ATI Final
kyphosis
excessive outward curvature of the causing hunching of the back.
-bed alarms -educating patient on safety -close placement of assistive devices -leaving call light next to patient -answering bed alarms
how can we protect a patient from injury?
secondary prevention
identifying and treating disorders in the early stages, before they become serious ie. teaching pts how to perform self-exams of breasts or recommending that pts over age 50 have fecal occult blood tests annually
full minute
if a patients pulse is irregular, how long should you take to measure a new count?
hypovolemia
increased Hgb indicates
-pain -nocturia -anxiety/emotional distress -sleeping disorders - environment -caffeine intake -illnesses
issues that can cause sleep disturbances
tertiary prevention
limiting complications from conditions ie. teaching pts with DM1 about foot care
referent
motivates one person to communicate with another
d. bounding pulse -sunken eyes, hypotension and poor skin turgor: fluid volume deficit
nurse assess pt with HF. pt has gained weight since last visit, and ankles are edematous. what other findings is another clinical manifestation of fluid volume excess? a. sunken eyeballs b. hypotension c. poor skin turgor d. bounding pulse
0-4
pH of gastric secretions should be between
B; assess lungs
patient is admitted to your floor for fluid volume excess. what is the first action you should take in order to keep patient safe? a. place patient on bed alarm b. assess lung sounds c. check for any IV complications d. hang isotonic fluids to help with excess
d; contact
patient was diagnoses with C.diff. what precautions should you take? a. droplet precautions b. airborne precautions c. standard precautions d. contact precautions
measles: airborne MRSA: contact
precautions taken for measles and MRSA
primary prevention
prevention of illness ie. educating about recommended immunization schedules for adults
1. Trust v. Mistrust 2. Autonomy v. Shame and Doubt 3. Initiative v. Guilt 4. Industry v. Inferiority 5. Identity v. Role Confusion 6. Intimacy v. Isolation 7. Generativity v. Stagnation 8. Integrity v. Despair
Erikons 8 steps of Psychosocial Development Theory
malpractice
Failure by a health professional to meet accepted standards
Guiac test
a commonly used test to detect blood in the stools
lordosis
abnormal anterior curvature of the lumbar spine (sway-back condition)
Scoliosis
abnormal lateral curvature of the spine
b; rescue, alarm, contain, extinguish
what does the E in the acronym RACE stand for? a. evacuate b. extinguish c. evaluate d. explore
b; ABC's of patient care, airway and breathing are main points of concern
what is a MAIN complication in patients who are immobile? a. insuffiecient nutirtion b. crackles in lungs c. UTI d. reddened pressure areas
b; purulent drainage
what is a sign of an infection in an abdominal wound? a. tenderness b. purulent drainage c. decreased bowel sounds d. pain
c; quad cane
what device below is best to use for patients with balance problems? a. walker b. crutches c. quad cane d. wheelchair
feedback
The receiver's response to a message
d. 2nd intercostal space to R. of sternum -mitral valve: 5th intercostal space just medial to midclavicular line -pulmonic valve: 2nd intercostal space to L. of sternum, -tricuspid valve: 5th intercostal to L. of sternum
where should nurse place stethoscope to auscultate aortic valve? a. 5th intercostal space just medial to midclavicular line b. 2nd intercostal space to L. of sternum c. 5th intercostal to L. of sternum d. 2nd intercostal to R. of sternum
a. vesicular -bronchial: heard over trachea, rhonchi: over trachea and bronchi if airways are narrow, bronchovesicular: either side of sternal border
which of the following breath sounds should nurse expect to hear over periphery of major lung fields? a. vesicular b. bronchial c. rhonchi d. bronchovesicular
d. using silence
which option below is an active listening technique? a. giving an opinion b. defending c. interpreting d. using silence
B
you are a nurse on a med-surg floor. you have given a medication to the wrong patient. what is the first thing you should do? a. call provider immediately b. assess patient c. document mistake in MAR d. administer correct medication
c; patient three. ABC's of nursing
you have 4 patients. patient one is complaining of urinary retention, patient two has an infiltrated IV, patient three is having SOB, and patient four is complaining of pain. which patient should the nurse attend to first? a. patient one b. patient two c. patient three d. patient four
D
you have a patient who is confused and keeps jumping out of bed, what should you do as a nurse to keep the patient safe? a. put all side-rails up b. restrain patient c. call health care provider d. place patient closer to nurses station
a, b, c
you must ask consent for which of the following actions? (SATA) a. removing dentures b. counting radial pulse c. checking edema d. checking content within a foley bag
intrapersonal communication
communication with oneself
hypervolemia
decreased specific gravity indicates
Na: 135-145 K: 3.5-5.0 Mg: 1.5-2.5 Ca: 4.5-5.5 Cl: 95-108 Hgb: 12-18
Na K Mg Ca Cl Hgb
d; foot board
a foot drop is a common complication in immobile patients. what devices can you use to help prevent this from occurring? a. pillows b. brace c. hand roll d. foot board
