Concepts I ATI exam A

a nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include? A. Advocacy ensures clients' safety, health, and rights. B. Advocacy ensures that nurses are able to explain their own actions. C. Advocacy ensures that nurses follow through on their promises to clients. D. Advocacy ensures fairness in client care delivery and use of resources.

A

A nurse is caring for client postop who refuses to use incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. B. Determine the reasons why the client is refusing to use the incentive spirometer C. Document the client's refusal to participate in health restorative activities D. Administer a pain medication to the client

B

Which is a pic of the patellar reflex?

Knee

A nurse is auscultation the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type o breath sounds.

Normal breath sounds

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? a. contact b. droplet c. airborne d. protective

b

A nurse is preparing to administer enoxaparin subcutaneous to a client. Which of the following actions should the nurse take? A. Administer the meds with the needle at a 45 degree angle B. Administer the meds into the clients non dominant arm C. Pull the clients skin laterally or downward prior to administration D. Massage the injection site after administration

A

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh length sequential compression sleeves. Which of the following actions should the nurse take? a. assist the client to a prone position b. place a sleeve over the top of each leg with the opening at the knee c. make sure two fingers can fit under the sleeves. d. set the ankle pressure at 65 mmHg.

c

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? a. you would have so much more time to spend with your family b. you should consider getting a part-time job doing volunteer work c. lets talk about how the change in your job status will affect you d. why wouldn't you want to retire and relax

c

A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number.)

107 mL/hr Formula: t otal volume/total hours = mL/hr Solution: Unit = mL/hr Volume ( mL) = 750 mL Time ( hr) = 7 hr Convert = NO * 750 mL/7 hr = 107.1 mL/hr = 107 mL/hr Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired Over Have method of calculation: Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 750 mL Step 3: What is the total infusion time? 7 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr = Time (hr) 750 mLX mL/hr = 7 hr X mL/hr = 107.14 mL/hr Step 6: Round if necessary. 107.14 mL/hr = 107 mL/hr Step 7: Determine if the amount to administer makes sense. If the prescription reads 0.9% sodium chloride 750 mL IV to infuse over 7 hr, it makes sense to administer 107 mL/hr. The nurse should set the IV pump to deliver 0.9% sodium chloride IV at 107 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 750 mLX mL/hr = 7 hr Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 750 mLX mL/hr = 7 hr Step 4: Solve for X. X mL/hr = 107.14 mL/hr Step 5: Round if necessary. 107.14 mL/hr = 107 mL/hr Step 6: Determine if the amount to administer makes sense. If the prescription reads 0.9% sodium chloride 750 mL IV to infuse over 7 hr, it makes sense to administer 107 mL/hr. The nurse should set the IV pump to deliver 0.9% sodium chloride IV at 107 mL/hr.

Client reports ever, cough, chills, and night sweats for past 2 weeks. Recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes on auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lbs in the last week. Has no appetite and is nauseated. Obtained bloodwork, chest x ray, and sputum culture. Chest x ray positive for inflammation and infiltrates in upper lobes. TB negative The nurse s placing the client on isolation precautions. Which of the following interventions should the nurse include? (SATA) A. Wear an N95 mask when caring for the client. B. Place a container for soiled linens inside the client's room C. Place the client in. Negative airflow room. D. Remove mask after exiting the client's room E. Wear a sterile, water-resistant gown if within 3 feet of the client,

A, B, C, D

A nurse is initiating a protective environment for a client who has an allogenic stem cell transplant. Which of the following precautions should the nurse plan for the client. A. Make sure the client's room has at least six air exchanges per hour B. Make sure the client wears a mask when outside her room if there is construction in the area C. Place the client in a private room with negative pressure airflow D. Wear an N95 respirator when giving the client direct care.

B

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° 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

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 nire someone to trim the tree tat nanes low over the stairs or my Tront porch. C. I will place mv alarm clock on mv bedroom dresser across the room D. I will replace the old throw rug in my kitchen with a new one

B

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. B. Regulate oxygen visa nasal cannula at a flow rate of no more than 6 L/min C. Make sure the reservoir bag of a partial rebreathing mask remains deflated D. Use petroleum jelly to lubricate the client's nares, face, and lips.

B

a nurse is assessing four adult clients. which of the following physical assessment techniques should the nurse use? A. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. B. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. D. Palpate the client's abdomen before auscultating bowel sounds.

B

a nurse is caring for a client who asks about the purpose of advanced directives. which of the following statements should the nurse make? A. "They allow the court to overrule an adult client's refusal of medical treatment." B. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." C. "They permit a client to withhold medical information from health care personnel." D. "They allow health care personnel in the emergency department to stabilize a client's condition."

