ATI FUNDAMENTALS review
instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitits
A nurse in an acute-care facility is assisting with planning care for a client who is alert but is temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse suggest to prevent a complication of immobility?
faint pedal pulses
a nurse is collecting data on a client. The nurse should recognize that which of the following findings places the client at risk for impaired skin integrity?
check capillary refill before applying an ice pack to the affected area
a nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?
Sit w/ your back supported keep your knees at hip level use an ergonomically designed computer keyboard
a nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include?
Sit on the toilet 30 minutes after eating a meal
a nurse is reinforcing teaching w/ an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
Antagonistic
a nurse is reinforcing teaching with a client who is postop following a knee arthroplasty about the muscles he will nee d to strengthen in physical therapy. Which of the following muscle groups are responsible for movement at the knee joint?
Antagonisitc
a nurse is reinforcing teaching with a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups are responsible for movement at the knee joint?
F = (C x 9/5) +32
FORMULA F-C
Suction equipment
a nurse ona. medical unit is caring for a client who has a seizure disorder. Which of the following items is the nurse's priorty to keep near the client at all times?
sensorimotor stage
birth-2 years ex- playing in sand
Cranial nerve XII hypoglossal
innervates the tongue, by observing a range of tongue movements
Vesicular
lung sounds over major part of lungs
TENS unit
modulates the transmission of pain impulse
antigravity muscle group
stabalizing knee joint
second intention expected findings
tenderness to touch, pink, shy tissue with a grainy appearance - granulation tissue, serosanguineous drainage
Leukoplakia
thick white patches found in mucosa of mouth
rooting reflex
touching the newborns cheek makes the head turn ot the side where the touch occurs. disappears after 4 months
Cranial nerve VIII vestibulocochlear
using Rinne and Weber tests, ask client if they can hear whisper
tertiary intention
using sutures to close an open would at a later date after the wound drains and starts to heal placing skin graft
Respiratory alkalosis
ABG's, high Ph. PaCO2 below expected range
diuresis
AKA polyuria (excessive urination)
intimacy vs. isolation
Erickson's stage for young adults - finding partner, adjust to living w/ partner, making plans to start family, raising/nurturing children, managing a home, establish an affiliation w/ a social group, civic responsibility
infection acquired from a diagnostic procedure
Iatrogenic HAIs directly result from diagnostic or tehrapeutic procedures
formal operation period
11- adulthood self-conciousness
formal operational reasoning
11-up describing interpersonal relationship- example
confirm unresponsiness
1st CPR step
decreased bowel sounds
a nurse is collecting data from a client whose potassium level is 2.8 meq/L which of the following findings should the nurse expect?
increased cerumen
a nurse is in a provider's office is collecting data from an older adult client. Which of the following findings should the nurse expect?
PIaget's preoperational period
2-7 yrs old animism- child attributes lifelike feeling and thoughts to inanimate objects play therapy- dolls, , toys
Babinski
reflex - newborns toes fan out when the nurse strokes the sole of foot
The basal metabolic rate could decrease
A nurse is reinforcing teaching about nutrition w/ a middle adult client who has a sedentary job. Which of the following factors should the nurse consider?
Depressed deep tendon reflexes, nausea, vomiting, bone pain, lethargy, weakness
Calcium level EXCESS expected findings
apply pressure to the bridge of the nose after instillation of the medication - to prevent systemic absorption
a nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?
Circle the area of the injection with a pen
a nurse is preparing to admnister a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take?
Leukopenia
decrease of WBCs
Tell me more about how you feel about dying
while in a hospital, a client who has a terminal illness tells the nurse, "I can't believe i'm dying. there are a lot of bad people in the world who are healthy, and here I am dying!" which of the following responses should the nurse offer?
place soiled linen in a single linen bag
a nurse is leading an education session about disposing of biohazards materials. Which of the following instructions should the nurse include in the teaching?
Ceasing to compare personal identity with those of others
A nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward which of the following developmental tassks
4mm identation
2+ edema
preoperational thinking
2-7 playign dress up- pretending
6 mm indentation
3+ edema
head lagging stops between
4-6 months
concrete operational period
7-11 seriation, reversibility
Hyper oxygenate the client before suctioning
A nurse is caring fo ra client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take?
Monitor the client at least once every hour
A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?
Feedback provided
A nurse is communicating w/ a group of clients about what to expect during the POp phase of a total hip arthroplasty. Which of the following elements of hte communication process should the nurse identify as a sign of effective communication
The client has slightly flexed elbows when ambulating w/ the crutches
A nurse is evaluating a clien'ts use of crutches. The nurese should identify that which of the following actions by the client indicates safe usage of teis equpiment?
Sitting
A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in whicho f the following positions for evaluation?
place the bladder of the cuff over the posterior aspect of the thigh
A nurse is obtaining the blood pressure in a client's lower extremity. Whcihof the following actions should the nurse take?
I will make sure to replace my pouch around 4 hours after I eat
A nurse is reinforcing teaching w/ a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
The involvement of the client in planning the change
A nurse is reinforcing teaching with a client who has heart failure about reducing his daily intake of sodium. Which of hte following factors is the most important in determining the clien'ts ability to learn new dietary habits?
Discuss the meaning of a common proverb
a nurse is performing a mental-status examination for a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly?
