ATI Ch 53
A nurse is reviewing the medical record of a client who has hypocalcemia. the nurse should identify which of the following findings as risk factors for the development of this electrolyte imbalance? A. Crohn's Disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism
A. CORRECT: Crohn's disease is a risk factor for hypocalcemia. this malabsorption disorder places the client at risk for hypocalcemia due to inadequate calcium absorption. b. a thyroidectomy places the client at risk for hypocalcemia due to the possible removal of or injury to the parathyroid glands. c. a history of bone cancer increases the client's risk of hypercalcemia due to the shift of calcium from bone to ECF. d. Hyperthyroidism places the client at risk for hypercalcemia due to the shift of calcium from bone to ECF.
3.During new employee orientation, a nurse is explaining how to prevent Iv infections. Which of the following statements by an orientee indicates understanding of the preventive strategies?a."I will leave the Iv catheter in place after the client completes the course of Iv antibiotics."B."as long as I am working with the same client, I can use the same Iv catheter for my second insertion attempt." C."If my client needs to use the rest room, it would be safer to disconnect his Ivinfusion as long as I clean the injection port thoroughly with an antiseptic swab."D."I will replace any Iv catheter when I suspect contamination during insertion."
3.a. nurses should remove catheters as soon as they are no longer clinically necessary to eliminate a portal of entry for pathogens. b. nurses should use a sterile needle or catheter for each insertion attempt for safety and prevention of infection. c. nurses should not disconnect tubing for convenience, because this increases the risk of bacteria entering the system. D. CORRECT: nurses should replace IV catheters when suspecting any break in surgical aseptic technique, such as in emergency insertions.
A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule. B. Check the client's weight each morning. C. Notify the provider of a urine output greater than 30 ml/hr. D. Encourage independent ambulation four times a day.
a. Hypotension is a manifestation of dehydration therefore the administration of antihypertensive medication would further lower the client's blood pressure and increase the risk for injury. B. CORRECT: The nurse should include obtaining the client's weight each day in the plan of care. To ensure accuracy the client's weight should be obtained at the same time each day using the same scale. by determining the client's weight gain or loss each day the nurse can evaluate the client's response to treatment. c. a urine output greater than 30 ml/hr is an expected finding and is an indicator of adequate fluid balance. The nurse should plan to monitor the client's urine output and notify the provider if it is less than 30 ml/hr. d. The client who has dehydration is at risk for falls due to orthostatic hypotension, possible decrease in level of consciousness, and possible gait instability. The nurse should encourage the client to use the call light and ask for assistance when getting out of bed or ambulating.
2.a nurse is collecting data from a client who is receiving Iv therapy and reports pain in his arm, chills, and "not feeling well." the nurse notes warmth, edema, induration, and red streaking on the client's arm close to the Iv insertion site. Which of the following actions should the nurse plan to take first?a. obtain a specimen for culture.B. apply a warm compress.C. administer analgesics.D.Discontinue the infusion.
2. a. the nurse should obtain a specimen for culture to identify pathogens causing infection. however, another action is the priority. b. the nurse should apply a warm compress to promote healing and comfort. however, another action is the priority. c. the nurse should administer analgesics to promote comfort. however, another action is the priority. D. CORRECT: the greatest risk to this client is injury from infection. the first action the nurse should take is to stop the infusion and remove the catheter because the catheter might be the source of infection.
4.a nurse on the Iv team is conducting an in‑service education program about the complications of Iv therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (select all that apply.)a."the temperature around the Iv site is cooler."B."the rate of the infusion increases."C."the skin at the Iv site is red."D."the Iv dressing is damp."e."the tissue around the venipuncture site is swollen."