B

a nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. which of the following observations should the nurse identify as a safety problem? A. The client uses a wool blanket on their bed. B. The client identifies the location of a fire extinguisher. C. The client stores an extra oxygen tank on its side under their bed. D. The client has a weekly inspection checklist for oxygen equipment.

B

a nurse is preparing a change of shift report. which of the following tools or documents should the nurse use to communicate continuity of care? A. Critical pathway B. Situation, background, assessment, and recommendation (SBAR) C. Transfer report D. Medication administration record (MAR)

B

a nurse is in a long term facility caring for a client who dies during their shift. identify the sequence in which the nurse should perform the following steps A. place name tag on the body B. obtain the pronouncement from the provider C. remove tubes and indwelling catheters D. wash the clients body E. ask the clients family if they would like to see the body

B, C, D, E, A

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. Check the client for injuries. B. Move hazardous objects away form the client C. Notify the provider D. Ask the client to describe how she felt prior to the fall

A

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. Use the complete name of the medication magnesium sulfate B. Delete the space between the numerical dose and the unit of measure C. Write the letter U when noting the dosage of insulin D. Use the abbreviation SC when indicating an injection

A

A nurse on a medical-surgical 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 every 8 hours after application C. Remove the restraints every 4 hours to evaluate the client's status D. Secure the restraint ties to the bed's side rails

A

a nurse is admitting a client who is having an exacerbation of heart failure. in planning care when should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. After consulting with the client's family

A

a nurse is caring for a client who has a terminal illness and is approaching death. the client is short of breath and has noisy respirations from secretions in their airway. which action should the nurse take? A. Turn the client every 2 hr B. Administer an antiemetic every 6 hr C. Hold oral care D. Increase the room's temperature

A

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

a nurse is preparing to administer an injection of an opioid medication to a client. the nurse draws out 1mL of the medication from a 2mL vial. which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage. B. Notify the pharmacy when wasting the medication. C. Lock the remaining medication in the controlled substances cabinet. D. Dispose of the vial with the remaining medication in a sharps container.

A

a nurse is caring for a client who has a peripheral IV inserted for fluid replacement Nurses' Notes Day 1:Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2:IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.​​ the nurse is assessing the client. which of the following actions should the nurse take? select all A. stop the IV infusion B. elevate the clients left arm C. apply heat to the clients left hand D. place a pressure dressing over the IV site. E. start a new IV in the clients left hand

A, B, C

select the 3 tasks the nurse should delegate to the assistive personnel. A. document client vitals B. measure intake and output C. transfer from wheelchair to bed D. insert NG tube E. collect data about clients pain level

A, B, C

a nurse is caring for a client who has COPD Nurses' Notes 1000:Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Vital Signs 1000:Temperature 38.6° C (101.5° F) BP 114/56 mm Hg Heart rate 99/minRespirations 32/min Oxygen saturation 85% on room air Diagnostic Results 1200:Chest x-ray shows lung hyperinflation and left upper lobe pneumonia. Select the 3 findings that require follow -up A. breath sounds B. bp C. o2 D. temp E. hr

A, C, D

a nurse is caring for a client who is receiving a unit of packed RBCs Nurses' Notes 0800: Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815: Client reports itching and anxiety. Client's face is flushed and has hives. Vital Signs 0800: BP 112/64 mm Hg Heart rate 80/minRespirations 18/minTemperature 37.1° C (98.8° F)Oxygen saturation 97% on room air 0815: BP 106/54 mm Hg Heart rate 100/minRespirations 22/minTemperature 37° C (98.6° F)Oxygen saturation 95% on room air the client has manifestations of ____ as evidenced by the _____

Allergic reaction Itching

A nurse is caring for a client who has a terminal illness and is at the end of the life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? A. "I am not worried because I still have hope that he will be okay." B. "I am relying on support from our 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

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? A. "We would consult the person appointed ov vour health care oroxv to make decisions. B. "we would give vou oxygen trougn a tube In your nose" C. "You would be unable to change vour previous wishes about vour care. D. "We would insert a breathing tube while we evaluate your condition.

