hold the enema container a maximum of 45 cm (18 in) above the rectum to prevent painful distention of the colon.

A nurse is collecting data about a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

Correct Answer: C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities the nurse does not evaluate the peripheral pulses routinely when measuring vital signs. Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to an extremity or during a comprehensive physical examination. A full evaluation of peripheral pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and dorsalis pedal pulses. Documentation of peripheral pulse evaluation should include the strength of pulsations as well as their equality and symmetry in all 4 extremities. Incorrect Answers: A. D. The nurse measures the client's pulse rate at the apical and radial sites. Determination of rate is not a component of peripheral pulse evaluation. B. The nurse does not need to specify details about all pulse points, but the evaluation should include the upper portion of the lower extremities.

A nurse is reinforcing teaching about bladder retraining for a client who has urinary incontinence. Which of the following instructions should the nurse include?

Correct Answer: C. Try to block the urge to urinate until the next scheduled time When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, the client should try to practice slow, deep breathing to help reduce the urge. The client can also try 5 or 6 strong and quick pelvic muscle exercises. Incorrect Answers: A. The client should wake up every 4 hours to urinate during the night; for most clients, this will occur just once during sleeping hours. B. Citrus juices can irritate the bladder, increasing the likelihood of incontinence episodes. D. The client should reduce fluid intake for 4 hours before bedtime; however, the client should drink plenty of fluids during other waking hours and avoid drinking large amounts at once.

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take?

Correct Answer: D Circle the area of the injection with a pen Circling the area using a pen ensures the nurse will examine the correct site when reading the test 48 to 72 hours later. Incorrect Answers: A. A 25- to 27-gauge needle is used for intradermal injections. B. The needle should be inserted at an angle of 10º to 15º. This ensures the solution will be injected into the intradermal area. C. The area should not be massaged because this can spread the injection into the tissue or out through the insertion site

A nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Correct Answer: D. Ceasing to compare personal identity with those of others Middle adults usually feel more comfortable with themselves and cease to make comparisons with others. Incorrect Answers: A. Young adults should focus on learning to manage a home. B. Young adults should focus on establishing themselves in the adult world. C. Young adults should focus on forming new friendships.

A nurse is reinforcing teaching for a client about managing her tracheostomy care. Which of the following instructions should the nurse include?

Correct Answer: D. Wear a tracheostomy cover when outdoors A tracheostomy cover protects the client's airway from dust, chilly air, and any other airborne particles that could otherwise enter the airway. Incorrect Answers: A. Within the home environment, clean gloves are sufficient. B. Within the home environment, tap water is sufficient for rinsing the inner cannula. C. At home, the client should perform tracheostomy care daily.

A nurse is collecting data from a client at admission. The client reports a latex allergy. Which of the following precautions should the nurse take when caring for this client?

Correct Answer: D. Wrap IV tubing with tape Although latex-free products are widely available, the nurse might encounter some products that contain latex such as IV tubing and monitoring cords and devices. The nurse should create a barrier between these items and the client (e.g., by wrapping them in non-latex tape or stockinette). Incorrect Answers: A. The nurse should not snap gloves on and off because these actions disperse any allergens in the gloves into the environment. B. Latex gloves that have "hypoallergenic" on the label still contain latex. Powder and cornstarch are dangerous because the latex allergen attaches to them and becomes an airborne carrier, enabling easy inhalation. The nurse should wear non-latex gloves such as nitrile gloves. C. Ethylene oxide can cause an allergic reaction in latex-sensitive clients. The nurse should rinse any items that had this type of sterilization with sterile water before use.