ATI FUNDAMENTALS A
a nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. which of the following tasks should the nurse assign to an assistive personnel? (Select all that apply) A. assist the client with a partial bed bath B. measure the client's BP after the nurse admins an antiHTN med C. test the client's swallowing ability by providing thickened liquids D. use a communication board to ask what the client wants for lunch E. irrigate the client's indwelling urinary catheter
A, B, D Rationales: -assisting a client with a bed bath places minimal risk to the client and is within the AP's range of function -measuring a client's VO poses minimal risk to the client and is within the AP's range of function -assessing the client's swallowing ability places the client at risk for aspiration and is not within the AP's range of function. nurse perform tasks that require assessment -using a communication board poses minimal risk to the client and is within the AP's range of function -irrigating the client's indwelling urinary catheter is an invasive procedure and is not within the AP's range of function
A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A. pad the client's wrist before applying the restraints B. evaluate the client's circulation q8h after application C. remove the restraints q4h to evaluate the client's status D. secure the restraint ties to the bed's side rails
A. pad the client's wrist before applying the restraints (rationale: the use of restraints w/o padding can abrade the client's skin, resulting in client injury) Other rationales: B>the nurse should evaluate the client's circulation, ROM, VS, and overall status every 15 min after initial application of restraints C> the nurse should remove the restraints at least q2h to reposition the client and assess needs for hygiene and toileting D> the should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury
a nurse is administering an otic med to an older adult. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A. press gently on the tragus of the client's ear B. place a small piece of cotton deep into the client's ear canal C. move the client's auricle down and back toward her head D. tilt the client's head backward for 5 min
A. press gently on the tragus of the client's ear (Rationale: pressing gently on the tragus of the ear will help the med get into the inner ear) Other Rationales: B> inserting a piece of cotton into the meatus of the canal could damage the ear. if cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward C> for an adult client, the nurse should move the auricle upward and backward or upward and outward to straighten the ear canal D> the client should lie on one side with the ear that received the instillation facing upward for 2-5 min
a nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the client? A. use a bed exit alarm system B. raise four side rails while the client is in bed C. apply one soft wrist restraint D. dim the lights in the client's room
A. use a bed exit alarm system (Rationale: the nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for ask. the client'd condition places them at risk for falling, therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and require assistance) other rationales: B> raising four side rails when the client is in bed is a form of restraint and increase the risk for falls and injury C> applying one soft wrist restraint is a physical restraint requiring a prescription. other forms of distraction or interventions to maintain client safety should be attempted for clients who have dementia D> dimming the lights in the room for a client who has dementia can reduce visibility and increase risk of injury
a nurse is caring for a client who has a terminal illness and is at the end of life. the nurse should recognize that which of the following statements by the client's partner indicates effective coping? A." i am not worried bc i still have hope that he will be okay." B. " i am relying on support from out family during this time." C." we can plan our family reunion once he recovers and comes home." D. " we don't see any reason to start discussing funeral arrangements right now."
B. " i am relying on support from our family during this time." (rationale: this statement indicates effective coping bc the partner is relying on others in the family for support during a time of crisis other rationales: A> this statement reflects false hope and possible denial of the terminal nature of the client's illness. denial involves the blocking of painful thoughts or feelings that induce anxiety C> this statement reflects false hope and possibly denial of the terminal nature of the client's illness. D> this statement reflects false hope and possible denial of the terminal nature of the client's illness. it also indicates the partner's potential inability or unwillingness to address unpleasant or challenging issues related to the client's death
a nurse is talking with the partner of a client who has dementia. the client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. the nurse should identify that the partner is experiencing which of the following types of role-performance stress? A. role ambiguity B. sick role C. role overload D. role conflict
C. role overload (rationale: the partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage other rationales: A> role ambiguity occurs when people are unclear about the expectations of their role in a given situation B> sick role refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver D> role conflict develops when a person must assume multiple roles that have opposing expectations
a nurse is providing discharge instructions to a client who will be using a walker. which of the following client statements indicates an understanding of the teaching? A. "I can place an extension cord across my living room to plug in my television" B. " I will hire someone to trim the tree that hangs low over the stairs of my front porch" C. "I will place my alarm clock on my bedroom dresser across the room" D. "I will replace the old throw rug in my kitchen with a new one"
B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" (Rationale: clearing stairs of any objects that could cause the client to trip or require them to bend over while walking will decrease the risk for falls) other rationales: A> extension cords should be securely flattened on the floor and should be run along the edge of the wall, if possible, to avoid the risk for tripping C> frequently used items like an alarm clock, glasses, or disposable tissues should be placed within reach, such as on the client's night stand. this helps to prevent the client from needing to get up and potentially falling in the night D> using throw rugs increases the client's risk for falls bc they create a tripping or slipping hazard for the client
a nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. which of the following precautions should the nurse plan for this client? A. make sure the client's room has at least six air exchanges per hour B. make sure the client wear a mask when outside her room if there is a construction in the area C. place the client in a private room with negative air flow D. wear an N95 respirator when giving the client direct care
B. make sure the client wears a mask when outside her room if there is construction in the area (Rationale: an allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. the client will need protection from breathing in any pathogens in the environment other rationales: A> a protective environment requires at least 12 air exchanges per hour C> the nurse should place the client in a private room that provides positive pressure airflow D> the nurse should wear an N95 respirator mask when caring for clients who require airborne precautions, not a protective environment
