Funds ATI review

A nurse is caring for a client who is in the terminal stages of cancer. Which of the following actions should the nurse take when she oversee the client crying?

Sit and hold the clients hand. Rationale- with this action the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client.

A nurse is caring for a client who has methicillin resistant staphylococcus aureus infection. A dietary assistant ask the nurse what precautions are necessary for entering room the clients room with the lunch tray. Which instructions should the nurse give the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting. Rationale: clients who have Mrs infection requiring contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require any staff member who will have contact with the client and as mask and googled are needed if secretions from infected areas could spray into the workers face. Since delivering the tray will require contact with the environment, the dietary assistant must wear gloves.

A nurse is reinforcing preoperative teaching with a client who is schedule for Arthroplasty in the next month and might require blood transfusion. The client expresses concern about the risk of acquiring infection from the blood transfusion.

Donate autofocus blood before the surgery Rationale: autologous blood transfusion is the collection and rein fusion of the clients own blood. With prepped stove autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored transfusion at the time of surgery. Autologous blood is the safest for of blood transfusion; exclusive use of a client blood eliminated exposure to transfusions transmitted infection.

A nurse is caring for adolescent who has sickle cell anemia. Which of the following manifestations is the result of chronic Vaso occlusive phenomena.

Enlarged heart,enuresis, leg ulcers, retinal detachment. Rationale: chronic vaso occlusive phenomena result from the obstruction organs by red blood cells which lead to status and enlargement of the organs, infarction due to ischemia and scarring. And enlarged heart, enuresis leg ulcers and retinal detachment are manifestations of chronic Vado occlusive phenomena.

A nurse is changing the dressing for a client who has 2 pentode drains near an abdominal incision. Which of the following adhering drives is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps Rationale: the nurse should apply the least restrictive priority setting framework which assigns priority to nursing interventions that are least restrict to the client as long as those interventions do not jeopardize Corinth safety.

A nurse is caring for a client who is receiving a fluid infusion through a peripheral iv catheter. The nurse notes that the part of the arm immediately surrounding the insertion site is red and feels warm. What should the nurse do next?

Remove the IV catheter. Rationale- the clients manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV catheter immediately. The nurse should then apply warm compress to the site.

A nurse is caring for an adult client who communicated an unmet spiritual need. Which of the following clients statements should indicate to the nurse that the client is experiencing spiritual distress

Spiritual distress is described an as impaired ability to integrate meaning and purpose in life through various means, including belief system and relationships. Rationale Spiritual distress can have manifestations that include that a higher power is punishing the invisible for some behavior.

A nurse is planning to obtain the vital signs of 2 year old child who is experiencing diarrhea and who may have right ear infection. Which of the following routes should the nurse use to obtain the temperature

Temporal: No invasive and can be used to obtain a temperature in a toddler who may have ear infection and who is having diarrhea. Don't use oral cause the child is under 3

A nurse is preparing to assist an older adult client with ambulation; the client has been on bed rest for three days. Which of the following actions should the nurse take to decrease the risk of a fall

Use a gait belt during ambulation Rationale: the nurse should use a gait belt to keep the clients center of gravity at midline and to decrease the risk of fall.

A nurse is preparing to instill a vaginal medication in suppository form to a client: which of the following actions should the nurse take during the procedure?

Use the index finger to insert the suppository Rationale- to ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse index finger is inside the vagina or as far inside as possible

A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the findings should the nurse report to the surgeon immediately?

Warm, tender area on the right calf. Rationale- The greatest risk to the client is an injury from thrombus formation therefore, this is the priority finding that the nurse should report to the surgeon immediately. This is life threatening postoperative complication because the thrombus could dislodge and become pulmonary embolism.

A nurse is reinforcing teaching for a client about managing her tracheostomy care. Which of the following instructions should the nurse include.

Wear a tracheostomy cover when outdoors. Rationale- a tracheostomy cover protects the client airway from dust, chilly air, and any other airborne particles that could otherwise enter the airway.

A nurse in providers office is reinforcing teaching with a client about foods are high in fiber. Which of the following choices made by the client indicated an understanding of the teachings.

Whole grain bread Black beans Dried peas, and beans including black beans are high in fiber and good choice for this client. Whole grains consist of the entire kernel of grain and are high in fiber.

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicated an understanding of the teaching?

"I will put a night light in the hallway." Rationales: the nurse should instruct the client to use night lights in and around the home as an into it's time safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect clients ability to see surroundings. Older adults and infants are at increased risk of serious injury from falls, most falls occur in the clients home.

A client has 1L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/ he. How many hours will it take for the liter to infuse?

1000/125 =8

A nurse is preparing to administer a transdermal contraceptive patch to a female client. Which of the following actions should the nurse plan to take?

Apply the patch to an area of skin on the lower abdomen. Rationale: the nurse should apply the patch to a clean, dry area of the lower abdomen, buttocks, upper outer arm, or the front or back of the upper torso. The nurse should avoid breast tissue or skin that is red, cut or irritated.

