Virtual ATI - Fundamentals
Normal range for creatinine
0.6-1.2
What is the normal levels of lithium?
0.6-1.2
To promote healing, what should be the protein intake for a patient?
1.5g/kg
Normal peak expiratory flowrate (PEFR)
10 L/sec or 600L/min (80%-100%)
Normal range for BUN
10-20 mg/dL
What is considered a fever for an infant?
100.4 or above
Normal Heart Rate for a Newborn
120-160
A nurse is caring for a client who is pregnant with a singe fetus and has a BMI of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate
25-35 lbs; (average weight gain with an average BMI is 11.5-16kg)
Normal Respiratory Rate for Newborn
30-60
To promote wound healing, what should be the proper total caloric intake?
35-40 kcal/kg
What is normal level for PCO2
35-45 mm hg
When can an infant turn from his abdomen to his back?
5 months old
When can an infant sit up without support?
6-8 months
When can an infant crawl on his hands and knees?
8-10 months
When can an infant pull up to a straight position?
8-10 months
Normal body temperature range
97.6-99.6
A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider? A client who has diabetes mellitus with a fasting blood glucose of 150 mg/dL A client who is prescribed digoxin (Lanoxin) and furosemide (lasix) with a potassium of 3.1 mEq/L A client who is prescribed oxygen therapy and albuterol (Proventil) with a PCO2 of 50 mm Hg
A client who is prescribed digoxin and furosemide This value is clearly abnormal and indicates that the client has hypokalemia, or decreased potassium. This is a common complication with the use of loop diuretics, such as furosemide. The nurse should also note that the client receives digoxin. Hypokalemia places the client at increased risk for digoxin toxicity, so this is the client who is at immediate risk for injury and whose laboratory findings should be reported to the provider.
A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles in the nurse functioning? Advocate Clinician Educator Manager
Advocate
What type of precautions is measles?
Airborne
A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin?
Allow the child to manipulate the medical equipment.
A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril? Aspirin (Bayer) Acetaminophen (Tylonal) Guaifenesin (Robitussin) Diphenhydramine hydrochloride (Benadryl)
Aspirin Aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE inhibitor. The nurse should reinforce to the client that aspirin has the potential to reduce the antihypertensive effect of captopril and should be avoided.
A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? Assessment Background Situation Recommnedation
Assessment
A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. A client reports burning pain in his chest. Which of the following actions by the nurse is appropriate?
Assist the client to a side-lying position - to move the top of the chest tube away from the tissues
A nurse is caring for a client with a spinal cord injury who has an indwelling catheter. Which of the following is the highest priority when providing perineal care for this client? Select one: a. Assess for perineal pain or discomfort. b. Assess the client's knowledge of importance of perineal hygiene. c. Avoid inadvertently advancing the catheter into the bladder. d. Examine condition of catheter and drainage tubing.
Avoid inadvertently advancing the catheter into the bladder
A nurse is teaching a client who has lower extremity how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? Support the majority of your weight on the axillae Keep your elbows extended Bear weight on both of your legs Move both crutches forward at the same time
Bear weight on both of your legs
A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching? Select one: a. Wheat bread b. Chicken breast c. Baked potato d. Broccoli with cheese sauce
Broccoli with cheese sauce Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats. Fat intake should be limited to reduce stimulation of the gallbladder. Other foods that may be contraindicated include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods.
A nurse caring for client who is recovering from a colon resection is changing the dressing over the client's incision. Which of the following is an appropriate action by the nurse? A. Use sterile gloves to remove the old dressing B. Place old dressing in the client's trash can C. Open sterile dressings before putting on sterile gloves D. Put date and time on dressing using a marker
C
A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care? a. Change tracheostomy ties when soiled. b. Remove soiled dressing with sterile gloves. c. Suction the tracheostomy before beginning care. d. Clean disposable inner cannula with hydrogen peroxide.
Change tracheostomy ties when soiled. CORRECT. Tracheostomy ties should be changed once a day or when soiled. Secure new ties in place before removing old soiled ones to prevent accidental decannulation. One or two fingers should be able to be placed between the tie tape and the neck.