d; BUN
a male patients lab values have been sent over: Hgb: 19 WBC: 6,500 Plt: 170,000 BUN: 29 which value is critical and in need of immediate attention? a. hgb b. wbc c. plt d. BUN
b, c; deep breathing exercises, continuous coughing
a patient has crackles in lungs. what are some autonomy strategies that a nurse can incorporate in the plan of care? (SATA) a. swallowing techniques b. deep breathing exercises c. continuous coughing d. administering medication to help open airway
b; sleep disturbance
a patient is anxious for an upcoming surgery. how will this effect the patients care? a. patient will develop urinary retention b. patient will have sleep disturbances c. patient will be unable to take medications d. patient can become nauseous
a; talk in a calm manner
a patient is being verbally abusive to you while explaining pain meds are not due. how should you react? a. talk in a calm manner b. respond in elevated voice c. walk out of room d. repeat why he cannot have his pain med
a, c, e
a patient is experiencing hypovolemia. what physiological effects will this have on the body? (SATA) a. decreased BP b. crackles in lungs c. increased HR and pulse d. urinary retention e. dyspnea
a; assess swallowing and gag reflex
a patient just had a bronchoscopy, what should you assess in addition to your normal physical assessment? a. assess swallowing/gag reflect b. asses patients ability to speak c. assess patient cough d. assess patient I&O's
a. bounding -full: +3, weak: +1
after assessing pts radial pulses, nurse documents "radial pulses 4+ bilaterally." nurse should document this finding as following what qualities? a. bounding b. full c. variable d. weak
letter M; mitral valve
based off the picture, where do you place stethoscope to take apical pulse?
interpersonal communication
communication between two people
a. pt who has HF and receiving 100% O2 via partial rebreather mask
nurse caring for group of pts receiving O2. which pt do you see first? a. pt who has HF and receiving 100% O2 via partial rebreather mask b. pt who has emphysema and receiving O2 at 3mL/min via nasal cannula c. pt who has an old tracheostomy receiving 40% humidified O2 d. pt who has COPD and receiving O2 at 2mL/min via nasal cannula
a. Cover the incision with a moist sterile dressing.
nurse caring for pt who is post-op following abdominal surgery. which action should nurse perform first after discovering pt wound has eviscerated? a. cover incision with moist sterile dressing b. have client lie on back with knees flexed c. call surgeon d. reassure pt
d. request prescription for isotonic enteral nutrition formula
nurse caring for pt who is receiving continuous enteral feedings through NG tube and develops diarrhea. what action should nurse take? a. change tube feed Q48hrs b. chill formula before use c. increase infusion rate d. request prescription for isotonic enteral nutrition formula
a. obtain apical and radial rate simultaneously apical-radial = pulse deficit
nurse caring for pt with dysrhythmia. which technique should nurse assess for pulse deficit? a. obtain apical and radial rate simultaneously b. check BP in left and right arms c. compare pulse strength in upper extremities d. palpate pulses in lower extremities
c. x-ray
nurse has a patient with an NG tube. when administering feeding, she notices that the exit mark on the tube has been moved since the last feed. which action should the nurse do? a. auscultate lung sounds while injecting air b. placed HOB flat c. obtain an x-ray of abdomen d. administer feeding if pH is >6
c. depressed deep-tendon reflexes
nurse has a pt with total calcium level of 12.7mg/dL. which of the following should nurse expect? a. muscle tremors b. positive Chvostek's signs c. depressed deep-tendon reflexes d. numbness around mouth
d. metabolic acidosis -due to regular PaCO2 but low pH, causes it be metabolic
nurse has pt in ED who has deep, rapid respirations. ABG includes: pH 7.25, PaCO2 40, and HCO3- 18. which acid-base imbalance should nurse report to HCP? a. respiratory alkaloisis b. metabolic alkalosis c. respiratory acidosis d. metabolic acidosis
a. sodium
nurse is caring for a client with peripheral edema. nurse should ID that which of the following nutrients regulates ECV? a. sodium b. calcium c. potassium d. magnesium
c. oil retention -carminative assists expel of flatus, hypertonic solution cleanses bowels (ie. prep for surgery), sodium polystyrene to pt with high K+
nurse is caring for pt with fecal impaction. before digital removal, which of the following types of enemas should nurse plan to administer to soften feces? a. carminative b. hypertonic c. oil retention d. sodium polystyrene sulfate
d. young adulthood
nurse is evaluating group of pts. according to erikson, developmental task of intimacy v. isolation occurs during? a. middle adulthood b. adolescence c. childhood d. young adulthood
b. K+ 3.0
nurse is monitoring pts lab results. which results should nurse report to HCP? a. sodium: 140 b. potassium: 3.0 c. chloride: 100 d. magnesium: 2.0
b. faint pedal pulses
nurse is performing a physical assessment of a client. nurse should recognize that which of the following places the patient at risk of impaired skin integrity? a. 3+ Achilles refelx b. faint pedal pulses c. feet warm to touch d. capillary refill of <2 sec
