SKILL SET ATI ( MOBILITY, INFECTION, BOWEL ELIMINATION, OSTOMY CARE)

A nurse is teaching a client who has bladder cancer about urinary diversion options. The nurse should inform the client that which of the following options will allow them to have some control over urinary eliminations? 1. Kock's pouch 2. Ileal conduit 3. Cutaneous ureterostomy 4. Nephrostomy

Kock's pouch *A Kock's pouch is a continent ileal bladder conduit that does not require an external drainage collection device because the client self-catheterizes every 2 to 4 hr to remove urine. This device will allow the client to have some control over urinary elimination.

Contact precautions would be mandated for a hospitalized adult patient diagnosed with? 1. Hepatitis B 2. Measles 3. Meningitis 4. Infectious Diarrhea

Infectious diarrhea *Hepatitis B - standard Measles - airborne Meningitis - droplet

A Nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? 1. Place the client in the dorsal recumbent position on the bedpan 2. Administer the enema while the client sits on the toilet 3.Administer an antidiarrheal medication 3 hrs prior to enema 4. Instill 200 ml of fluid over an hour at 15 min intervals

1- Place the patient in the dorsal recumbent position on a bedpan *A patient who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the patient over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid likely to be expelled promptly and thus help maintain the patient's dignity.

A nurse is observing an assistive personnel (AP) who is using a mechanical lift w/ a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene? 1. Places a removable cover over the sling 2. Leaves the bed in the lowest position throughout the procedure 3. Locks the hydraulic valve before attaching the sling to the lift 4. Raises the head of the bed to a sitting position just before transfer

Leaves the bed in the lowest position throughout the procedure *the bed should be raised to a comfortable working position in order to prevent injury to nursing staff and to properly position the lift under the client's bed.

After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respiration, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? 1. The gloves 2. The gown 3. The face shield 4. The N95 respirator

The gloves *Gloves are considered the most contaminated and should be removed first, followed by face/eye protection, gown, and mask/respirator.

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include? 1. "Lean on the crutches to support your body weight when standing." 2. "Fully extend your arms when holding onto the hand grips." 3. "Hold the crutches on your unaffected side when preparing to sit in a chair." 4. "Hold the crutches 9 inches in front of and to the side of each foot."

"Hold the crutches on your unaffected side when preparing to sit in a chair." *The crutches should be held on the unaffected side when preparing to sit in a chair.

A nurse is teaching a client about extended-wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence? 1. Use an oil-based lotion on the peristomal area. 2. Apply the skin barrier while the skin is slightly moist. 3. Leave the residue from the previous appliance on the skin. 4. Press gently around the barrier for 30 seconds to 1 min.

Press gently around the barrier for 30 seconds to 1 min. *The nurse should instruct the client to press gently around to barrier for 30 seconds to 1 min because the pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence.

A nurse is caring for a client who has mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client? 1. Wear a respirator 2. Protect their eyes 3. Put on clean gloves 4. Wear shoe covers

Protect their eyes.

A nurse is reinforcing teaching with a client about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest? 1. Lift up on both sides of the skin barrier simultaneously. 2. Release one corner of the barrier and pull it quickly over the stoma. 3. Push the skin away from the barrier while removing it. 4. Gently roll the barrier end-over-end across the stoma.

Push the skin away from the barrier while removing it. *If the client is experiencing pain with the initial release of the barrier, the nurse should suggest removing the barrier by starting in one corner and gently pulling it across the stoma while pushing the skin away from the barrier. This technique can help prevent skin stripping.

A nurse is reinforcing teaching with a client about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest? 1. Lift up on both sides of the skin barrier simultaneously. 2. Release one corner of the barrier and pull it quickly over the stoma. 3. Push the skin away from the barrier while removing it. 4. Gently roll the barrier end-over-end across the stoma.

Push the skin away from the barrier while removing it. *If the client is experiencing pain with the initial release of the barrier, the nurse should suggest removing the barrier by starting in one corner and gently pulling it across the stoma while pushing the skin away from the barrier. This technique can help prevent skin stripping.

A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions? 1. Prone 2.Dorsal Recumbent 3.Right lateral with both knees at chest 4. Left lateral with right leg flexed

4. Left lateral with the right leg flexed *This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The flexed leg promotes exposure of the anus for insertion of the rectal tube.

