ATI Final Test Practice Questions

______________ promote healing in stage 1 pressure injuries by preventing further friction and shearing.

Transparent

Single lumen NG tubes are used for intermittent suction with the machine being set at?

80 to 100 mm Hg. Higher suction settings can traumatize the gastric lining.

when performing range-of-motion exercizes on the patient, what things should we do?

1. repeat each joint motion 3 to 5 times to maintain the clients mobility 2. move the joint to the point that it reaches slight resistance 3. sit at the side of the bed closest to the joint being exersized (not 2 ft away) 4. exersize large joints first

BUN range

10-20 mg/dL

A protective environment requires at least ______ air exchanges per hour.

12

Sodium range

136 to 145 mEq/L.

_________ dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. It forms a soft gel when it comes in contact with drainage.

Alginate

a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. Herpes zoster is not a contraindication for the use of this mind-body technique.

Biofeedback

a nurse is caring for a client who has fecal impaction. before digital removal of the mass, which of the following types of enemas should the nurse planto administer to soften the feces? A. Carminative B. Hypertonic C. Oil retention D. Sodium polystyrene sulfate

C. Oil retention - The nurse should administer an oil retention enema prior to removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client. A. - The nurse should administer a carminative enema to assist a client to expel flatus. B. - The nurse should administer a hypertonic fluid solution to cleanse the client's bowels. One use for this type of enema is preparation for surgery. D. - The nurse should administer a sodium polystyrene sulfate enema to a client who has very high levels of potassium.

A nusrse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the client in a side-lying position. B. Instill 15 mL of irrigation fluid into the catheter with each flush. C. Subtract the amount of irrigant used from the client's urine output. D. Subtract the amount of irrigant used from the client's urine output.

C. Subtract the amount of irrigant used from the client's urine output. - The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output. A. - For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter. B. - Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid. D. - The nurse should use a 30- to 50-mL syringe to perform open irrigation.

What kind of patients require protective precautions?

Clients who have a compromised immune system, such as those who have received an allogeneic stem cell transplant, require a protective environment. This precaution keeps them from acquiring infections from others.

Contact precautions are for clients who ? examples?

Contact precautions are a requirement for clients who have infections that spread via direct contact or from environmental contact.

Fine to course bubbly sounds (not cleared with coughing) as air passes through fluid or re-expands collapsed small airways

Crackles or rales

a client is caring for a client hwo has a sodium level of 125 mEq/L. Which of the following finding should the nurse expect? A. Numbness of the extremities B. Bradycardia C. Positive Chvostek's sign D. Abdominal cramping

D. Abdominal cramping - This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea. A. - Numbness of the extremities is a manifestation of hyperkalemia. B. - Tachycardia is a manifestation of hyponatremia along with hypovolemia. C. - A positive Chvostek's sign is a manifestation of hypomagnesemia and hypocalcemia.

which of the following is a lower-intensity acitvity of daily living? A. sweeping the floor B. Shoveling snow C. Cleaning Windows D. Washing dishes

D. Washing dishes (sweeping the floow and. cleaning the windows are moderate-intensity activities)

a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking it. However, herpes zoster is not a contraindication for the use of this type of therapy.

Feverfew

a scratching or squeaking sound that persists throughout the respiratory cycle.

Friction rub

ice cream is allowed on what kind of diet?

Full liquid

_____________ promote healing in stage 2 pressure injuries by creating a moist wound bed.

Hydrocolloid dressings

glasgow coma scale is used to measure

LOC

BID

means twice daily

The nurse should use the __________ to document medication administration.

Medication administration record (MAR)

__________ promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed.

Moistened gauze

dry, coarse, loud, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions (can clear with coughing).

Rhonchi

closure of the mitral and tricuspid calves dignals the beginning of ventricular systole (contractions) and produces the _______ sounds

S1 (lub)

closure of the aortic and pulmonic valves signals the beginning of ventricular diastole (relaxation) and produces the _______ sounds

S2 (dub)

__________ is a communication tool nurses use to relate a client's status during a change-of-shift report.

SBAR

The nurse should use a _____________when the client is moving from one health care area or facility to another.