d. perform blanch test
nurse is performing a physical assessment of pt. what action should nurse take to assess pts tissue perfusion? a. perform Romberg test b. check nails for Beau's lines c. palpate respiratory excursion d. perform blanch test
a. use gait belt -client should sit on edge of bed for 60sec, wearing non-skid shoes/slippers, and nurse should walk beside patient
nurse is preparing to assist an older client with ambulation following bed rest for 3 days. which of the following actions should nurse take to decrease risk of fall? a. use gait belt during ambulation b. ensure client is wearing socks before ambulating c. instruct client to sit on edge of bed for 15sec before ambulating d. walk 2ft behind client
b. client who is 2 days post-op following colectomy due to cancer and has ostomy bag full of bright red, bloody drainage
nurse on an oncology unit receives report for 4 pts who are post-op. which pt should nurse see first? a. pt who is 1 day post-op following lobectomy and has chest tube with 35mL/hr bright red, blood drainage b. pt who is 2 days post-op following colectomy due to cancer and has ostomy bag full of bright red, bloody drainage c. pt who is 2 days post-op following excision of abd mass and has portable wound suction device with 20mL/hr serosanguinous drainage d. pt who is 1 day post-op following excision of bladder and has continuous bladder irrigation with 300mL/hr reddish-pink urine
b. ask to ID specific allergies
nurse performing admission assessment for client who has asthma and reports several food allergies. which action should nurse take first? a. document allergies in record b. ask pt to ID specific food allergies c. monitor for indications of anaphylaxis d. have epinephrine available
d. granulation tissue fills wound during healing
nurse providing teaching about wound healing by secondary intention. which piece of info should nurse include in teaching? a. wound edges are well-approximated b. wound closed at later date c. skin graft placed over wound bed d. granulation tissue fills wound during healing
a. respiratory alkalosis
nurse reviews pts lab tests. pts ABG levels are: pH 7.5, PaCO2 32, HCO3- 24. nurse should determine which following acid-imbalances? a. respiratory alkalosis b. metabolic acidosis c. respiratory acidosis d. metabolic alkalosis
b. edema at infusion site
nurse should ID that which of the following findings is an indication of infiltration? a. redness at infusion site b. edema at infusion site c. warmth at infusion site d. oozing of blood at infusion site
a. pt holds cane on unaffected side
nurse teaching pt about use of straight-legged cane. which pt action indicates pt understands procedure of cane walking? a. pt holds cane on unaffected side b. pt walks by stepping with unaffected leg before affected leg c. pt holds cane directly next to foot d. pt holds cane with straight elbow
d. clamp tubing below collection port
pt with indwelling catheter needs a urine sample to test for a UTI. which action would you take? a. withdraw specimen from drainage bag b. cleanse collection port with soap and water c. place specimen in clean specimen cup d. clamp tubing below collection port
Romberg test
test that checks patients balance ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed
channel
the means by which a message is communicated ie. phone calls, emails, letters, video
b, c
what are the MAIN purposes of documentation? (SATA) a. educating patient b. communication between health care team c. legal document of care d. to allow patient opportunity to take medications
a, c, d
what can increase a patients risk of having a dehiscence of a wound? (SATA) a. improper nutrition b. immobility c. obesity d. infection
clarification
what communication technique is used below? "When did you first start feeling like this?" "Did you always feel like this?"
C; education
what is the main priority of a patient who is about to have a procedure/surgery? a. getting him showered before surgery b. making sure patient has adequate amount of sleep c. educating patient about procedure d. controlling pain
a; witness
what is the nurses role in a patient signing an inform consent sheet? a. acting as a witness b. educating doctor on patients health literacy c. obtaining signed consent for physician d. creating informed consent sheet
c; inspect, auscultate, percuss, palpate
what order do you assess a patients abdomen? a. palpate, ascultate, inspect, percuss b. ascultate, percuss, palpate, inspect c. inspect, auscultate, percuss, palpate d. inspect, auscultate, palpate, percuss
a, c, d, e
what vitamins are needed for proper wound care? (SATA) a. vitamin A b. vitamin D c. vitamin K d. vitamin c e. vitamin B12
allergies
when admitting a patient into your care, what is one of the first things you should document and asses from the patient?
at admission
when does discharge planning begin?
grimace, guarding, avoiding activities, moaning, lip biting, muscle tension, clenched teeth NOT MOANING
when monitoring a post-op patient, what are some nonverbal signs of pain that the patient can demonstrate?
a; conjunctiva
where can you see signs of cyanosis in patients with dark skin? a. conjunctiva b. nails c. mouth d. ear lobes
