med surg ATI

A nurse is assessing a client who has systemic lupus erythematosus and is taking hydroxylchlroroquine. The nurse should report which of the following adverse effects to the provider immediately?

Blurred vision. When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding to report to the provider is blurred vision, as this is a manifestation of hydroxychloroquine toxicity and can be an indication of retinal damage.

A nurse is admitting a client who has pertusis. Which of the following types of transmission-based precaution should the nurse intiate?

Droplet. The nurse should initiate droplet precautions for clients who have infections that spread by droplets larger than 5 microns, including mumps, streptococcal pharyngitis, and pertussis.

A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?

Wear an N95 respirator mask. The nurse should wear an N95 respirator mask or a high-efficiency particulate air (HEPA) filter mask when caring for a client who has an infection that requires airborne precautions, such as disseminated varicella zoster, rubeola, or tuberculosis.

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?

Contact precaution. Contact precautions are a type of transmission-based precaution for clients who have an infection, such as VRE, which spreads either by direct or indirect contact.

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

Mask. The nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 1 m (3 ft) of the client.

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

Measure head circumference every shift. The head circumference of a 6-year-old can't increase since the fontanels and sutures have been closed since the child was 18 months old. Therefore, it is unnecessary to measure the child's head circumference.

A nurse is providing teaching a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instructions shuold the nurse provides?

Wash the affected area with soap and water before applying cream. The client should wash the affected area with soap and water and dry it thoroughly before applying the cream.

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

Purulent drainage is noted from the site. Signs of infection include warmth, redness, swelling, and possible purulent drainage.

A nurse is caring for a client who has cancer and is receiving total parental nutrition (TPN). Which of the following lab values indicates the treatment is effective?

Albumin 4.2 g/dL Clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the expected reference range and indicates the client is receiving adequate amounts of protein.

A nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which of the following actions should the nurse take when the client reports bleeding gums?

Check the value of the client's current platelet count. The nurse should recognize that the bleeding is likely due to the adverse effect of the chemotherapy and needs to be evaluated further. Bleeding gums is a sign of thrombocytopenia (decreased platelet count) secondary to bone marrow suppression, which can be life-threatening in a client who is receiving chemotherapy.

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment(PPE) should the nurse remove first ?

Glove The nurse should remove the gloves first, as they are the most contaminated.

A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE tiems should the nurse remove first?

Gloves According to evidence-based practice, the nurse should remove the most contaminated item, the gloves, first.

A nurse is caring for a client who has active pulmonary tuberculosis(TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport and client safely to the radiology department for a chest x-ray?

Have the client wear a mask. When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last?

Mask. With a client who requires airborne precautions, the nurse will continue to need the protection of the mask while removing other contaminated PPE.

A nurse is caring for a client who ahs had an allogeneic hematopoitetic stem-cell transplant. Which of the following infection-control precautions shuold the nurse use while caring for this client?

Protective. Clients whose immune system is compromised, such as from chemotherapy, AIDS, or after a stem-cell transplant, require a protective environment.

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following information should the nurse provide?

Urine and other secretions might turn orange. Rifampin might turn the urine and other secretions reddish-orange. This includes sputum, tears, and sweat.

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

WBC cound. An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

Wear clean glove. The nurse should wear clean gloves to prevent the transmission of MRSA.

A nurse is preparing to administer amoxicillin 500 mg PO every 12hr. The amount available is amoxicillin 250mg/5mL suspension. How many mL should the nurse administer? (round the whole nurmber)

10 mL

A nurse is providing discharge to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hr as needed. The amount available is diphenhydramine elixir 12.5mg/5mL. How many mL should the nurse administer per dose? ( round to the tenth).

10 mL

A nurse is providing teaching to a client who has oral canididiasis and a new prescription of nystatin suspension. Which of the following statements by the client indiciates an understanding of the teaching?

I will store the medication at room temperature. Nystatin oral suspension should be stored at room temperature.

A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

I will wear gloves and a gown when bathing a client who has open skin lesions. The AP should wear personal protective equipment when in direct contact with a client's bodily fluids, such as gloves and a gown when coming in contact with wound exudate is possible.

A nurse is admitting a child who has leukemia. Which of the following clients shuold the nurse place in the same room with this child?