The nurse should use a transfer report when the client is moving from one health care area or facility to another.

Examples of illnesses requiring airbone precautions

Varicella, tuberculosis, and measles

Gelatin is allowed on what kind of diet?

a clear liquid diet are those that are clear and liquid at room temperature

in fluid or solid tissue, this can indicate pneumonia or tumor

dullness

when carrying a clients soiled linens, they should place them in a _____ bag?

fluid-resistant bag to reduce the risk of infection transmission.

in the presence of air, this can indicate pneumothorax or emphysema

hypperresonance

Examples of illnesses requiring droplet precautions?

rubella, meningococcal pneumonia, and streptococcal pharyngitis.

Cottage cheese is allowed on what kind of diet?

soft diet

When lifting more than 35 pounds of patient weight:

use an assistive device

after the intitial application of restraints, the nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every _______

15 mins

the nurse should remove the restraints at least every _________ to reposition the client and assess needs for hygeine and toileting

2 hours

For patients with a gastrostomy tube, feeding bags should be washed out after each feeding and replaced with a new feeding bag every __________ to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination.

24 hr

a nurse is explaining the use of written consent forms to a newly liscenced nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed red blood cells B. A client who is being transported for a radiography of the kidneys, ureters, and bladder C. A client who has a prescription for a tuberculin skin test D. A client who has a distended bladder and needs urinary catheterization

A. A client who has a prescription for a transfusion of packed red blood cells - Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure. B. - Clients admitted to a hospital sign a general consent form when admitted. This form allows consent for this diagnostic examination. C. - Implied consent is given when the client cooperates through actions, such as holding out an arm to allow the nurse to perform the procedure. D.- Implied consent is given when the client cooperates through actions, such as holding out an arm to allow the nurse to perform the procedure.

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 fo infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site

B. Edema at the infusion site - Edema due to fluid entering subcutaneous tissue is an indication of infiltration. A. - Redness at the infusion site is an indication of phlebitis or infection. C. - Warmth at the infusion site is an indication of phlebitis or infection. D. - Oozing of blood at the infusion site is an indication that the IV system is not intact.

a nurse is teachinga client who has lower extremity weakness how to use a four-point crutch gait. Which of the followin instructions shoudl the nurse include in the teaching? A. "Support the majority of your weight on the axillae." B. "Keep your elbows extended." C. "Bear weight on both of your legs." D. "Move both crutches forward at the same time."

C. "Bear weight on both of your legs." - The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs. A. - Pressure on the axillae increases risk to underlying nerves, which could result in partial paralysis of the arms. B. - The client should keep his elbows flexed about 30°. D. - The client should move each leg alternately with each opposite crutch so that three points of support are on the floor at all times.

A nurse is reviewing the medical record for a client who is recieving continuous enteral feedings. Which of the following should the nurse report to the provier? A. Gastric residual of 50 mL B. Weight gain of 0.23 kg (0.5) lb in 24 hr C. Blood glucose of 105 mg/dL D. Gastric aspirate pH of 7

D. Gastric aspirate pH of 7 - The nurse should identify that a gastric pH of 7 is an indication the nasogastric tube is not in the stomach. Gastric pH is usually between 1 and 4 but can be up to 6, if the client receives a medication that alters gastric pH. The client is at risk for aspiration and the nurse should report this finding to the provider. A. - The nurse should report a gastric residual of greater than 100 mL for a client who is receiving continuous enteral feedings. A high gastric residual can indicate delayed gastric emptying and increases the client's risk for aspiration. B. - The nurse should identify that a weight gain of more than 0.91 kg (2 lb) in 24 hr is a manifestation of fluid volume excess and places the client at risk for heart failure. C. - The nurse should identify that a blood glucose of 105 mg/dL is within the expected reference range of 74 to 106 mg/dL.