A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an older patient who has hyperkalemia. The nurse should insert the tip of the rectal tube 1. 2.5cm-3.5cm 2. 5cm-7.5cm 3. 7.5cm-10cm 4. 10cm-12.5cm

7.5 cm to 10 cm (3 to 4 in)

A nursing is caring for a client who has a healthcare-associated infection (HAI). Which of the following describes an exogenous HAI? 1. A salmonella infection that occurs after eating contaminated food from the cafeteria 2. An infection that occurs during a therapeutic procedure 3. A yeast infection that occurs while receiving broad spectrum antibiotics 4. A UTI that occurs after a sterile catheter insertion

A Salmonella infection that occurs after eating contaminated food at the cafeteria.

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique? 1. Positioning the chair slightly behind the nurse so that the seat faces the client's bed 2. Placing the client's left leg in front of the right leg just prior to the transfer 3. Aligning the nurse's knees with the client's knees just before the transfer 4. Grasping the client under the axillae to assist them to their feet

Aligning the nurse's knees with the client's knees just before the transfer *This is a correct strategy that helps the nurse safely stabilize the client while moving to a standing position.

A nurse is replacing the ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first? 1. Measure the stoma. 2. Cover the stoma with gauze. 3. Remove the backing on the skin barrier. 4. Cleanse the stoma and the peristomal skin.

Cleanse the stoma and the peristomal skin. *The first action the nurse should take is to remove any effluent adhering to the stoma and the peristomal skin to facilitate the assessment of the area.

A nurse is obtaining health history from a client who has a colostomy. The client reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The client tells the nurse that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend? 1. Consume foods that are low in fiber content. 2. Take an ounce of mineral oil twice a day. 3. Add buttermilk and cranberry juice to the diet. 4. Increase water intake to 3 to 3.5 L per day.

Consume foods that are low in fiber content. *The nurse should recommend that the client consume foods low in fiber to help thicken the stool. Examples of low-fiber foods include rice, noodles, white bread, and cheese.

What should the nurse do to maintain standard precautions? 1. Rinsing gloves that become visibly soiled during use 2. Using antimicrobial soap for routine handwashing 3. Disinfecting hands immediately after removing gloves 4. Keeping gloves on when touching environmental surfaces

Disinfecting hands immediately after removing gloves Although it might seem as though hands covered by intact gloves would be as clean as they were when you donned the gloves, it is an essential component of standard precautions to disinfect your hands immediately after glove removal. This often concludes a patient care procedure, and hand hygiene is mandated between patient contacts. Also, you cannot assume that the integrity of each glove has not been breached, that no powder or other residue remains on your hands, and that your hands have not been contaminated during glove removal.

To decontaminate your hands with an alcohol-based gel, you rub them together until all of the gel has evaporated and your hands are dry. The primary reason you do this is that? 1. Drying provides the full antiseptic effect 2. Residual alcohol can easily stain clothing 3. Excess gel could transfer to the client 4. Slippery gel can make the nurse drop supplies

Drying provides the full antiseptic effect.

A nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include? 1. Apply hydrocortisone cream to the skin when changing the appliance. 2. Empty the pouch when it is less than half full. 3. Wash the peristomal skin frequently with deodorizing soap and water. 4. Choose a time shortly after a meal for replacing the pouch.

Empty the pouch when it is less than half full. *The nurse should instruct the client to empty the pouch when it is between 1/3 to 1/2 full because waiting to empty the pouch until it is more than 1/2 full increases the risk of leakage. Leakage of Ileostomy effluent is irritating to peristomal skin

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take? 1. Wrap both arms around the client's arms and shoulders. 2. Move both feet together when the client begins to fall. 3. Protect the client's extremities while lowering them to the floor. 4. Extend one leg and allow the client to slide down the leg to the floor.

Extend one leg and allow the client to slide down the leg to the floor. *This action helps prevent injury to the client. As the client gets close to the floor, the nurse should bend both legs to continue supporting the client.

A nurse is about to irrigate a client's open wound. Besides gloves, which of the following ppe should the nurse wear? 1. sterile gown 2. Goggles 3.face shield 4. N95 respirator

Face shield

A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder? 1. Adducting the arm so that it lies next to the client's side 2. Flexing the shoulder by raising the arm from a side position to a 180° angle 3. Abducting the arm to a 90° angle from the side of the body 4. Circumducting the shoulder in a 180° half circle

Flexing the shoulder by raising the arm from a side position to a 180° angle *This demonstrates full ROM of shoulder. The client's fingers should be pointing directly upward.