A nurse is collecting a diet history for a client with chronic renal failure. Which food choice indicates the client would benefit from further education? Select one: a. Cheddar cheese b. Small sweet potato c. Wheat bread d. Small amounts of kiwi
Cheddar Cheese
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? Cover the incision with a moist sterile dressing Have the client lay on his back with his knees flexed Call the client's surgeon Reassure the client
Cover the incision with a moist sterile dressing
A nurse is caring for a client who is receiving bolus tube feedings via a gastrostomy tube. Which of the following is an appropriate action the nurse should take when preparing to administer the feeding? A: Assess condition of the nares through which the tube is inserted B: Flush the gastrostomy tube with 30 mL of normal saline C: Place amount of tube feeding in bag that will run in within 4 hours D: Verify placement of tube by checking pH of stomach aspirate
D; A is incorrect because the patient does not have an NG tube but a tube through the abdomen wall B is incorrect because although 30ml is correct for a flush, you should use tap water C is incorrect because this is not a continuous feeding; it is a bolus
A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? (Select all that apply) Drooling Stridor Difficulty Swallowing Croupy Cough High-Grade Fever
Drooling, stridor, difficulty swallowing, high-grade fever
What type of precautions is rubella?
Droplet
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? Redness at the infusion site Edema at the infusion site Warmth at the infusion site Oozing of blood at the infusion site
Edema at the infusion site
A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis?
Elevated Temperature
What is symptom of pregnancy-induced hypertension that should be reported to a doctor?
Facial Edema
A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1 Liter of IV fluid over 2 hours. Which intervention is the priority? Select one: a. Monitor urine output. b. Fill out an incident report. c. Report the defective equipment. d. Document the amount of fluid infused.
Fill out an incident report
A nurse is providing dietary education to a client with a new ileostomy. What foods should the nurse instruct the client to avoid in the first weeks after surgery? Select one: a. Lean meats b. Strained fruit juices c. Cream cheese d. Fresh vegetables
Fresh Vegetables During the first weeks after surgery, many providers recommend low fiber diets, particularly for clients with ileostomies, because the small bowel requires time to adapt to the diversion. Cream cheese is low in fiber and would therefore be included in the dietary recommendations for the client.
A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls? Select one: a. Hourly rounding by the nurse. b. Use of a night-light. . d. Place bedside table in close proximity.
Hourly Rounding by the Nurse
A nurse is caring for a neonate who was delivered at weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for?
Hypoglycemia because It is a corticosteroid (hyperglycemia in mother)
A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching? I should eat frequently I should avoid eating 1-2 hours prior to my treatment I should eat foods served cold I should eat low carb foods
I should eat low carbohydrate foods. Clients who are experiencing nausea should eat foods high in carbohydrates, such as crackers, yogurt, toast, bananas, and sherbet.
A nurse is preparing a client for discharge after an anterior-posterior colporrhaphy. Which of the following statements made by the client indicates a need for further teaching? Select one: a. "I will increase my fiber intake to stay regular." b. "I will tighten my pelvic muscles when coughing." c. "I will avoid standing for prolonged periods of time." d. "I will increase my daily fluid intake."
I will increase my fiber intake to stay regular
A nurse is providing discharge education for a female client diagnosed with Chlamydia. Which statement made by the client would indicate the need for further instruction? Select one: a. "Symptoms of reinfection may include yellow vaginal discharge." b. "Possible complications to monitor for include pelvic inflammatory disease." c. "I will refrain from sexual intercourse until completion of antibiotics." d. "I will return to the clinic in one month for re-screening."
I will return to the clinic in one month for re-screening.