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? A. Use battery-operated equipment for personal care. B. Apply mineral oil to protect the facial skin from irritation. C. Remove the television set from the client's bedroom. D. Wear cotton clothing to avoid static electricity.

D. Wear cotton clothing to avoid static electricity. - The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark. A. - Electrical equipment in good condition with no frayed wires is acceptable for personal care when oxygen is administered. B. - Most oils and petroleum products are flammable when used on the body, which is a contraindication for their use because oxygen is a highly combustible gas. C. - As long as the television is in proper working order, there is no oxygen-related need to remove it from the client's bedroom.

the nurse should dispose of items that have a large amounts of blood in a _____ bag?

biohazard The nurse should dispose of items that have a large amount of blood in a biohazard bag that is impervious to micro-organisms.

Circulatory overload occurs when? symptoms?

blood is administered too quickly for the client's circulatory system to handle. Dyspnea, cough, headache, and hypertension are indications of circulatory overload.

Place the steps in the correct sequence for caring for a patient who dies during their shift. 1. Wash the clients body 2. place a name tage on the body 3. obtain the pronouncemnt of death from the provider 4. ask the client's family members if they would like to view the body 5. remove the tubes and indwelling lines

3, 5, 1, 4, 2 The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

Potassium range

3.5 to 5 mEq/L

When placing thigh-length sequential compression sleeves, the nurse should set the ankle pressure between ____________ mm Hg to achieve a therapeutic effect while also preventing damage to the client's skin and circulatory impairment.

35 and 55 mm Hg

Calcium normal range (signs of hypo/hypercalcemia)

8.4-10.5 mg.dL Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia. Hypercalcemia occurs when the client's total calcium level is above 10.5 mg/dL. The nurse should assess the client for lethargy, weakness, and other clinical manifestation of hypercalcemia, but not a positive Chvostek's sign.

A _________ is an interprofessional approach to planning all phases of client care

A critical pathway is an interprofessional approach to planning all phases of client care

A nurse us oreoarubg an education program for staff about advocacy. Which of the following information should the nurse include? A. Advocacy ensures clients' safety, health, and rights. B. Advocacy ensures that nurses are able to explain their own actions. C. Advocacy ensures that nurses follow through on their promises to clients. D. Advocacy ensures fairness in client care delivery and use of resources.

A. Advocacy ensures clients' safety, health, and rights. - Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care. B. - Accountability, not advocacy, is the responsibility of nurses to explain their own actions to their clients and employer. C. - Fidelity, not advocacy, is an agreement by nurses to follow through with promises made to clients. D. - Justice, not advocacy, is fairness in client care delivery, including the distribution of resources and care.

a nurse is preparing to administer an injection of an opiod medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage. B. Notify the pharmacy when wasting the medication. C. Lock the remaining medication in the controlled substances cabinet. D. Dispose of the vial with the remaining medication in a sharps container.

A. Ask another nurse to observe the medication wastage. - A second nurse must witness the disposal of any portion of a dose of a controlled substance. B. - Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance. C. - The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substances Act. D. - The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substances Act.

A nurse is preparing to insert a new IV catheter for a client. Which of the following actions should the nurse plan to take? A. Choose a vein that is palpable. B. Use the client's dominant arm to start the IV. C. Select an insertion site at an area of flexion. D. Elevate the extremity prior to insertion.

A. Choose a vein that is palpable. - The nurse should choose a vein that is palpable and straight to limit the risk of infiltration. B. - The nurse should use the client's nondominant arm to start the IV to limit the risk of the client accidentally dislodging the catheter. C. - The nurse should start the IV distal to the client's wrist to ensure that the tip of the catheter will not be at the point of flexion because this can increase irritation of the vein and lead to the catheter becoming dislodged. D. - The nurse should place the extremity in a position that is below the level of the client's heart to increase the dilation of the vein.

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? A. Cover the incision with a moist sterile dressing. B. Have the client lie on his back with his knees flexed. C. Call the client's surgeon. D. Call the client's surgeon.