A child who has nephrotic syndrome. A child who has leukemia is at risk for infection. Nephrotic syndrome is not an infectious disorder poses no risk to a child who has leukemia.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (selct all that apply)

1. emptung urine from an indwelling urine collection bag. 2. providing oral care. 3. Changing an ostomy pouch. Delivering a food tray to a client who has AIDS is incorrect. Standard precautions indicate that the nurse does not have to wear gloves unless in direct contact with bodily fluids, nonintact skin, mucous membranes or contaminated items. Delivering food trays to clients is not included in standard precautions. Placing oral medication tablets into a client's hand is incorrect. Standard precautions indicate that the nurse does not have to wear gloves unless in direct contact with bodily fluids, nonintact skin, mucous membranes or contaminated items. Administering medications to a client is not included in standard precautions.

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precaution should the nurse initiate for the client?

Airborn precaution The nurse should initiate airborne precautions when a client has an infection that spreads through small droplets that remain airborne for longer periods, such as tuberculosis and measles. The client requires a negative-pressure airflow room, and staff should wear an N95 respirator when in contact with the client.

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

Gloves The greatest risk to safety is pathogen transmission. The gloves are the most contaminated item of PPE, so the nurse should remove them first. Failing to remove the most contaminated item first increases this risk.

A nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching?

I'll call my doctor if I notive any unusual menstrual bleeding. Clients should be taught bleeding precautions and to report bruising or excessive bleeding.

A nurse is caring for a client who has an infection. The nurse shuold use which of the following strategies to prevent the transmission of the client's infection?

Performing hand hygiene before, during, and after direct contact with the client. The nurse can help prevent the transmission of micro-organisms by washing her hands frequently before, during, and after client care procedures.

A nurse is caring for a child who has a suspected diagnosis of bacterial meningities. Which of the following actions is the nurse's priority?

Place the child in isolation. Bacterial meningitis is highly contagious. Therefore, the nurse should protect others from infection by placing the child in isolation.

A nurse is preparing a sterile field. Which of the following actions should the nures perform when opening the sterile pack?

Reach around the pack and open the top flap away from the body. The nurse should pull the uppermost flap away from her body, grasping it from the side to avoid reaching over the sterile field and contaminating it.

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive pressure airflow room. To which of the following rooms should the nurse assign the client?

Room 208. A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds. The staff should rub the product over all aspects of the hands and fingers until they are dry, which generally takes 20 to 30 seconds.

A nurse is caring for a client who has E. coli infection and a prescription for gentamicin 5 mg/kg/day by intermittent IV bolus every 8 hr. Which of the following manifestations indicate the client is experiencing gentamicin toxicity? (select all that apply).

Tinnitus and dizziness. Insomnia is incorrect. A client with gentamicin toxicity is at risk for neurotoxicity. Clinical manifestations can include ringing of the ears and complaints of dizziness. -Tinnitus is correct. A client with gentamicin toxicity is at risk for neurotoxicity. Clinical manifestations can include ringing of the ears and complaints of dizziness. -Dizziness is correct. A client with gentamicin toxicity is at risk for neurotoxicity. Clinical manifestations can include ringing of the ears and complaints of dizziness. -Restlessness is incorrect. A client with gentamicin toxicity is at risk for neurotoxicity. Clinical manifestations can include ringing of the ears and complaints of dizziness. -Xerostomia is incorrect. A client with gentamicin toxicity is at risk for neurotoxicity. Clinical manifestations can include ringing of the ears and complaints of dizziness.

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area of the puncture thoroghly with soap and water. The greatest risk to this client is injury from any bloodborne pathogens on the needle; therefore, the first action the nurse should take is to provide immediate first aid by scrubbing the area thoroughly with soap and water.

A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, " why do I need that? I am drinking plenty of fluids. Which of the following responses should the nurse provide?

Your provider has prescribed antibiotic therapy to be administered IV every 6 hours. Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.

A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has a staphylococci infection. Available is clindamycin premisxed in 50 mL 0.9% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr ? ( round to the whole number).

100 mL/hr

A nurse is caring for client who has sepsis and a prescription for vancomycin 1 g in 250 mL dextrose 5% (D5W) over 2 hr IV intermittent bolous. The nurse should set the IV pump to deliver how many mL/hr? (round to the whole number).

125 mL/hr

A nurse is caring for a client who is prescribed tetracylcine 2 grams daily PO in four divdided doses eery 6 hr. Available is tetracylcine 250 mg capsules. How many capsules should the nurse administer per dose? (round the tenth).