A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure? 1. Cecostomy 2. Loop colostomy 3. Ileostomy 4. Descending colostomy

Ileostomy *After removing the entire large intestine and the rectum, the provider will create an ileostomy to divert feces from the small intestine to the abdominal surface and into an ostomy pouch

Which of the following is an advantage of using alcohol-based gel? 1. Its use takes less time than washing with soap and water does 2. It removes gross contamination better than soap and water 3. Its protective nature reduces the need for frequent hand washing 4. It provides adequate protection before surgical applications

Its use takes less time than washing with soap and water does *During an 8 hours shift, an estimated 1 hour of intensive care unit nurse's time is saved by handrubbing with an alcohol based ge

A nurse is administering a return flow enema to a client. After instilling 100 mL of enema fluid which of the following actions should the nurse take? 1. Instruct the client to retain the fluid 2. lower the container to allow the solution to flow back out 3.Help the client to the toilet or bedside commode 4. Wait 5 min and instill another 100mL of fluid

Lower the container to allow the solution to flow back out *Return flow enemas involve moving 100-200 mL of fluid into and out of the rectum. After instilling the solution, the nurse lowers the container to allow the solution to flow back into the container and then repeats the process five or six times.

While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following actions should the nurse take? 1. Measure the client's vital signs 2. Notify the primary care provider 3. Lower the enema fluid container 4. Stop the enema instillation

Lower the enema fluid container *Some abdominal cramping is to be expected during enema administration. To ease the patient's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container.

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take? 1. Place the stockings on the client after the client ambulates to the restroom. 2. Ensure the client's toes are visible after placing the stockings on the client. 3. After applying the stockings, place two fingers between the client's leg and stocking to check the fit. 4. Measure the client's calf circumference and leg length from heel to knee.

Measure the client's calf circumference and leg length from heel to knee. *To ensure proper fit, the nurse should measure the widest part of the client's calf as well as the length of client's leg from heel to knee. Antiembolic stockings that are too large will not apply the pressure needed to prevent DVT. Antiembolic stockings that are too small could impair circulation in the client's legs.

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip? 1.Move their leg behind their body. 2. Move their leg forward and up. 3. Move their leg medially toward their other leg.

Move their leg behind their body. *This movement demonstrates hyperextension of the hip.

Which of the following products can affect the permeability of gloves? 1.Antimicrobial soap and water 2.Alcohol based antiseptic gel 3.Petroleum based hand lotion 4.Water based hand lotion

Petroleum based hand lotion The use of petroleum based hand lotions or creams can impair the integrity of latex gloves, weakening them and increasing their permeability

A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? 1. Cleansing 2. Return-flow 3. Medicated 4. Oil-retention

Return flow *Return flow enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention.

A nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following info should the nurse include in the teaching? 1. Expect the effluent from the sigmoid colostomy to be loose and continuous. 2. Use irrigation to help establish a regular bowel pattern. 3. Change the stoma's appliance every other day. 4. Expect effluent from the newly created stoma within 24 hr after surgery.

Use irrigation to help establish a regular bowel pattern *Clients with sigmoid colostomies can use irrigation to help control the passage of stool. Once the client has established a regular bowel pattern, the they can wear a stoma cap over the site, but they do not need an external appliance.

A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following is an appropriate step in the procedure? 1. warm enema solution prior to instillation 2. prepare 1,500 mL of enema fluid 3.Use tap water as the enema fluid 4.Hang the enema container 24 inches above the anus

Warm the enema solution prior to instillation *It is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa.

After assisting a newly admitted patient in removing his shoes and outwear, the nurse notices what appears to be soil or grime on their hands. which of the following actions should the nurse take? 1. Cleanse your hands with an alcohol based gel 2. Wash your hands with soap and water 3. Brush off the soil against a cloth surface 4. Use a wet paper towel to remove the soil

Wash your hands with soap and water

A nurse is preparing to administer an oil retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for? 1. The duration of the procedure 2. 10-15 min 3. until the client feels the urge to defecate 4. at least 30 min

at least 30 minutes *The enema will be most effective in softening the stool and lubricating its passageway if the patient retains the oil for as long as he can - 1 to 3 hr if possible. It takes between 30 min and 3 hrs for the oil to exert its therapeutic effect.

A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the handwashing procedure, it is important to take which of the following actions 1. Make sure the water is hot 2. Wash for at least 20 seconds 3. Use a liquid soap prep 4. Remove rings and watches first

wash for at least 20 seconds * reduces bacterial counts and can remove loosely adherent transient flora