A nurse is caring for a client who is from a culture different than his own. Which action by the nurse is most important in the provision of culturally competent care? Include the family in the client's care identify one's own beliefs and values determine the client's cultural beliefs encourage the client to discuss the influence of illness on cultural practices
Identify one's own beliefs and values
A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurses' priority concern? Facial Abrasions Penetrating Head Wound Incomplete amputation of the foot Tibia fracture requiring open reduction
Incomplete amputation of the foot; Should be assigned to the immediate triage category because injuries are life-threatening, but survivable if immediate care is received Penetrating head wounds would be black tag because likelyhood of survival is slim
What type of medication is Acetylcysteine
Mucolytic agent; management of acetaminohphen poisoning
A nurse manager is teaching a group of newly licensed nurses about VRE infections. Which of the following information should the nurse manager include in the teaching? VRE infection is transmitted through the air by coughing and sneezing VRE infection requires health care workers to wear an N95 respirator VRE infection is treated with vancomycin antibiotics VRE is a nosocomial infection
Nosocomial infection
A nurse is caring for a todler who has taryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse? Administer nebulized epinephrine Ensure adequate hydration Obtain an oxygen saturation level Encourage parents to comfort the client
Obtain an oxygen saturation level ASSESSMENT FIRST
A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak? Lethargy Neuralgia Bradycardia Oliguria
Oliguria When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death.
A nurse is preparing to provide chest physiotherapy for client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? Place the client in Trendelenburg's position Perform percussions directly over the client's bare skin Use a flattened hand to perform percussions Remind the client that chest percussions can cause mild pain
Place the client in Trendelenburg's Position (place patient in right side lying position)
A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. Which of the following foods should the nurse instruct the client to avoid? Select one: a. Broiled liver and white rice. b. Roast chicken and cooked spinach. c. Pork chop and brown rice. d. Grilled salmon and cooked apricots.
Pork Chop and Brown Rice
A nurse is caring for a client who is receiving intermittent enteral feedings via G tube. Which of the following actions should the nurse take when administering the feeding? Unclamp the client's G-Tube before connecting the syringe to it Verify that the client's gastric pH is at least 7 prior to feeding Pour the client's formula into the syringe, raising or lowering it to control the rate of flow Apply sterile gloves before accessing the client's G-Tube
Pour the client's formula into the syringe, raising or lowering it to control the rate of flow
A nurse is educating a client who observes Kosher laws of food preparation. When planning menus with this client, which of the following would not be an appropriate food choice? Select one: a. Eggs b. Rabbit c. Tuna d. Spinach
Rabbit
A client with pneumonia has an oxygen saturation of 85%, heart rate of 88, respiratory rate of 22, and blood pressure of 132/88. Which of the following is the priority nursing intervention? Select one: a. Reassess pulse oximetry b. Administer albuterol inhaler c. Immediately notify the provider d. Place the client on 2 Liters oxygen
Reassess pulse oximetry
A nurse is caring for a client with a diagnosis of sepsis with a temperature of 40.8 C (105.5 F). The provider has ordered a cooling blanket. Which intervention is appropriate to delegate to an Unlicensed Assistive Personnel (UAP)? Select one: a. Obtain a fan for the client's use b. Bathe the client to keep the skin damp c. Report shivering by the client d. Assess the client's skin for any reddened
Report shivering by the client
A nurse is caring for school-age client was diagnosed with sickle cell anemia and has been admitted for vaso-occlusive crisis. Which of the following findings has the highest priority?
Slurred Speech
A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider? Fine hand tremors Mild Thirst Weight gain Slurred Speech
Slurred speech all four actions are adverse effects of lithium and should be reported to the provider, but one of the findings needs to be reported immediately
A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching? Lentils Soybeans Broccoli Oatmeal
Soybeans; food sources of complete proteins contain sufficient quantities of all nine essential amino acids to support body growth and maintenance
A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis?
Sputum culture for acid-fast bacillus
What type of precautions for Rocky Mountain spotted Fever?
Standard
What type of precautions is for Hep A?
Standard
A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching? My child will need to be followed medically for at least 5 years My child can resume moderate activity after his fever subsides This illness will not recur because my child has now had it In a few weeks or months by child could experience sudden, involuntary movements.
This illness will not recur because my child has now had it. It is possible for rheumatic fever to recur, so prophylactic treatment with monthly IM injections of benzathine penicillin G, or daily oral doses of penicillin or sulfadiazine, will be needed. This statement by the parent is not appropriate and indicates a need for further teaching.
A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching (STTA) Urinary Tract Surgical Wound Musculoskeletal System Respiratory Tract Blood Stream
Urinary Tract, Surgical Wound, Respiratory Tract, Blood Stream
In SBAR, what should be in the Assessment?