2 capsules

A nurse is caring for a client who has a fungal infection and has a new prescription for amphotericin N. Which of the following laboratory values should the nurse report to the provider before initiating the medication?

BUN 55 mg/dL This BUN level is above the expected reference range (10-20 mg/dL). Amphotericin B is nephrotoxic and is contraindicated if BUN is > 40mg/dL. The nurse should report this laboratory value to the provider before initiating the medication.

A nurse is caring for a client in the ED who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first?

Date of the client's last tetanus immunization. The greatest risk to this client is injury from infection with Clostridium tetani; therefore, the priority assessment the nurse should perform is to determine whether the client will require a tetanus immunization by identifying the date the client last received one. An adult should have a tetanus booster immunization every 10 years and after any severe or dirty wound.

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

Opening a sterile package over the middle of the sterile field. Opening a sterile package over the middle of the sterile filed requires reaching into the field, which can result in contamination. The nurse should place the object on the field by approaching the field from an angle.

A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?

Perfom hand hygiene frequently and consistently. The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care.

A nurses is reviewing the medical record for a client who has a health care- associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?

The client is 71 years old. Clients older than 70 years of age are at an increased risk of acquiring an HAI. Decreased immune system function increases the susceptibility to infection.

A nurse is assessing a client prior to administering a seasonal influenza vaccine. The client says he read about an influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize that which of the following findings is a contraindication for the client receiving the live attenuated infleunza vaccine (LAIV)?

The client's age is 62. Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is contraindicated for this client. Pregnancy and immunocompromised status are also contraindications.

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Whihc of the following precautions should the nurse include when creating a sign to post outside of the client's room> ( select all that apply)

-A protective mask is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering the room requires respiratory protection, in the form of an appropriate filtration mask. -A closed door is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering or leaving the room should close the door behind them.- -A gown is incorrect. Gowns are unnecessary for every individual entering the room; however, any staff who anticipate contact with body fluids should wear them. -A puncture-proof sharps container is correct. Nurses must always dispose of needles and sharp instruments in puncture-proof sharps containers. -Hand hygiene is correct. Hand hygiene is essential before and after all contact with clients.

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (select all that apply).

-Providing hygiene care to a client who is HIV-positive is incorrect. Unless the nurse has any reason to believe that the client's body fluids will splash into her eyes, the nurse does not need to wear eye protection. -Emptying a urinary drainage bag for a client who has pneumonia is incorrect. Unless the nurse has any reason to believe that the client's body fluids will splash into her eyes, the nurse does not need to wear eye protection. -Irrigating a client's abdominal wound is correct. The nurse should wear protective eyewear when irrigating a wound because wound exudate and fluids could splash into her eyes. -Transporting a cerebrospinal fluid specimen to the laboratory is incorrect. The cerebrospinal fluid is in a sealed specimen container, so there is no reason for the nurse to anticipate it splashing into her eyes. -Suctioning a client's new tracheostomy tube is correct. The nurse should wear protective eyewear when performing tracheal suctioning because the client's secretions could splash into her eyes.

A nurse is preparing to aminister fluconazole 400 mg by intermittent IV bolus daily. Available is fluconazole 400 mg in 0.9% sodium chloride (NaCl) 200 mL to infuse over 2 hr. The nurse should set the IV pump to deliver how many mL/hr? ( Round to the tenth/whole number).

100 mL

A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room.

Remove the gloves- > remove the eyewear -> remove the gown, -> remove the face mask -> perform hand hygiene. The nurse should remove the most contaminated item of PPE first and the least contaminated item last. The gloves are the most contaminated, so the nurse should remove them first, and then the eyewear, the gown, and finally, the mask. Finally, the nurse should perform hand hygiene and then leave the room.

A public health nurse is teaching a group of nurses about smallpox. Which of the following statements by one of the nurses indicates understanding of the teaching?

unlike chickenpox, the vesicles of smallpox are more abundant on the face. he rash in smallpox is more centrifugal than chickenpox in its presence of lesions. The lesions appear mostly on the face and extremities. Chickenpox lesions are centripetal with lesions more frequently found on the trunk of the body.

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

wear a mask when providing care to the client. The nurse should wear a mask when within 3 feet of a client who requires droplet precautions.