4.A.CORRECT: a decrease in skin temperature around the site is a manifestation of infiltration due to the Iv solution entering the subcutaneous tissue around the venipuncture site. b. when infiltration occurs, the rate of infusion can slow or stop, not increase, as the solution is no longer infusing directly into the vein. this occurs due to dislodgement of the catheter or rupture of the vein. c. when infiltration occurs, the skin around the Iv site is pale, not red, because the solution is no longer infusing directly into the vein and enters the subcutaneous tissue around the venipuncture site. D. CORRECT: a damp IV dressing is a common finding with infiltration due to the Iv solution entering the subcutaneous tissue and leaking out through the venipuncture site. E.CORRECT: swollen tissue around the venipuncture site is a manifestation of infiltration due to the Iv solution entering the subcutaneous tissue and causing swelling, as the fluid is no longer infusing into the vein.
5.a nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride Iv at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (select all that apply.)a."I feel lightheaded."B."I feel as though my heart is racing."C."I feel a little short of breath."D."the nurse technician told me that my blood pressure was 150 over 90."e."I think my ankles are less swollen."
5.a. a manifestation of fluid overload is hypertension. Lightheadedness is a manifestation of hypotension.B.CORRECT:a manifestation of fluid overload is tachycardia due to the increased blood volume, which causes the heart rate to increase.C.CORRECT:a manifestation of fluid overload is shortness of breath or dyspnea due to the increased amount of fluid entering the air spaces in the lungs, which reduces the amount of circulating oxygen.D.CORRECT:a manifestation of fluid overload is hypertension due to the increased blood volume, which causes the blood pressure to increase.e. a manifestation of fluid overload is edema. If the client's ankles are less swollen, this is an indication that the edema and the fluid overload are resolving.
A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? A. Infuse hypotonic IV fluids. B. Implement a fluid restriction. C. Increase sodium intake. D. Administer sodium polystyrene sulfonate.
A. CORRECT: Hypotonic IV fluids, such as 0.225% sodium chloride, are indicated for the treatment of hypernatremia related to fluid loss to expand the EcF volume and rehydrate the cells. b. Increased fluid intake is indicated for the treatment of hypernatremia. c. Decreased sodium intake is indicated for the treatment of hypernatremia. d. administration of sodium polystyrene sulfonate is indicated for the treatment of hyperkalemia.
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Pallor
A. CORRECT: Restlessness is an early manifestation of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. B. CORRECT: Tachypnea is an early manifestation of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. D. CORRECT: Confusion is an early manifestation of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. E. CORRECT: Pallor is an early manifestation of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. C. INCORRECT: Bradycardia is a late manifestation of hypoxemia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias.
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.
A. CORRECT: The nurse must be prepared to provide supplemental oxygen in response to any decline in oxygen saturation while performing tracheostomy care. B. CORRECT: The nurse should use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. C. CORRECT: This helps move mucus and contaminated material away from the stoma for easy removal. D. INCORRECT: To help keep the skin clean and dry, the nurse should replace the tracheostomy ties if they are wet or soiled. There is a risk of tube dislodgement with replacing the ties, so he should not replace them routinely. E. INCORRECT: The nurse should use a commercially prepared tracheostomy dressing with a slit in it. Cutting gauze squares can loosen lint or gauze fibers the client could aspirate.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? (Select all that apply.) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis, every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts.
A. CORRECT: The nurse should apply suction pressure only while withdrawing the catheter, not while inserting it. D. CORRECT: The nurse should not reuse the suction catheter unless an inline suctioning system is in place. E. CORRECT: To prevent hypoxemia, the nurse should limit each suctioning session to two to three attempts and allow at least 1 min between passes for ventilation and oxygenation. B. INCORRECT: The nurse should not suction routinely, because suctioning is not without risk. It can cause mucosal damage, bleeding, and bronchospasm. C. INCORRECT: Endotracheal suctioning requires surgical asepsis.