VS, Pain assessment, changes in assessment findings
What type of medication is Amyl Nitrite
Vasodilator; can treat and prevent chest pain (angina)
What is the safest muscle to administer an IM for a young adult client?
Ventrogluteal
What are three signs of digoxin toxicity?
Vomiting, slow heart rate, and anorexia
A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine ear drops for pain relief. Which of following actions by the nurse is appropriate when administering the ear drops?
Warm refrigerated drops to room temp prior to instillation
A fire in a first floor operating room is forcing evacuation of clients from a second floor unit to another building. Which of the following clients would have the highest priority for the charge nurse to evacuate? Select one: a. A client receiving IV antibiotics every six hours for a leg ulcer. b. A client semi-comatose after a cerebrovascular accident with an indwelling urinary catheter. c. A client post left hip replacement of two days ago whose daughter is visiting. d. A client admitted with pancreatitis with nasogastric tube and PCA pump in place.
a. A client receiving IV antibiotics every six hours for a leg ulcer.
What type of medication is Buspirone?
an anxiolytic medication to treat anxiety
myasthenia gravis (MG)
autoimmune neuromuscular disorder characterized by weakness of voluntary muscles (common symptoms are loss of bladder and bowel control, diplopia, parethesias)
Intrinsic motivation
behavior that is driven by internal rewards
What does Vitamin K help?
blood clotting
s/sx of hemolytic reaction
chills, low back pain, hypotension, tachycardia
Serous drainage
clear or slightly yellow thin plasma
A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions? Select one: a. "I should increase my fluid intake to 8-10 glasses of water a day." b. "I should increase my consumption of protein." c. "I should consume a diet low in carbohydrates." d. "I should limit my sodium intake to 4 grams per day."
d. "I should limit my sodium intake to 4 grams per day."
A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention? Select one: a. The baby has an axillary temperature of 100.4 F. (38 C) b. The baby develops swelling or redness at the injection site c. The baby develops a localized or generalized rash d. The baby is crying inconsolably for more than three hours
d. The baby is crying inconsolably for more than three hours
Oliguria
decreased urine output (<400-500 ml in 24 hours)
Rheumatic Fever
disease that affects heart, joints, brain, and skin. Can develop if strep throat and scarlet fever if not treated
Nonmaleficence
do no harm
S/Sx of circulatory overload
dyspnea, cough, headache, hypertension
Justice
fairness
Fidelity
faithfulness
s/sx febrile reaction
fever, chills, headache, flushing
s/sx of sepsis reaction
high fever, vomiting, diarrhea
Autonomy
independence
How is borderline personality disorder is characterized?
interpersonal relationships, emotional instability, impulsitivity, unstable mood, and self image distortions
In SBAR, what should background include?
medical history, lab findings, allergies, code
What kind of drug is Cromolyn Sodium?
non-steroidal anti-inflammatory (asthma prophylactic)
A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of following is the priority action by the nurse? Wrap the cord in a towel saturated with 0.9% sodium chloride Apply oxygen via face mask Place client in knee-chest position Increase IV fluid rate
place client in knee-chest position Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the fetus off the cord.
In SBAR, what should be in the situation?
problems the client is experiencing
Dumping syndrome
results from emptying of the stomach into the small intestine after eating, and manifests as vertigo, tachycardia, syncope, sweating, pallor, palpitations
After a supratentorial craniotomy, what position should the patient be in?
supine with head elevated to 30 degrees; promote drainage and prevents hemorrhage by reducing blood flow to the brain
What are the symptoms of acute alcohol withdrawal?
tachycardia, hypertension, diaphoresis, disorientation, hand tremors; can progress visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, grand mal seizures
Purulent Drainage
thick, milky liquid or thick liquid that turns yellow, tan, grey, green or brown
Saguineous drainage
thick, red blood
What does abdominal distention mean in a newborn?
tumor or abdominal wall defect
What is solifenacin (vesicare) used for?
urinary incontinence
Right sided Hemiparesis
weakness on the right side of the body
Leukorrhea
white discharge from the vagina