Warm the irrigating solution to 37 C to minimize discomfort and vascular constriction
a nurse is preparing to irrigate a clien'ts wound. which ofthe following actions should the nurse take?
Taut skin around the IV catheter site that is cool to the touch
a nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which ofh the following findings should the nurse identify as infiltration of hte IV infusion site?
Cleanse the wound with 0.9% sodium chloride irrigation
a nurse is collecting a specimen for culture from a clien'ts infected wound. Which of the following actions should the nurse take?
clamp the tubing below the collection port
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?
Below the medial malleoulus
a nurse is collecting baseline data of a clien'ts peripheral vascular system. in which of the following locations should the nurse palpate the posterior tibial pulse?
Albumin
a nurse caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. a laboratory result w/in the expected reference range for which of the following substances is an indication that the client has adequate protein uptake and synthesis?
Physical examination
a nurse employs a through , systematic method for obtaining objective data about the client. Which of the following method should the nurse use to collect information?
pocketing food
a nurse in a long-term care facility is feeding a client. Which of the following observations should the nurse identify as an indication that the client requires an evaluation for dysphagia?
Have another nurse witness the disposal of the medication
a nurse is administering a controlled substance to a client who is postop. The IM dosage requires the nurse to use only part of the amount of the medication in the vial. Which of the following actions should the nurse take?
I'll wash my hands before I remove the old dressing and again before putting on the new one
a nurse is assisting with preparing a client for discharge and providng instructions about performing dressing changes at home. WHich of the ofllowing statements indicates that the client understands medical asepssis?
monitor the client's blood glucose level
a nurse is carign for a client who is receiving continous enteral feedings. WHich of the following actions should the nurse take?
clean the drain site from the center outward
a nurse is caring fo ra client who requires a dressing change. which of the following actions should the nurse take?
collapse air from the device before emptying
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 fo the device?
collapse air from the device after emptying
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?
elevate the client's head of bed 45 degrees before the feeding
a nurse is caring for a client who has a NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
Hyperglycemia cortisol-increase
a nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which ofthe following to occur?
starch
a nurse is caring for a client who has xerostomia with a lack of saliva. the nurse should identify that which of teh following nutrients will be affected by teh lack of salivary amylase?
HCT 55%
a nurse is caring for a client who is dehydrated. Which of the following lab values shoudl the nurse expect for this client?
Provide more water with feedings
a nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?
identify the client using 2 identifiers
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 ifrst?
Advise the client to perform ROM exercises in bed
a nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?
supports self-determination
a nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?
montgomery straps
a nurse is changing the dressings for a client who has 2 penrose drains near an abdominal incision. Which of the followin gadhering devices is the best choice fo rthe nurse to use to decrease skin irritation?
a nurse will show me how to care for my wound
a nurse is reinforcing discharge teaching with a client who has a prescription for daily wound care via home health care services. Which of the following statements by the client indicates an understanding of the teaching?
elevates the finger above heart level
a nurse is reinforcing teaching w/ a client about how to obtain a capillary finger-stick blood sample. Which of the following actions by the client requires the nurse to intervene?
apply light pressure to the scanner head once it is in position
a nurse is using a portable ultrasound bladder scanner to measure a clients post-void residual. Which of ht following actions should the nurse take?
Rhonchi
adventitious (abnormal) breath sounds loud, harsh, gurgling, have a snoring or moaning quality
Cranial nerve V trigeminal
ask client to clench teeth and palpate masseter muscle for contraction to test this cranial nerve
Sanguineous
blood-tinged drainage
Hypocalciuma
deep tendon reflexes, positive Chvostek's sign (tightening of muscles in face when the nurse taps the client's facial nerve)
Protein-calorie malnourishment
dry, brittle hair edema poor wound healing
Depression
during this stage, the client has realized the full impact of the loss and might express hopelessness and despair
Complete proteins
eggs, meat, poultry, seafood, milk, yogurt, cheese, soybean, soybean products
Hold cane on unaffected side
for cane
Metabolic acidosis
higher ph, paCO2 within expected range
fight-or-flight response
hypertension increased respiratory rate dilated pupils bronchiolar dilation
Leukocytosis
increase in circulating WBC in response to WBC existing from blood vessels- result of inflammation
generativty vs. stagnation
middle adult hood community involvement, parenting, mentoring, teaching
Dorsalis pedis
most distal pulse
serous
mostly serum, clear portion of blood
ROM -neck- flexion
moving neck up and down
moro reflex
newborn extends both arsm and legs outward and thend raws then back inward as a response to a loud noise
Braden scale
nutrition, sensory perception, moisture, activity, mobility, friction and shear parameters of this test
to test trigeminal nerves
obtain cotton whisps, safety pain, clench teeth
primary intention
occurs when the provider closes the wound using sutures or staples at the time the incision is made, the suture lines becom ewell approximated when healing
incomplete proteins
pasta, peanut butter, cereal (unless you add milk) lentils, veggies, grains, nuts s, seeds missing 1 or more of the essentail amino acids necessary to support growth and maintain homeostasis
Intraoperative
phase of care begins w/ transferring the client to the surgical suite table and ends with transfer to PACU
initiative vs. guilt
preschoolers guilt, frustration and help control impulses and cooperative w/ others altered development can result from harsh punishment and excessive limits on behavior