ATI Exam 10%

a nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. which of the following tasks shouldd the nurse assign to an AP (select all) 1. assist with partial bed bath 2. measure BP after nurse gives antihypertensive meds 3. test the clients swallowing ability by providing thickened liquids 4. use a communication board to ask what the client wants for lunch 5. irrigate indwelling catheter

1,2,4

palliative care

end of life care

a client who is nonambulatory notifies the nurse to tell her that his trash can is on fire. after confirming the fire, which of the following actions should the nurse take next? 1. call emergency code 2. extinguish the fire 3. confine the fire 4. evacuate patient

evacuate patient (RACE)

a nurse is planning to insert a peripheral IV cathetar in an older adult client. which of the follwoing actions should the nurse plan to take? 1. insert the catheter at a 45 degree angle 2. position arm in dependent position 3. shave excess hair 4. initiate it in veins of hair

place in dependent position - makes veins distend because of gravity (shaving> infection, hand veins> poor conduction, angle> 15-35)

a nurse is caring for a client who cannot bear weight on his fracture ankle. which of the following client statements indicates a need for further teaching regarding three-point gait crutch walking? 1. when i get out of a chair, ill hold both crutches on the side next to my weak leg 2. when i sit down ill transfer my weight to my crutches and my strong leg 3. when i go up stairs, ill alternate putting weight on my crutches and my strong leg 4. when i go down stirs ill start by moving both my crutches to the step below

when i get out of a chair ill hold both crutches on the side next to my weak leg

a nurse is performing a spiritual assessment on a client newly admitted to the unit. the nurse recognizes that the purpose of performing a spiritual assessment is to 1. identify the client's religious and spiritual beliefs, affiliations and practices 2. apply commonly accepted concepts of spirituality to the nurse's interactions with the client 3. allow the nurse to make educated assumptions about the client's spiritual needs related to health care 4. encourage the client to focus on beliefs that are consistent with health care interventions

Identify the client's religious and spiritual beliefs, affiliations and practices -help the nurse make appropriate referrals and incorporate the clients practices and resources into the plan of care

A nurse is admitting a new client. which of the following actions should the nurse take while performing medication reconciliation? 1. verify the client's name on his ID bracelet with the MAR 2. call the pharmacy to determine if the client's medications are available 3. compare the client's home medications with the provider's prescriptions 4. place the client's home medication bottles in a secure location

compare the client's home medications with the provider's prescription -reconciliation- the process of creating the most accurate list possible of all meds a patient is taking

a nurse contacts the facility's interpreter to explain a therapeutic procedure for a client who does not speak English. which of the following guidelines should the nurse follow when working with the interpreter? 1. speak slowly to allow interpreter to interpret each word 2. explain the purpose of the communication to the interpreter 3. address the interpreter when explaining the procedure information 4. supplement words with gestures and nonverbal reinforcement

explain the purpose of the communication to the interpreter -should have prior meeting, so the nurse can clarify expectations of the session

a nurse is caring ffor a client and performing blood glucose monitoring. which of the following is an appropriate nursing intervention? 1. wipe away first drop of blood 2. massage finger distal-proximal 3. puncture tip of finger 4. hold finger elevated prior to testing

wipe away first drop of blood -typically more serous and contains fewer RBC (puncture lateral side, less nerve endings)

a nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. the nurse should set the infusion pump to deliver how many mL/hr?

107 mL/hr 1. what is the unit of measurement to calculate? mL/hr 2. what is the volume needed? 750 mL 3. what si the total infusion time? 7 hr 4. should the nurse convert the units of measurement? no 5. set up equation and solve for X. volume/time = X 750/7= X 107.14 rounded = 107

a nurse in a clinic is providing teaching to an older adult client about nutritional considerations associated with aging. which of the following should the nurse include in the teaching? 1. protein intake is often inadequate in older adults 2. vitamin and mineral requirements decline in older adults 3. thirst sensation increases in older adults 4. lack of adequate fat in the diet is often seen in older adults

Protein intake is often inadequate in older adults - protein intake is less than recommended in many older adults due to the lack of financial resources and dental problems the rest of the answers are opposite (thirst decreases, fat decreases, vit and min increases)

a nurse is caring for a client who is receiving medication IM. the nurse should recognize that this route 1. increases infection rates 2. in the safest option 3. has the slowest absorption rate 4. decreases the clients risk for reactions

increases infection rate (it breaks skin integrity)

following administration of levothyroxine 125 mcg at 0800, the nurse discovers the med was given to a client for whom it wasn't prescribed. which of the following is the correct way to document this error in medical record of the client who received the medication? 1. med 125 mcg given at 0800 in error. client in no distress. 2. med 125 mcg given at 0800. provider notifies 3. med 125 mcg given at 0800. incident report filed 4. med 125 mcg given at 0800. client informed of error

med 125 mcg given at 0800. provider notified

a nurse is caring for a client who is combative in ED. the provider orders wrist restraints after the client attempts to assult the admitting nurse. which of the following actions is appropriate for the nurse to take? 1. tie restraints to the lower edge of the side rail 2. remove each restraint one at a time ever 2 hrs 3. ensure 3 finger-widths of space between the restraint and the client's wrist 4. use a square knot to securely tie the restraints to the bed

remove 1 at a time every 2 hrs -allows client to preform ROM exercises and the nurse to perform Neuro check

a client is scheduled for surgery. the intraoperative nurse finds a necklace on the client after anesthesia has been administered. which of the following interventions should be initiated 1. leave necklace on the client 2. give the necklace to a family member 3. place the necklace in the clients chart 4. notify security for placement of the necklace

notify security for placement of the necklace

a nurse is caring for a client who had a fasting blood sugar drawn at 0600. the client tells the nurse, "all i had since midnight is water and some juice." which of the following nursing actions is appropriate? 1. document the caloric intake 2. reschedule this lab test for the next morning 3. notify the lab to obtain another specimen 4. obtain a prescription for a glucose tolerance test

reschedule lab - ensure accuracy of fasting blood sugar- client needs to fast 8-12 hours before

A nurse is caring fro a client who is postoperative and has signs of hemorrhagic shock. when the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. from a legal perspective, which of the following actions should the nurse take next? 1. document provider's statement in the medical record 2. complete and incident report 3. consult the facility's risk manager 4. notify the nurse manager

notify the nurse manager -the greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure the necessary care.

to prevent foot drop in a client who has decreased mobility, the nurse should 1. place pillow under the clients knees 2. position a trochanter roll under the clients feet 3. advise the client to wear rubber-soled slippers 4. place the clients feet against a foot board perpendicular to the mattress

place the clients feet against a foot board perpendicular to the mattress -keep feet dorsiflexed