A nurse is presenting an in service session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk?

Lactose Rationale: the nurse should identify that lactose is a form of sugar that is found in milk.

A nurse is evaluating a clients repeat laboratory result four hours after administering fresh frozen plasma. (FFP). Which of the following laboratory values should the nurse review?

Prothrombin time Rationale: the nurse should review the clients prothrombin time after the administration of FFP which plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.

A nurse is reviewing the laboratory data of a client who has fever and watery diarrhea. What should the nurse report to the provider?

Sodium 150 mEq/L Rationale- reference range for sodium is 135-145. The client is at risk for dehydration due to diarrhea.

A nurse is planning to obtain the vital signs of a two year old child who is experiencing diarrhea and maybe have a right ear infection. Which of the following routes should the nurse use to obtain the temperature ?

Temporal Rationale- the temporal street route, while not as accurate as the rectal route for obtaining a precise body temperature. Is no invasive and can be used to obtain a temperature in a toddler who may have ear infection and is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic but should avoid place king it over an area covered with hair.

A nurse is evaluating a clients use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

The client should slightly glexed elbows when ambulating with the crutches. Rationale- the client should have slightly flexed elbows when ambulatijg with crutches. This allows thr client to bear weight on the hands and not on the axillae.

A hospice nurse is visiting with the family members if a client. The family members states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the clients insomnia?

The client watched television in bed during the day. Rationale: to promote sleep, the client should avoid watching television in bed. She should be in bed only for sleep or sexual activities.

A nurse is reinforcing teaching about bladder retraining for a client who has urinary in continence. Which do the following instructions should the nurse include?

Try to block the urges to urinate until the next schedule time. Rationale: when the client is following schedule of voiding and feels the urge to urinate before the next schedule time the client should try to practice slow deep breathing to help reduce the urge s the client can also try 5 or 6 strong and quick pelvic muscle exercise.

A nurse is reinforcing teaching with a group of healthy older clients about screening after age 50 years. Which of the following health screening should the nurse recommend the clients complete annually?

Visual acuity

A nurse is caring for a client who is well hydrated and no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances as an indication that the client has adequate protein uptake and synthesis

Albumin Rationale: the nurse should identify that an albumin level within the expected reference range is an indication that the client has adequate protein uptake and synthesis. Albumin levels measure protein status. They are useful for identify long term protein depletion rather than short term or acute changes in nutritional status.

A nurse is taking a clients vitals. Which of the following is outside the expected reference range?

BP 145/90 mmHg Rationale: the nurse should identify that this blood pressure is greater than the expected reference range and report this finding to provider

A nurse is collecting a specimen for culture from a clients infected wound. Which of the following actions should the nurse take?

Cleanse the wound with 0.9 sodium chloride irrigation. Rationale- The nurse should cleanses the wound with sterile water or 0.9 sodium chloride irrigation to remove any surface debris of old exudate.

A nurse is collecting data from a client who has fluid-volume excess. Which of the following findings should the nurse expect?

Crackles in the lung fields. Rationale- manifestations of fluid volume excess include crackles in the lungs, dependent edema, full neck veins when the client is upright, increased blood pressure and sudden weight gain.

A nurse in a providers office is reviewing the medication history of a client. The client asks the nurse if she should begin taking high dose vitamins as she aged. Which of the following pieces of information should the nurse provide about high does of vitamin supplements

High doses of water soluble vitamins can have adverse effects Rationale- can harm the body

A nurse is reinforcing teaching with a group of older adult about expected changes of aging. Which of the following statements by a group of member indicates that the teaching has been effective?

I should expect my heart rate to take longer to return to normal after exercise as I get older. Rationale: older adults experience decreased cardiac output which cause increased pulse rate during exercise. However the pulse rate takes longer to return to normal after exercise.

A nurse in emergency department is caring for an inmate who has laceration and is bleeding. The client was brought to the facility by a guard who ask the nurse about the clients hiv infection status. Which of the following actions should the nurse take?

Instruct the guard to ask the inmate Rationale: the nurse is not able to supply this information to the guard. In order for the guard to obtain this information, the client must offer the information freely.

A nurse is part of a committee that is developing age appropriate care standards for older adult clients. Which of eriksons Developments task should the nurse recommend as the focus?

Integrity c's despair is the conflict that older adult clients must resolve when they reflect on their lives and roles. If a client has achieved a sense of unity and fulfillment about life, he/she will accept death with sense sense of integrity not fear.

A nurse is assisting with planning care for a client who has snore is and nausea due to cancer treatment. Which of the following interventions should the nurse suggest?

Limit drinking liquids when eating food Rationale: drinking beverages with food leafs to early satiety and bloating, which results in the client consuming fewer calories.