A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration? (select all that apply.) A. Hct 55% B. Serum osmolarity 260 mOsm/kg C. Serum sodium 150 meq/l D. Urine specific gravity 1.035 E. Serum creatinine 0.6 mg/dl
A. CORRECT: This Hct is greater than the expected reference range of 42‑52% for men and 37‑47% for women and is an indication of dehydration due to hemoconcentration. b. This serum osmolarity is within the expected reference range of 285‑295 mOsm/kg. a serum osmolarity greater than 295 mOsm/kg is an indication of dehydration. C. CORRECT: This serum sodium level is greater than the expected reference range of 136‑145 meq/l and is an indication of dehydration due to hemoconcentration. D. CORRECT: This urine specific gravity is greater than the expected reference range of 1.005‑1.030. an increased urine specific gravity is an indication of dehydration.e.This serum creatinine is within the expected reference range of 0.6 to 1.3 mg/dl. an elevated serum creatinine level is an indication of dehydration.
A nurse on a medical‑surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning. B. A client who has chronic constipation. C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took an overdose of sodium bicarbonate antacids
A.CORRECT: The nurse should identify that a client who has nasogastric suctioning is at risk for hypovolemia due to excessive gastrointestinal losses. B. diarrhea, rather than constipation, places the client at risk for hypovolemia due to excessive gastrointestinal losses. c. syndrome of inappropriate antidiuretic hormone places the client at risk for hypervolemia due to overhydration. d. an overdose of sodium bicarbonate antacids places the client at risk for hypervolemia due to excessive sodium intake.
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client to Fowler's position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases.
B. CORRECT: The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to care delivery is to relieve the client's dyspnea (difficulty breathing). Fowler's position facilitates maximal lung expansion and thus optimizes breathing. With the client in this position, the nurse can better assess and determine the cause of the client's dyspnea. A. INCORRECT: The client may need more oxygen, as hypoxemia may be the cause of his difficulty breathing. However, administering oxygen and adjusting the fraction of inspired oxygen requires the provider's prescription after a careful assessment of the client's oxygenation status. There is a higher priority given the nature of the client's distress.C. INCORRECT: The client may need suctioning or expectoration, as pulmonary secretions may be the cause of his difficulty breathing. However, there is a higher priority given the nature of the client's distress. D. INCORRECT: It is important to check the client's oxygenation status, and in many nursing situations, assessment precedes action, but there is a higher priority given the nature of the client's distress.
A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. Report any nasal stuffiness, nausea, or fatigue. E. Post "no smoking" signs in a prominent location
C. CORRECT: A disadvantage of this oxygen delivery device is that it dislodges easily. The client should form the habit of checking its position periodically and readjusting it as necessary. D. CORRECT: Oxygen toxicity is a complication of oxygen therapy, usually from high concentrations or long durations. Manifestations include a nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation. The client should report any of these promptly. E. CORRECT: Oxygen is combustible and thus increases the risk of fire injuries. No one in the house should smoke or use any device that might generate sparks in the area where the oxygen is in use. A. INCORRECT: Protecting the nares from the drying effects of oxygen therapy is important, but the client should use water-based lubricant. B. INCORRECT: A nasal cannula does not interfere with eating. The client should keep it in place during meals.
A nurse on a medical‑surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites
a. a client who has adrenal insufficiency is at risk for isotonic fluid volume deficit (hypovolemia) because of a decrease in aldosterone secretion and an increase in sodium and water excretion B. CORRECT: The nurse should anticipate a client who has heart failure to require fluid and sodium restriction to reduce the workload on the heart. c. a client who has diabetic ketoacidosis is at risk for dehydration because hyperglycemia can cause osmotic dieresis which leads to dehydration and electrolyte loss. d. a client who has ascites is at risk for hypovolemia because of a fluid shift from the intravascular space to the abdomen.
A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." B. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." C. "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle." D. "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location."
a. after seeing a flashback of blood, the nurse should lower the hub close to the skin to prepare for threading the needle into the vein, then loosen the needle from the catheter and pull back slightly on the needle so that it no longer extends past the tip of the catheter. the nurse should use the thumb and index finger to advance the catheter into the vein until the hub rests against the insertion site. Inserting the needle all the way into the vein could puncture the vein. B. CORRECT: the nurse should use a smooth, steady motion to insert the catheter through the skin at an angle of 10° to 30° with the bevel up. this is the optimal angle for preventing the puncture of the posterior wall of the vein. c. the nurse should apply pressure approximately 3 cm (1.2 in) above the insertion site to reduce the backflow of blood into the vein prior to removing the needle. d. the nurse should not use a vein in the antecubital fossa for Iv insertion, except for emergency access, because it will limit the mobility of the client's arm.
