ATI - LS - Fundamentals 2

a nurse is caring for a group of clients who are receiving oxygen therapy. which of the following clients should the nurse plan to see first?

a client who has heart failure and is receiving 100% oxygen via a partial rebreather mask = The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe his own exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. Oxygen is a gas which can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.

a nurse is replacing the surgical dressing on a client who had abdominal surgery. which of the following actions should the nurse take?

don clean gloves to remove the old dressing = The nurse should use standard precautions by applying clean gloves whenever there is a possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean, not sterile, gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing.

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 funding as which of the following types of drainage?

purulent exudate = Purulent exudate drainage on the client's dressings is thick yellow, green, and brown drainage and usually indicates wound sloughing or infection.

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 halo of erythema on the surrounding skin = The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider.

a nurse is reinforcing teaching with a client who has a new colostomy about proper care. which of the following information should the nurse include in the teaching?

cleanse the skin around the stoma with warm water = The nurse should instruct the client to cleanse the skin around the stoma with warm water, because using soap can leave a residue on the skin and cause poor adherence of the pouch adhesive.

a nurse is caring 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 plan to take when obtaining the specimen?

collect the specimen upon arising in the morning = The nurse should plan to collect the sputum specimen when the client arises in the morning because the client is able to more easily cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it's preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container.

a nurse is reinforcing teaching with a client who is recovering from gallbladder surgery about how to use an incentive spirometer. which of the following information should the nurse include in the teaching?

hold breath for 5 seconds after goal volume is reached = The nurse should instruct the client to hold her 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.

a nurse is changing the bed linens for a client who is on bed rest. which of the following actions should the nurse plan to take?

hold the linens away form the body and clothing = The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms.

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?

montgomery straps = The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips.

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?

offer the client tart or sour foods first = The client who has 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 preparing to remove an NG tube for a client who had a partial colectomy. which of the following actions should the nurse take?

pinch the NG tube while removing the tube = The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.

a nurse is helping a client change his hospital gown. the client has an IV infusion on an infusion pump. which of the following actions should the nurse take first?

remove the sleeve of the gown form the arm without the IV line = According to evidence-based practice, the nurse should first remove the gown from the client's arm without the IV line. Beginning this process will enable the nurse to move the gown fully off the client and last stop the system to remove the gown off the line, resulting in minimal interruption of the IV flow.

a nurse is contributing to the plan of care for a client who is confused and requires a prescription for wrist restraints. which of the following interventions should the nurse include in the plan of care?

renew the prescription for the use of restraints within 24 hour. = The nurse should plan to renew the prescription for the restraints within 24 hr and only after the provider has evaluated the client.

a nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. which of the following findings should the nurse identify as infiltration of the IV infusion site?

taut skin around the IV catheter site that is cool to the touch = The client who has taut skin around the IV catheter site that is cool to touch might have an infiltrated IV site. 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 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?

turn the stocking inside out up to the heel before applying = The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles.

a nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. the nurse notes no urine output in the past 2 hr. which of the following actions should the nurse take first?

check to determine if the catheter tubing is kinked = The nurse should apply the least invasive priority-setting framework when caring for this client. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. The first action the nurse should take is to inspect the tubing carefully, straightening out any kinks, and make certain that there are no dependent loops. A common reason a tube is not draining is that there is a kink in the tubing or that the client is lying on it

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?

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

a nurse is preparing to administer eye drops to client following surgery. which of the following actions should the nurse take when instilling the eye drops?

drop the eye medication into the lower conjunctiva sac = The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.

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

elevate the client's head of bed 45" before the feeding = The nurse should elevate the client's head of bed between 30° to 45° to prevent aspiration.

