ATI Remediation 2
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 nurse is caring for an older adult client who has dysphagia following a CVA. Which of the following actions should the nurse take when assisting the client at mealtime?
Offer the client tart or sour foods first. (stimulates saliva production) Patient should dry swallow between bites of food.
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 redness on the surrounding skin. Indicating underlying infection.
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 hours. Which of the following actions should the nurse take first?
Check to determine if the catheter tubing is kinked.
A nurse is providing teaching to a client who has a 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.
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.
A nurse is planning care 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 take when obtaining the specimen?
Collect the specimen upon arising in the morning.
A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take?
Don clean gloves to remove the old dressing.
A nurse is preparing 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.
Removing a soiled dressing is a procedure that requires wearing
clean, not sterile, gloves.
Why should you not put an aspirin pill in the ostomy pouch to decrease odor?
it can cause stoma bleeding.
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 from an arm without the IV line. Slow the infusion using the roller clamp. Disconnect the IV line from the pump. Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown.
Calcium
to prevent osteoporosis when used with vitamin D; however, it does not assist in the client's wound healing.
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.
What does pneumonia affect?
alveoli
sangineous exudate
bloody drainage
A nurse is assessing 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?"
How long should a nurse allow between suctioning passes to prevent hypoxia and to hyperventilate the client?
1 minute
Stages of wound healing
1. Inflammatory (initial) -immediate phase, lasts about 3 days -increased blood supply and phagocytosis (delivers oxygen, wbcs, and nutrient to the wound to support healing) -control bleeding for clot formation 2. Proliferative (granulation) -second phase -fibroblasts synthesize collagen -formation of granulation tissue 3. Maturation and Remodeling -continued granulation and strengthening of tissue -scar formation
How many times should you remove a patient's antiembolitic stockings?
1x per shift
How often should you change the pouch?
3-7 days
Routine treatment for COPD patient
Administer low oxygen dose therapy- 2 L/min. To drive their respiratory rate.
Routine treatment for a client who has an old tracheostomy
Administration of humidified oxygen or air via tracheostomy collar. 6 L/min= 40% oxygen
Why?
After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra.
Purulent exudate
Drainage which contains pus, usually yellow, green or brown; indicates infection
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?
Drop the eye medication into the lower conjunctival sac. NOT the cornea.
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 degrees before the feeding (at least 30 to 45 degrees)
A nurse is teaching a client who is recovering from gallbladder surgery 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 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 tup of the tubing 8 cm.
A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?
Lower abdomen
How much of the tubing should the nurse lubricate the tube?
Lubricate it 5-8 cm
a nurse is changing the dressing for a client who has an abdominal incision and a Hemovac drain. Which of the following actions should the nurse take?
Montgomery straps
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.
A nurse is planning to collect a stool specimen 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 specimen collection container in a biohazard bag.
A nurse is planning 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 restrains within 24 hr.
A nurse is caring for a client who is receiving an IV fluid replacement, Which of the following findings should the nurse identify as infiltration of the IV infusion site?
Taut skin around the IV catheter that is cool to touch. (Note: this should not happen.)
What happens if an antiembolitic stocking is too long>
The nurse should apply another size stocking if the stocking is too long. Rolling the stocking partially down can decrease venous return and cause skin irritation.
Why?
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.
Why?
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 is 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 preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the infection?
The side hip between the iliac crest and anterior iliac spine
A nurse is applying antiembolitic stockings for a client who has a history of deep vain 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.
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 risl of a fall?
Use a gait belt during ambulation.
Routine treatment for chronic lung conditions
Use of a transtracheal oxxygen cannula; low rate of oxygen. 3 L/min of oxygen=32% oxygen
A nurse is planning 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
Vitamin K and iron
Vitamin K is important for normal clotting of blood and for impaired intestinal synthesis caused from antibiotics. Iron is needed to rebuild RBCs for a client; however, neither is needed directly in the client's wound healing.
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.
Secondary intention healing
wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring
How many passes should a nurse perform with the suction catheter?Why?
3 passes. Because suctioning can cause hypoxia and induce dysrhythmia.
How long should a patient dangle their legs on the edge of the bed?
60 seconds before attempting to ambulate to decrease the risk of a fall caused from orthostatic hypotension.
A nurse is planning care 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.
Why?
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 planning care for an adult client who has fluid volume excess.Which of the following interventions should the nurse plan to include the monitor the client's weight?
Weigh the client on arising.
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 actions should the nurse take first?
Determine whether the client is able to breathe.
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.
Serosanguineous exudate
RBC and serous fluid
Vitamin D
maintain normal calcium and phosphorus levels in the blood and it may protect against cancer. Vitamin D is important when used with calcium to prevent osteoporosis;
What should a nurse hyperventilate the patient with?
100% oxygen for at least 2 min before suctioning to decrease hypoxia.