ATI study questions
A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply) A: Keep the head of the bed elevated 30 degrees B: Massage the client's bony prominences frequently C: Apply corn startch liberally to the skin after bathing D: Have the client sit on a gel cushion when in a chair E: reposition the client at least every 3 hours while in bed
A - slightly elevate head - helps to reduce the shearing forces that could tear sensitive skin on the sacrum, buttocks and heels D- have pt sit on gel pad while sitting in chair
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply) A: stage 3 pressure injury B: Sutured surgical incision C: Casted bone fracture D: laceration sealed with adhesive E: Open burn area
A - stage 3 injury E - open burn Secondary intention is the process for wound that have tissue loss and widely separated edges
A nurse is reviewing the medical record of a client who has a blood glucose of 260 mg/dL and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia as an adverse effect? (Select all that apply) A: diuretics B: corticosteroids C: Oral anticoagulants D: Opioid analgesics E: Antipsychotics
A : diuretics B: corticosteroids E: antipsychotics
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (select all that apply) A: Increase in incisional pain B: Fever and chills C: reddened wound edges D: increase in serosanguineous drainage E: decrease in thirst
A- increase incision pain B- fever and chills C- reddened wound edges
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply) A: Auscultate bowel sounds B: Assist the client to an upright position C: test the pH of gastric aspirate D: warm the formula to body temp E: Discard any residual gastric contents
A: Auscultate bowel sounds B: Assist the client to an upright position C: test the pH of grastric aspirate
A nurse who works in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include. (Select all that apply) A: Older adults are more prone to dehydration than younger adults are B: Older adults need the same amount of most vitamins and minerals as younger adults do. C: Many older men and women need calcium supplementation D: Older adults need more calories than they did when they were younger E: Older adults should consume a diet low in carbohydrates.
A: Older adults are more prone to dehydration than younger adults are B: Older adults need the same amount of most vitamins and minerals as younger adults do. C: Many older men and women need calcium supplementation
A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (select all that apply) A: Review a signal the client can use if feeling any distress B: lay a towel across the client's chest C: Administer oral pain medication D: Obtain a dobhoff tube for insertion E: Have petroleum-based lubricant available
A: Review a signal the client can use if feeling any distress B: lay a towel across the client's chest
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply) A: Weber test showing lateralization to the right ear B: Light reflexes at 10 o'clock in the left ear C: Indications of obstruction in the left ear canal D: Rinne test showing less time for air and bone conduction E: Rinne test showing air conduction less than bone conduction in the left ear
A: Weber test showing lateralization to the right ear - with sensorineural loss the weber test demonstrates lateralization to the unaffected ear. D: Rinne test showing less time for air and bone conduction With sensorineural hearing loss in the left ear, length of time is decreased
Client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply) A: Cover the area with saline-soaked sterile dressing B: Apply an abdominal binder snugly around the abdomen C: Use sterile gloves to apply gentle pressure to the exposed tissues D: Position the pt supine with the hips and knees bent E: Offer the client a warm beverage
A: cover area D: position minimizes the pressure on the abdominal area
A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (select all that apply) A: Furosemide B: Ibuprofen C: Cimetidine D: Simvastatin E: Aminodarone
A: furosemide and B: Ibuprofen
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe, the client asks the nurse why the water in necessary. Which of the following responses should the nurse make? A: water helps clear the tube so it doesn't get clogged B: flushing helps make sure the tube stays in place C this will help you get enough fluids D: adding water makes the formula less concentrated
A: water helps clear the tube so it doesn't get clogged
A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. Their HGb is 12g/dL and BMI is 17.1. The incision is approximated and free of redness, with scan serious drainage on the dressing. The nurse should recognize the client has which of the following risk factors for impaired wound healing? (Select all that apply) A: Extremes in age B: Chronic illness C: Low hemoglobin D: Malnutrition E: Poor wound care
B - chronic illness C- low hemoglobin D- malnutrition
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A: give the client thin liquids B: Instruct the client to tuck their chin when swallowing C: Have the client use a straw D: Encourage the client to lie down and rest after meals
B - tucking the chin when swallowing allows food to pass down the esophagus more easily
A nurse is caring for a client who had a stroke and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply) A: Speak at a higher volume to the client B: Make sure only one person speaks at a time C: Avoid discouraging the client by indicating that they cannot be understood D: Allow plenty of time for the client to respond E: Use brief sentences with simple words
B Make sure only one person speaks at a time, D Allow plenty of time for the client to respond and E Use brief sentences with simple words
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A: auscultate breath sounds B: stop the feeding C: obtain a chest x-ray D: initiate oxygen therapy
B: stop the feeding
A nurse is preparing to instill an enteral feeding for a client has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A: check how long the feeding container has been open B: verify the placement of the NG tube C: Confirm that the client does not have diarrhea D: make sure the client is alert and oriented
B: verify the placement of the NG tube
A nurse is caring for a patient who weights 80 kg (176 lb) and is 1.6 m (5 ft, 3in) tall. Calculate the BMI and determine is this patient is underweight, healthy weight or overweight / obese.
BMI is calculated by height (kg)/ weight (m^2) 80/ 1.6^2 = 31.25 He is classified as obese.
A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A: Cooked barley B: Purred broccoli C: Vanilla custard D: Lentil soup
C - Vanilla custard - a low residue diet consists of foods that are low in fiber and are easy to digest. Diary products and eggs (custard and yogurt) are appropriate for low residue diet.
A nurse if caring for a client who had an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement? A: Immediately complete a thorough assessment B: Encourage visitors to distract the client C: Provide a private room, and limit stimulation D: speak at a higher volume to the patient.
C: Provide a private room, and limit stimulation
A nurse is watching a self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply) A: Perform SMBG once daily at bedtime B: Wipe the hand with an alcohol swab C: Hold the hand in a dependent position prior to the puncture D: Place the puncturing device perpendicular to the site E: Prick the outer edge of the fingertip for the blood sampling
C: the client should hold the hand in a dependent position to increase blood flow to the fingers D: Place the puncturing device perpendicular to the site to ensure the correct piercing depth E: client should use the outer edge of the fingertip
A nurse attempting to collect a capillary blood specimen via finger stick for blood glucose monitoring is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? A: Puncture another finger to obtain a capillary specimen B: Test the urine with a urine reagent strip C: Wrap the hand in a warm, moist cloth D: Perform a venipuncture to obtain a venous sample.
C: when providing patient care first use the least invasive intervention. Warm the client's finger with warm moist cloth to promote blood flow in preparation for the next finger stick.
A nurse is reviewing instructions with a client who has hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A: I use a damp cloth to clean the outside part of my hearing aids B: I clean the ear molds of my hearing aids with rubbing alcohol C: I keep the volume of my hearing aids turned up so I can hear better D: I take the batteries out of my hearing aids when I take them off at night
D - to conserve battery power. Client should turn off the hearing aids and then remove the batteries when not in use.
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most amount of energy? A: fat B: Protein C: Glycogen D: Carbohydrates
D: Carbohydrates are the body's greatest energy source, providing energy for cells is their primary function. They provide glucose which burns completely and efficiently without end products to excrete. They are also a ready source of energy, spare proteins from depletion.
A nurse teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? A: Smear the blood onto the strip B: Squeeze the blood onto the strip C: Touch the puncture to stimulate bleeding D: Hold the test strip next to the blood on the fingertip
D: Touch the puncture to stimulate bleeding