A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (select all that apply.) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor
a. distended neck veins is an expected finding of hypervolemia. b. Hypothermia is an expected finding of hypovolemia. C. CORRECT: Tachycardia is an expected finding of hypovolemia. D. CORRECT:syncope is an expected finding of hypovolemia. E. CORRECT: decreased skin turgor is an expected finding of hypovolemia.
A nurse is providing education for a client who has severe hypomagnesemia due to alcohol use disorder. the client is to receive magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "You will receive magnesium in a series of intramuscular injections." B. "You should receive a prescription for a thiazide diuretic to take with the magnesium." C. "You should eliminate whole grains from your diet until your magnesium level increases." D. "You will have your deep‑tendon reflexes monitored while you are receiving magnesium."
a. magnesium sulfate is administered either orally or IV. Im administration of magnesium is avoided due to pain and the potential for tissue damage. b. thiazide diuretics increase magnesium output, thereby worsening the client's hypomagnesemia. c. the nurse should encourage the client's intake of foods that are high in magnesium, such as whole grains and dark green vegetables. D. CORRECT: the nurse should instruct the client on the need to monitor deep‑tendon reflexes during administration of magnesium. this assessment helps identify hypermagnesemia that can occur during IV administration of magnesium sulfate
A nurse is collecting data from a client who has hypercalcemia as a result of long‑term use of glucocorticoids. Which of the following findings should the nurse expect? (select all that apply.) A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea and vomiting
a. the nurse should expect the client who has hypercalcemia to have decreased reflexes. B. CORRECT: the nurse should expect the client who has hypercalcemia to have confusion and a possible decreased level of consciousness. c. the nurse should expect the client who has hypocalcemia to have a positive Chvostek's sign. D. CORRECT: the nurse should expect the client who has hypercalcemia to have bone pain. E. CORRECT:the nurse should expect the client who has hypercalcemia to have nausea and vomiting along with anorexia.
A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/l. When notifying the provider, the nurse should anticipate which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage
a. the nurse should initiate an IV infusion of a fluid containing dextrose to promote the movement of potassium from ECF to ICF. b. the nurse should withhold oral potassium and provide the client with a potassium‑restricted diet. C. CORRECT: a potassium level of 5.2 mEq/l indicates hyperkalemia. the nurse should anticipate the initiation of continuous cardiac monitoring due to the client's risk for dysrhythmias such as ventricular fibrillation. d. Gastric lavage is not indicated for the treatment of hyperkalemia. However, the nurse should prepare the client for dialysis if hyperkalemia becomes severe.
A nurse is reviewing with a group of nursing students how to perform postural drainage. Use the ATI Active Learning Template: Nursing Skill to complete this item. Under Nursing Actions (pre, intra, post), list the specific positions that facilitate secretion drainage from at least eight specific lung areas.
● Nursing Actions ◯ Both lobes in general: high Fowler's ◯ Apical segments of both lobes: sitting on the side of the bed ◯ Right upper lobe, anterior segment: supine with head elevation ◯ Right upper lobe, posterior segment: on the left side with a pillow under the right side of the chest ◯ Right middle lobe, anterior segment: three-quarters supine with dependent lung in Trendelenburg ◯ Right middle lobe, posterior segment: prone with thorax and abdomen elevation ◯ Right lower lobe, lateral segment: on the left side in Trendelenburg ◯ Left upper lobe, anterior segment: supine with head elevation ◯ Left upper lobe, posterior segment: on the right side with a pillow under the left side of the chest ◯ Left lower lobe, lateral segment: on the right side in Trendelenburg ◯ Both lower lobes, anterior segments: supine in Trendelenburg ◯ Both lower lobes, posterior segments: prone in Trendelenburg
