ATI Fundamentals 7

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

Granulation tissue fills the wound during healing because a beefy red tissue called granulation tissue fills the wound and is healed by his secondary intention which occurs usually within 5 to 21 days

A nurse is assessing a client who is postoperative which of the following findings should the nurse identify as an indication that the client is experiencing pain ?

Grimacing because bed size the client self reported pain facial expressions may be the cause

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media which of the following actions should the nurse plan to take ?

Hold the dropper 1 centimeter or .5 inches above the ear canal during administration

A nurse on an oncology unit receives report at the beginning of her shift about four clients who are postoperative which of the following clients should the nurse see first ?

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red blood drainage

A nurse on a telemetry unit is caring for a client who had a myocardial infarction the client states all this equipment is making me nervous which of the following responses should the nurse offer ?

All of this equipment can be frightening as this response is therapeutic

A nurse is assessing a client who reports nausea and vomiting for two days which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit ?

An increased heart rate should indicate to the nurse that the client is experiencing fluid volume deficit other findings could be BUN levels dry mucous membranes and dark yellow urine

A nurse is preparing to administer eye drops for a client who has glaucoma when installing the medication which of the following actions should the nurse take ?

Apply pressure to the puncta after instilling the medication for one to two minutes afterwards to prevent systemic

A nurse is caring for a client who has methicillin resistant staph look caucus heiress infection a dietary assistant asked the nurse what precautions are necessary for entering the clients room with the lunch tray which of the following instructions should the nurse give to the dietary assistant ?

Don gloves when entering the room and use hand sanitizer when you exit because you will be having contact with the client's environment and if you are going to contact with the patient then you must wear a gown

A nurse is caring for a client who has stage two pressure ulcer which of the following wound dressings should the nurse apply to the ulcer ?

Hydro coleoid because dressing to a stage two pressure ulcer is applied to absorb the exit and to produce a moist environment that will facilitate healing while preventing maceration of the surrounding skin

A nurse is caring for a client who requires a chest X ray prior to the client being transported for the procedure which of the following actions should the nurse take first ?

Identify the client using two identifiers should be the very first thing

A nurse is measuring a client's vital signs the client resting radial pulse rate is 55 per minute which of the following actions should the nurse take next?

Measure the client's apical pulse rate Asked to assess and collect more data from the client

A Hospice nurse is reviewing religious practices of a group of clients with the newly licensed nurse which of the following statements by the newly licensed nurse indicates an understanding of the teaching ?

People who practice Judaism stay with the body of the deceased until burial because in the Jewish faith a family member often stays with the body

A nurse is preparing to provide a tracheostomy care for a client which of the following actions should the nurse perform first ?

Perform hand hygiene should be the very first thing you do

A nurse is preparing to provide chest physiotherapy for a client who has a left lower lobe atelectasis which of the following actions should the nurse plan to take ?

Place the client in a tread dillenberg position which is right cited to promote drainage from the clients left lower lobe

A nurse is caring for a client who is receiving a fluid infusion through a peripheral Ivy catheter the nurse notes that the area of the army immediately surrounding the insertion site is red and feels warm which of the following actions should the nurse take ?

Remove the Ivy catheter the clients manifestations suggest phlebitis The nurses stop the infusion and remove the Ivy catheter immediately the nurse should then apply warm compressions to the site

A nurse is assessing a client's incision and observes the drainage to be blood tinged which of the following terms should the nurse use to document this finding ?

Sanguineous as this type of drainage contains large amounts of red blood cells indicating the damaged capillary are allowing the escape of red blood cells from the plasma

A nurse is caring for a client who has methylin resistant Staphylococcus Aris which of the following precautions should the nurse implement ?

Staphylococcus Aris is a contact isolation so the nurse should put on a gown when entering into the room

A nurse is assessing the pH of a client's gastric fluid to confirm placement of an Ng tube in the stomach which of the following pH values should the nurse expect ?

The answer is 2 because a pH of two is within the expected reference range of zero to four for gastric secretions

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home the client expresses concern and concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences which of the following responses should the nurse offer ?

The dietitian will help you choose foods you are used to that also meet your health needs

A nurse is planning to perform passive range of motion exercises for a client which of the following actions should the nurse take?

The nurse must repeat each joint movement five times during each session to maintain the client's joint mobility

A nurse is collecting a urine specimen for 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 ?

The nurse should clamp the tubing below the collection ports to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it into a sterile specimen cup

A nurse is caring for a client who begins having a tonic clonic seizure while sitting in a chair at the bedside which of the following actions should the nurse take first?

The nurse should lower the client to the floor as to apply the safety and risk reduction priority setting framework which poses the greatest safety risk to the client

A nurse is caring for a client who has a prescription for a vest restraint which the following actions should the nurse take ?

Tie the restraint with a quick releasing knots so the nurse should use a quick release knot that can be unit you untied easily in case the client's well-being requires quickly removing the restraints

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client dentures be removed prior to surgery which of the following responses should the nurse provide ?

What worries you about being without your teeth this response is therapeutic and validates the client's feelings of agitation and seeks a reason

A nurse is reviewing a client's laboratory reports the clients ABG levels R pH 7.5 PA CO232 and HCO 3 at 24 the nurse should determine that the client has which of the following acid base balance imbalances ?

respiratory alkalosis because the pH is in the reference range of seven point 3527.45 indicating alkalosis additionally the clients P CO2 is below the expected reference range of 35 to 45 which indicates a respiratory origin hence the nurse should include conclude that the clients elevated pH and decreased pH CO2 indicates respiratory alkalosis