A. Cover the incision with a moist sterile dressing. - An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client. B. - The nurse should use this position to reduce pressure on the incision. However, the nurse should take another action first. C. - The nurse should notify the surgeon or direct a colleague to notify the surgeon while tending to the client's immediate need. However, the nurse should take another action first. D. - The nurse should respond to the client's emotional needs. However, the nurse should take another action first.

a nurse in a provider;s office is rebiewing the laboratory findings of a patient who reports chills and aching joints. The nurse hsould identify which of the following findings as an indication that the client has an infection? A. WBC 15,000 mm3 B. Erythrocyte sedimentation rate (ESR) 15 mm/hr C. Urine pH 7.2 D. Urine specific gravity 1.0063

A. WBC 15,000 mm3 - This finding is above the expected reference range and is an indication of infection. B. - Although an elevated ESR can indicate an infection, this finding is within the expected reference range. C. - A urine pH of 7.2 is within the expected reference range. D. - A urine specific gravity of 1.0063 is within the expected reference range.

a nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood Pressure C. Specific gravity D. Intake and Output

A. Daily weight - According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 liter of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement. B. - While blood pressure can indicate a client's fluid gains or losses, it is not the most accurate method used to measure fluid changes. Evidence-based practice indicates that another assessment provides the most accurate information. C. - Specific gravity reflects the kidney's ability to concentrate urine. While specific gravity reflects client's fluid gains or losses, it is not the most accurate method used to measure fluid changes. Evidence-based practice indicates that another assessment provides the most accurate information. D. Intake and output reflects a client's fluid status. However, it's not the most accurate method to measure fluid changes. Evidence-based practice indicates that another assessment provides the most accurate information.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in Trendelenburg's position. B. Perform percussions directly over the client's bare skin. C. Use a flattened hand to perform percussions. D. Remind the client that chest percussions can cause mild pain.

A. Place the client in Trendelenburg's position. - The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe B. - The nurse should perform percussions over a single layer of clothing. C. - The nurse should use a cupped hand to provide percussions. D. - Chest percussions should not cause pain when the procedure is performed correctly.

A nurse is providing oral care for aclient who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure. B. Use the thumb and index finger to keep the client's mouth open. C. Rinse the client's mouth with an alcohol-based mouth wash following the procedure. D. Cleanse the client's mucous membranes with lemon-glycerin sponges.

A. Place the client in a lateral position with the head turned to the side before beginning the procedure. - The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions. B. - The nurse should use a padded tongue blade, not a thumb or an index finger, to keep the client's mouth open. If the client suddenly bites down, the nurse's fingers could be injured. C. - The nurse should use either water or alcohol-free mouth wash to rinse the client's mouth. D. The nurse should use a foam swab because lemon-glycerin swabs dry and irritate the mouth and can cause damage to the teeth.

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastic decompression. Which of the following actions should the nurse include in the plan of care? (SATA) A. Set the suction machine at 120 mm HG. B. Provide oral hygiene frequently. C. Measure the amount of drainage from the NG tube every shift. D. Secure the NG tube to the client's gown. E. Apply petroleum jelly to the client's nares.

Answer: B, C, D A. set the suction machine at 120 mm HG is incorrect. Single lumen NG tubes are used for intermittent suction with the machine being set at 80 to 100 mm Hg. Higher suction settings can traumatize the gastric lining. B. Provide oral hygiene frequently is correct. Frequent oral hygiene provides comfort for the client since mucous membranes easily become dry and uncomfortable when a client cannot drink fluids. C. Measure the drainage from the NG tube every shift is correct. Measuring the drainage at least every shift helps the provider to calculate fluid loss and prescribe appropriate replacement therapy. D. Secure the NG tube to the client's gown is correct. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately. E. Apply petroleum jelly to the client's nares is incorrect. The client could aspirate an oil-based lubricant like petroleum jelly into the lungs, which could possibly result in lipid pneumonia. A water-soluble lubricant should be applied to the nares to help prevent or relieve dry skin.