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)

Provide oral care to a client who cannot take oral fluids. Rationale- providing oral care to a client who cannot take oral fluids is within the range of function for an AP. Therefore, the nurse can assign this task to the AP

A nurse on medical unit is caring for a client who has a seizure disorder. Which of the following items is the nurse priority to keep near the clients at all times?

Suction equipment. Rationale- the greatest risk to a client who has seizure is an injury from aspirating secretions or vomited therefore the nurse should have suction equipment available to use clear the clients mouth of secretions or vomited and reduce this risk.

A nurse in an acute care clinic is talking with a client who reports that her osteoarthritis pain in her knees is increasing each day. The client wants to discuss non pharmacological approaches that will help relive her pain. Which of the following interventions should the nurse suggest?

Apply warm compresses to sore joints Rationale: warm packs or warm soaks such as in a bath or hot tub are often effective for relieving arthritic pain. The nurse should encourage they the client to avoid temperatures hot enough to cause burns. She should use a temperature just a little warmer than body temperature for optimal comfort.

A nurse is collecting data from a client who has asthma and resorts several food allergies. Which of the following actions should the nurse perform first?

Ask the client to identify the specific food allergies. Rationale: the first action the nurse should take is to collect data about the clients allergies and identify the specific allergens so that the nurse can ensure those foods are not offered to the client during meals

A nurse is assisting with teaching newest license nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include.

Clients who are age 65 or older are reluctant to report pain. Rationale- clients age 65 and older frequently are reluctant to report pain because they might not want to bother or anger caregivers and might believe that pain is expected. Nurses should recognize that these clients might not report pain that they are experiencing.

A nurse in a providers clinic is taking a clients age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process.

Data collection Rationale- gathering this information is included in the data collection portion of the nursing process. In addition the nurse should explore the clients health history and perform physical examination

A nurse is assisting with the care of client who is in labor. Which of the following findings should the nurse report to the provider?

Fetal heart rate baseline of 90bpm.Rationale: a fetal rate baseline of 90b is considered bradycardia and should be reported the provider. Fetal bradycardia is associated with fetal cardiac defects, maternal hypoglycemia and fetal viral infections.

A charge nurse on a medical surgical unit is assigning client care for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel.

Measuring Clemente intake and output. Providing postmortem care to a client. Rationale: measuring clients intake and output and providing postmortem care are within the range of function for an assistive personnel (AP)

A nurse is preparing a client who is schedule for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider about the clients decision. Rationale-acting as the client advocate. The nurse should support the client in her decision and notify the provider.

During the insertion of a urinary catheter for a client, the tip of the catheter brushed against the nurse arm. Which of the following actions should the nurse take?

Obtain a new catheter and reattempt insertion. Rationale- insertion of a urinary catheter is a steroid procedure. The only way to ensure sterility is to obtain a new sterile catheter and by following surgical asepsis through the insertion procedure.

A nurse is caring for a client who has neurocognitive disorder and wanders at night. Which of the following actions should the nurse take promote the client safety?

Put the clients mattress on the floor. Rationale- this action reduces the clients risk of injury from falling out of bed when confused or getting up to wander

A nurse is helping a client change his hospital gown. The client has iv infusion and infusion pumps. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the iv line. Rationale- according to evidence based prestige, the nurse should first remove the gowns from the clients arm without the iv line. Beginning the process this way will enable the nurse to move the gown fully off the client and then stop the system to remove the gown from the line, resulting in minimal interruption of the iv flow

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. What should the nurse do?

Request a prescription for isotonic enteral nutrition formula. Rationale- nurse should assist a client who develops diarrhea while receiving NG tube feedings by consulting with the provider and the dietitian regarding changing the clients formula to an isotonic formula. The formulation can be easier for the client to digest and can decrease diarrhea.

A nurse is preparing to insert an NG tube for a client. Which will help the insertion of the tube?

Coat the tip of the tube with water soluble lubricant. Ask the client to swallow water while the tube enters her throat. Tell the client to tilt her head backward as insertion begins. Rationale- lubrications the tubes eases its passage. It's important to use water based gel that will dissolve if the tube slips into the clients airway. Using petroleum jelly could cause respiratory issues. Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the esophagus. Hyperextending the neck reduces the curvature of nasopharyngeal which facilitates the insertion of the NG tube.

A nurse is performing an otoscopic examination of a clients right ear. The light related is vis-à-vis in the lower quadrant of the type if tympanic membrane . What should the nurse take in response to this finding.

Document this an expected finding. Rationale: the light the is todo for reflects off the tympanic meme range is cone shaped or triangular. In the right ear it is visible in the lower right quadrant of the eardrum. In the left ear it's visible in the lower left quadrant.

A nurse in a providers office is reinforcing reach with a client who is experiencing stress due to the loss of job. Which of the following instructions should the nurse give?

Exercise for 140 minutes each week. Rationale- the nurse should instruct the client to exercise for 140 minutes per week or 20 min per day by participating in moderate intensity aerobic such as walking. Ex cerise can reduce stress and increase endorphin levels