B

A nurse is teaching a client and his family how to care for the clients tracheostomy at home. Which of the following instruction should the nurse include in the teaching? A. Remove the outer cannula cautiously for routine cleaning B. Use tracheostomy covers when outdoors C. Use sterile technique when performing tracheostomy care at home D. Cleanse irritated skin with full strength hydrogen peroxide

B

a nurse is providers clinic is caring for a client who has diarrhea. Vital Signs Temperature 36.2° C (97.2° F)Pulse rate 116/minRespiratory rate 24/minBP 102/68 mm HgOxygen saturation 95%Weight 52.2 kg (115 lb) Nurses' Notes 1000: Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. Weight at previous visit was 56.2 kg (124 lb). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100: Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching provided for managing diarrhea.​ Physical Examination 1015: Oriented to person, place, and time; lethargic, reports headache Tachycardia, hypotension, thready pulse, dry mucous membranes, tenting present. Respirations slightly labored, chest clear. Bowel sounds x 4 quadrants hyperactive. Reports urine is dark, minimal amount. the nurse is providing reaching for the client. select the 4 instructions she should include A. increase intake high calcium foods B. eat probiotic foods, such as yogurt C. avoid alcohol while experiencing diarrhea D. eat raw vegetables E. eat 3 large meals a day F. avoid caffeine G. drink hot liquids several times a day H. drink carbonate beverages to replace lost fluid I. follow a low fiber diet

B, C, F, I

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the clients room. When the nurse ask if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? A. I will return Hartley after i document this in your record B. Most men live a long time with prostate cancer C. I am available to talk if you should change your mind D. I will make a referral to a cancer support group for you.

C

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. The top of the cane is parallel to the client's waist. B. When walking, the client moves the cane 46 cm (18 in) forward. C. The client holds the cane on the stronger side of her body. D. The client moves her stronger limb forward with the cane.

C

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? A. Insert the needle at a 15 angle B. Aspirate for blood return prior to administration. C. Administer the medication into the abdomen. D. Massage the site rollowing the injection.

C

a client who is post op is verbalizing pain as a 2 on a pain scale of 10. which of the following statements should the nurse identify as an indication that the client understands preoperative teaching she received about pain management A. "I think I should take my pain medication more often, since it is not controlling my pain." B. "Breathing faster will help me keep my mind off of the pain." C. "It might help me to listen to music while I'm lying in bed." D. "I don't want to walk today because I have some pain."

C

a nurse is administering 1 L of 0.9% sodium chloride to a client who is post op and has FVD. which of the following changes should the nurse identify as an indication the treatment was successful? A. Increase in hematocrit B. Increase in respiratory rate C. Decrease in heart rate D. Decrease in capillary refill time

C

a nurse is admitting a new client. which of the following actions should the nurse take with performing medication reconciliation? A. Verify the client's name on their identification bracelet with the medication administration record. B. Call the pharmacy to determine whether the client's medications are available. C. Compare the client's home medications with the provider's prescriptions. D. Place the client's home medication bottles in a secure location.

C

a nurse is performing a skin assessment for a client who expresses concern about skin cancer. which of the following findings should the nurse identify as potential indication of a skin malignancy? A. A lesion with uniform pigmentation B. New appearance of petechiae C. A mole with an asymmetrical appearance D. The presence of a papule

C

a nurse is planning is planning strategies to manage time effectively for client care. which of the following strategies should the nurse implement? A. Combine 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

a nurse is talking with the partner of a client who has dementia. the clients 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

a nurse is using an open irrigation technique to irrigate a clients indwelling urinary 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 amount of irritant used from the clients urine output D. perform the irrigation using a 20-mL syringe

C

A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? A. I have been weighing myself every other morning B. I am trying to decrease my intake of food with potassium C. I am limiting my sodium intake to 2 g daily D. I am eating fewer potato chips and more fruit for snacks E. I lie down and rest after meals F. I know to call my doctor if i gain 3 pounds for more in two days

C, D, F

a nurse is caring for a client who is postoperative following abdominal surgery. Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200: Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort. Medication Administration Record Morphine 4 mg IV bolus every 4 hr PRN painMetoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting Vital Signs 1100: Temperature 36.2° C (97.2° F)Heart rate 76/minRespirations 18/minBP 122/68 mm HgOxygen saturation 95% on room air 1200:Temperature 36.8° C (98.2° F)Heart rate 116/minRespirations 20/minBP 112/68 mm HgOxygen saturation 93% on room air assessment findings that the nurse should report to the physician A. Neurological assessment B. Incisional drainage C. Urinary output D. Reported pain level E. Gastrointestinal assessment F. Vital signs

C, D, F

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Discuss the risk factors for colon cancer. B. Focus teaching on what the client will need to do in the future to manage his illness C. Provide the client with written info about the phases of loss and grief D. Reassure the client that this is an expected response to grief

D

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 minutes and report back in 1 hour. Which of the following actions should the nurse take? A. Document the providers statement in medical records. B. Complete an incident report. C. Consult The facilities risk manager D. Notify the nursing manager

D

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? A.Bend at the waist. B. Keep his feet close together. C. Use his back muscles for lifting. D. Stand close to the cabinet when lifting it.