a nurse is planning to insert a peripheral IV catheter for an older adult client. which of the following actions should the nurse plan to take? A. insert the catheter at a 45 degree angle B. place the client's arm in a dependent position C. shave excess hair from the insertion site D. initiate IV therapy in the veins of the hand
B. place the client's arm in a dependent position (rationale: the nurse should place the client's arm in a dependent position bc the veins will dilate due to gravity) other rationales: A> generally, the nurse should insert the catheter at a 10-30 degree angle, however, for an older adult client an angle of 10-15 degrees is preferable bc veins are closer to the skin surface as aging diminishes SC tissue C> the nurse should clip excess hair from the IV insertion site and avoid shaving the area bc shaving can cause breaks and cuts in the skin that could place the client at risk for infection D> the nurse should avoid using the fragile veins of an older adult's hands bc the loss of SC tissue can allow those veins to roll away from the needle. also, having an IV catheter in the client's hang can interfere with the client's performance of activities of daily living and can diminish an older adult's sense of independence and mobility
a nurse is assessing a client who has required bed rest for the past month. which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. bladder distention B. decreased BP C. calf swelling D. diminished bowel sounds
C. calf swelling (Rationale: swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility) Other Rationales: A> urinary retention, which causes bladder distention, is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscle B> a client who requires bed rest can develop postural hypotension, which is a drop in BP when the client moves from a lying to a siting position. the nurse should also assess the client for an increase in pulse rate and dizziness D> a decrease in bowel sounds reflects slowed peristalsis. constipation is a common complication of immobility
a nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. verify the client's name on their ID bracelet with the MAR B. call the pharmacy to determine whether the client's meds are available C. compare the client's home meds with the provider's prescriptions D. place the client's home medication bottles in a secure place
C. compare the client's home meds with the provider's prescriptions (Rationale: the nurse should compare the client's home meds with the provider's prescriptions when performing medication reconciliation) Other Rationales: A> the nurse should verify the client's name on their ID bracelet when admin meds, however, this action is not a part of performing med reconciliation B> the nurse should call the pharmacy if the client's med are not available to admin at the appropriate time, however, this action isn't a part of med reconciliation D> the nurse should place the client's home meds in a secure location to ensure safe handling of prescribed meds, however, this action is not a part of med reconciliation
a nurse is administering 1 L of 0.9% sodium chloride to a client who is post and has fluid volume deficit. which of the following changes should the nurse identify as an indication that the treatment was successful? A. increase in hematocrit B. increase in resp rate C. decrease in heart rate D. decrease in cap refill time
C. decrease in heart rate (rationale: fluid volume deficit causes tachycardia. with correction of the imbalance, the heart rate should return to the expected range) other rationales: A> fluid volume deficit causes and increase in hematocrit level due to depletions of extracellular fluid. with correction, the hematocrit level should decrease B> fluid volume deficit causes an increase in resp rate. with correction the resp rate should return to expected range D> fluid volume deficit slows cap refill, with correction cap refill time should return to expected range
a nurse is using an open irrigation technique to irrigate a client's indwelling catheter. which of the following actions should the nurse take? A. place the client in a side-lying position B. instill 15 mL of irrigation fluid into the catheter with each flush C. subtract the amt of irrigant from the client's urine output D. perform the irrigation using a 20-mL syringe
C. subtract the amt of irrigant from the client's urine output (Rationale: the nurse should calculate the fluid used for irrigant and subtract it from the client's total urinary output) other rationales: A> for a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter B> open irrigation technique requires instilling 30-40 mL of irrigation fluid D. the nurse should use a 30 to 50 mL syringe to perform open irrigation
a home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. the client has recently developed diarrhea. which of the following should the nurse identify as a possible cause of the diarrhea? A. the client is receiving formula at room temp B. the feedings infuse at a slow, continuous drip over 8 hr each night C. the client's caregiver washes the feeding bag with warm water once every 24 hours D. the client's caregiver flushes the tubing with water before and after administering meds
C. the client's caregiver washes the feeding bad with warm water once every 24 hr (rationale: feeding bags should be washed out after each feeding and replaces with a new feeding bag every 24 hr to prevent bacterial contamination. the nurse should reinforce this info with the client's caregiver to avoid future contamination other rationales: A> cold formula can cause gastric cramping, therefore, room temp formula is appropriate and is likely not the cause of the client's diarrhea B> diarrhea is more likely to develop with rapid instillation of enteral formula D> it is correct to flush tubing with water before and after admin meds to prevent clogging of the tube
a nurse is planning strategies to manage time effectively for client care. which of the following strategies should the nurse implement? A. continue client care tasks when caring for multiple clients B. wait until the end of the shift to document client care C. use the planning step of the nursing process to prioritize client care delivery D. allow for interruptions in tasks to discuss client care issues with colleagues
C. use the planning step of the nursing process to prioritize client care delivery (rationale: setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. the priority to do list is an efficient tool for optimal time management other rationales: A> the nurse should complete the tasks for one client before beginning the tasks for another client to reduce fragmentation of care and avoid potential errors B> documentation should be completed in a timely manner after care is performed to reduce errors and unsafe client care. performing documentation at the end of the shift is not effective time management D> an important principle of time management is controlling interruptions to reduce errors and loss of care delivery time
a nurse is caring for a client who is postop and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's VS every 15 min and to report back in 1 hr. which of the following actions should the nurse take next? A. document the provider's statement in the medical record B. complete an incident report C. consult the facility's risk manager D. notify the nursing manager
D. notify the nursing manager (rationale: the greatest risk to the client is not receiving timely interventions for a deterioration in physiologic status, therefore the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care other rationales: A> the nurse should document the provider's directions in the medical record for later reference, however, another action is the nurse's priority B> the nurse should prepare an incident report, detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action if the nurse's priority C> the nurse should discuss the situation with the facility's risk management to help determine the need for preventive actions, however, another action is the nurse's priority