A nurse is asessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client;s saefty needs? (SATA) A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields E. Visual acuity

Answer: B, D, E Lacrimal apparatus is incorrect. If clients have an impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge. Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. Appearance of bulbar conjunctivae is incorrect. The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client's safety. Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. Visual acuity is correct. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I rrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? A. "We would consult the person appointed by your health care proxy to make decisions." B. "We would give you oxygen through a tube in your nose." C. "You would be unable to change your previous wishes about your care." D. "We would insert a breathing tube while we evaluate your condition."

B. "We would give you oxygen through a tube in your nose." - Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. A. - The staff must honor the client's wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the client's health care proxy to make decisions about the client's care. C. - Clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives. D. - Intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will.

a nurse is reponding to a parent;s question about his infant's expected physical development during the first year of life. Which of the follwoing information should the nurse include? A. A 2-month-old infant can turn from his abdomen to his back. B. A 10-month-old infant can pull up to a standing position. C. A 10-month-old infant can pull up to a standing position. D. A 6-month-old infant can crawl on his hands and knees.

B. A 10-month-old infant can pull up to a standing position. - An 8 to 10-month-old infant can pull himself to a standing position. A. - An infant cannot turn from his abdomen to his back until he is 5 months old. C. A 6 to 8-month-old infant can sit up without support. D. - An 8 to 10-month-old infant can creep on his hands and knees.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? A. Insert the suction catheter while the client is swallowing. B. Apply intermittent suction when withdrawing the catheter. C. Place the catheter in a location that is clean and dry for later use. D. Hold the suction catheter with her clean, nondominant hand.

B. Apply intermittent suction when withdrawing the catheter. - The nurse should insert the suction catheter while the client is inhaling to avoid inserting the catheter into the esophagus. A. - The nurse should insert the suction catheter while the client is inhaling to avoid inserting the catheter into the esophagus. C.- The nurse should discard the suction catheter after use to eliminate the risk of reintroducing pathogens into the respiratory tract. D. - The nurse should discard the suction catheter after use to eliminate the risk of reintroducing pathogens into the respiratory tract.

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the follwing instructions hsould the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use. C. Cough deeply after each use. D. Use the spirometer every 8 hr.

B. Cough deeply after each use. - Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs. A. - The nurse should instruct the client to inhale deeply to elevate the balls in the device. C. - The nurse should instruct the client to clean the mouth piece with water and dry it after each use. D. - The nurse should instruct the client to use the spirometer several times every hour while awake.

a nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 min. B. Fill the bag two-thirds full with ice. C. Place the ice bag uncovered on the client's ankle. D. Tell the client that it is expected to feel numbness when the ice bag is in place.

B. Fill the bag two-thirds full with ice. - The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle. A. - The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle. C. - The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle. D. - The nurse should remove the ice bag if the client feels numbness because numbness is an indication that the client's skin is too cold and at risk for injury.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A. Insert the catheter at a 45° angle. B. Place the client's arm in a dependent position. C. Shave excess hair from the insertion site. D. Initiate IV therapy in the veins of the hand.

B. Place the client's arm in a dependent position. - The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. A. - Generally, the nurse should insert the catheter at a 10° to 30° angle. However, for an older adult client, an angle of 10° to 15° is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue. C.- The nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection. D. - The nurse should avoid using the fragile veins of an older adult's hands because the loss of subcutaneous tissue can allow those veins to roll away from the needle. Also, having an IV catheter in the client's hand can interfere with the client's performance of activities of daily living and can diminish an older adult's sense of independence and mobility.