D

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L

D

a nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. which of the following types of transmission precautions should the nurse initiate? A. Protective environment B. Airborne precautions C. Droplet precautions D. Contact precautions

D

a nurse is assessing a client who reports increased pain following physical therapy. which of the following questions should the nurse ask when assessing the quality of the clients pain? A. "Is your pain constant or intermittent?" B. "What would you rate your pain on a scale of 0 to 10?" C. "Does the pain radiate?" D. "Is your pain sharp or dull?"

D

a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take when inserting the NG tube? A. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. B. Remove the NG tube if the client begins to gag or choke. C. Apply suction to the NG tube prior to insertion. D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

D

a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid

D

A nurse is caring for a client who has pneumonia. Vital Signs 0800:Heart rate 109/minRespirations 26/minBP 125/65 mm HgTemperature 39.2° C (102.6° F)Oxygen saturation 95% 1200:Heart rate 94/minRespirations 18/minBP 115/65 mm HgTemperature 37.8° C (100° F)Oxygen saturation 96% Medication Administration Record 0.45% sodium chloride IV at 125 mL/hr Vancomycin 1 g intermittent IV bolus every 12 hr Acetaminophen 650 mg PO every 6 hr PRN temperature greater than 38.3° C (101° F) Codeine 20 mg PO every 4 hr PRN cough​ Oriented to person, place, and time. Appears fatigued. Diaphoretic, febrile. Reports not sleeping well last night due to "coughing a lot." Moves all extremities well. Tachycardia. All pulses palpable. Reports chest discomfort with coughing. Respirations 26/min, shallow. Auscultation reveals diminished breath sounds and bilateral crackles. Pulse oximetry 95% on O2 2 L via nasal cannula. Hypoactive bowel sounds present in all four quadrants. States tolerating diet with no nausea or vomiting but has no appetite. Client states voiding using the bedside commode with no difficulty. Output of 500 mL clear, yellow urine flushed. IV infusing to right arm, no noted redness or irritation at site. Acetaminophen administered for temperature. 1200: States feeling better following administration of acetaminophen. Vancomycin infusion started. Client voices no discomfort at this time. 1300: Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified.​ The nurse should identify the client may be experiencing _________________ as evidenced by _____________

Extravasation IV catheter site

a nurse is caring for a client who has a new diagnosis of a seizure disorder. Nurses' Notes 0800:Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. 0900:On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. Medication Administration Record Carbamazepine ER 200 mg PO twice per dayLorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min the nurse should first address the clients ____ followed by the clients ____

Physical safety Positioning

A nurse in an emergency department is caring for a client. Physical examination: Influenza with nausea, vomiting, and diarrhea for the past 3 days. Client is tachycardia, hypotensive, and tachypenic, with weak pulses, dry mucous membranes, poor tugor, and oliguria. Plan: admit for IV fluids Vital signs: 1200: Temp: 101.1F Pulse rate: 126/min RR: 28/min BP: 92/54 mm Hg O2: 93% Nurse notes: 1900: Client is disoriented, confused. Client attempting to to get out of bed without assistance and states, I'm going home. Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to clients family. No answer. 1915: Client remains disoriented. Attempted to pull out IV line. Call was returned by family, they were updates. Med Administration Record -Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hr Promethazine 25mg IV bonus every 4-6hr PRN nausea and vomiting Diphenoxylate 5mg PO 4x daily Acetaminophen 625mg PO very 6 hours PRN temperature greater than 101.5F The nurse should first ___ followed by _____

Review medications that might be causing confusion Using other methods to keep the client safe

The nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have a fuse the treatment due to the religious beliefs. Which of the following actions should the nurse take? a. examine personal values about the issue b. tell the parents this is a necessary procedure c. inform the parents that the staff does not require their consent d. contact a spiritual support person to explain the importance of the procedure

a

A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to address the client's safety needs? a. lacrimal apparatus b. pupil clarity c. appearance of bulbar conjunctivae d. visual fields e. visual acuity

b, d, e

Nurse caring for client who has herpes zoster. Client asks about complementary and alternative therapies for pain control. Nurse should inform client that this condition is a contraindication for which of the following therapies? a. biofeedback b. aloe c. feverfew d. acupuncture

d