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?

exert pressure on the bony prominences when holding the eyelids open. = The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.

a nurse is caring for a client who has major fecal incontinence and report irritation in the perianal area. which of the following actions should the nurse take first?

check the client's perineum = Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by checking the area of irritation.

a nurse is caring for a client who has a hearing impairment. which of the following interventions should the nurse use when speaking with the client?

face the client when speaking = The nurse should always directly face the client who has a hearing impairment and stand or sit at the same level to maximize communication. Many clients who are hearing impaired combine lip reading with their residual hearing when communicating.

a nurse is assisting to teach a group of unit nurses about a client who has a surgical wound that is healing by secondary intention. which of the following information should the nurse include in the teaching?

granulation tissue fulls the wound during healing = The nurse should include in the teaching that a beefy, red tissue called granulation 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 administering a cleansing enema to a client who is scheduled for a diagnostic procedure. which of the following actions should the nurse take?

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.

a nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. at which of the following locations should the nurse tape the catheter?

lower abdomen = The nurse should secure with tape the client's urinary catheter to the lower abdomen or the upper inner aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.

a nurse is planning to collect a stool speciment for ova and parasites from a client who has diarrhea. which of the following actions should the nurse take when collecting the specimen?

place the stool speciment collection container in a biohazard bag = The nurse should place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification, and to prevent contamination with microorganisms.

a nurse is preparing to administer an intramuscular injection to a client who is overweight. which of the following sites should the nurse select for the injection?

the side hip between the iliac crest and anterior iliac spine = The side hip between the iliac crest and anterior iliac spine forms the boundaries for ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is the preferred site for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (right hand on left hip, for example) with the first two fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape.

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?

use a gait belt during ambulation = The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall.

a nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. which of the following actions should the nurse take first?

use the pain scale to determine the client's pain level = The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority, when caring for this client. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs priority setting framework the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchical levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, to meet the client's physiological needs, the first action the nurse should take is to begin pain management by asking the client to describe her pain.

a nurse is contributing to the plan of 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?

vitamin C and zinc = The client's body needs both vitamin C and zinc to help fight a wound infection. The client should receive a multivitamin plus a mineral supplement of both. In addition, vitamin E supplements also are needed to aid in skin and wound healing.

a nurse is contributing to the plan of care for ma client who has fluid volume excess. which of the following interventions should the nurse plan to include to monitor the client's weight?

weigh the client on arising = The nurse should weigh the client on arising each day, after voiding, and before breakfast. An accurate weight requires the client to be weighed wearing the same type of garments, and on the same carefully calibrated scale (balanced to zero before each use). Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid.

a nurse is collecting data from 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 client?

what do you think caused the onset of your pain? = The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than one or two words.

a nurse is preparing to insert an NG tube for a client who has a bowel obstruction. which of the following actions should the nurse take first?

explain the procedure to the client = The nurse should apply the least invasive priority-setting framework when caring for this client. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Informing the client about the procedure reduces fear and assists in gaining the client's cooperation, which is important for NG tube insertion and is the priority nursing intervention.

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?

inability of the toddler to cry or speak = When the client 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 performing a straight urinary catheterization for a female client who has urinary retention. which of the following actions indicates the nurse is maintaining sterile technique?

wipes the labia minora in an anteroposterior direction = The nurse should wipe anteroposterior both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.

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?

collapse the device of air after emptying = The nurse should collapse the device of air after emptying the contents and periodically, to create enough suction to pull fluid exudate into the collection area of the device.

a nurse is assisting a client who is eating at mealtime. the client grabs her neck with both hands and appears frightened. which of the following action should the nurse take first?

determine whether the client is able to breathe = Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The client is demonstrating the universal choking gesture. If the client is unable to move air in our out, severe airway obstruction is present. The client would need emergency interventions to clear a partial obstruction, indicated by stridor or minimal airway passage. As long there is good air exchange and she can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition.

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?

i am going to listen to your abdomen = A common reason clients experience nausea and vomiting after surgery is 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.

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

pull suction catheter back 1 cm (0.5 in) if the client starts coughing = The nurse should pull the suction catheter back 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.

a nurse is caring for a client who has a history of dysrhythmias. upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli. has no respirations. and is pulseless. which of the following actions should the nurse take first?

start chest compression = The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to the client is loss of adequate circulation to the tissues; therefore, following the sequence of cardiopulmonary resuscitation, the nurse should first initiate chest compression. The following steps include opening the airway and breathing for adults and pediatric clients because evidence indicates there is a greater survival rate when chest compression are started before a breath is initiated.