A home health nurse is planning to provide health promotion activities to a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? A. teaching clients to perform self-examinations of breath and testicles B. educating clients about the recommended immunization schedule for adults C. Teaching clients who have type 1 Diabetes about the care of the vet D. recommending that clients over the age of 50 have a fecal occult blood test annually

B. educating clients about the recommended immunization schedule for adults - primary prevention: includes health education about disease prevention A. this is an ex of secondary prevention: measures that identify the early stages of a condition [X] C. tertiary prevention: occurs after diagnosis of a condiiton and the focus is to limit complications from the condition D. secondary prevention

A hospice nurse is reviewing the religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licenses nurse indicates an understanding of the teaching? A. "People who practice the Islamic faith pray over the deceased for a period of 5 days before burial." B. "People who practice the Hindu faith bury the deceased with their head facing north." C. "People who practice Judaism stay with the body of the deceased until burial." D. "People who are practicing the Buddhist faith have the female family members prepare the body following death."

C. "People who practice Judaism stay with the body of the deceased until burial." A. For those who practice the Islamic faith, the body of the deceased is washed and wrapped during a ritual and then buried as soon as possible following death. B. People who practice the Hindu faith may place the body with the head facing north following death. However, cremation rather than burial is practiced by those of the Hindu faith. [X] D. Male family members prepare the body following death for individuals practicing the Buddhist faith.

A nurse is prividing discharge teaching to a client about self-administering heparin. Which of the following instructions hsould the nurse include? A. Insert the needle at a 15° angle. B. Aspirate for blood return prior to administration. C. Administer the medication into the abdomen. D. Massage the site following the injection.

C. Administer the medication into the abdomen. - The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. A. - The nurse should instruct the client to insert the needle at a 45° to 90° angle to administer the medication into the subcutaneous tissue. B. - The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. D. - The nurse should instruct the client not to massage the site because this can cause tissue damage and bruising.

a nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. Verify the client's name on their identification bracelet with the medication administration record. B. Call the pharmacy to determine whether the client's medications are available. C. Compare the client's home medications with the provider's prescriptions. D. Place the client's home medication bottles in a secure location.

C. Compare the client's home medications with the provider's prescriptions. - The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation. A.- The nurse should verify the client's name on their identification bracelet when administering medication; however, this action is not a part of performing medication reconciliation. B. - The nurse should call the pharmacy if the client's medications are not available to administer at the appropriate time; however, this action is not a part of performing medication reconciliation. D. - The nurse should place the client's home medications in a secure location to ensure safe handling of prescribed medications; however, this action is not a part of performing medication reconciliation.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. insert the rectal tube 7 to 10 cm (3-4 in.) B. Wear sterile gloves to insert the tubing C. Position the client on his left side D. Hold the solution bag 91 cm (36 in) above the client's rectum

C. Position the client on his left side - client is place on the left side to facilitate the flow of enema solution into the sigmoid and descneding colon [X] A - should inster 7 to 10 cm (3 to 4 in.) B - wear clean gloves not sterile D - should hold the bag 30 cm (12 in.) above clients rectum for a low enema, and 45 cm (18 in) for a high enema. (if bag is held too high, enema might flow too fast)

A nurse is assessing a patient who has abdminal trauma. Which os the following assessment finding should hte nurse identify as an indication of hypovolemic shock? A. warm, dry skin B. Increased urinary output C. Tachycardia D. Bradypnea

C. Tachycardia A. Cool, clammy skin is an indication of hypovolemic shock. B. Urine output of 30 mL/hr or less is an indication of hypovolemic shock. [X} C. Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate. D. Tachypnea is an indication of hypovolemic shock.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. The top of the cane is parallel to the client's waist. B. When walking, the client moves the cane 46 cm (18 in) forward. C. The client holds the cane on the stronger side of her body. D. The client moves her stronger limb forward with the cane.

C. The client holds the cane on the stronger side of her body. - The client should hold the cane on the stronger side of her body to increase support and maintain alignment. A. - The top of the cane should be parallel to the client's greater trochanter. B.- To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. D. - The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. This nurse notifies the surgeon, who tells the nurse to continue to measure the client's vitals every 15 minutes and to report back in 1 hr. Which of the following actions should the nurse take next? A. Document the provider's statement in the medical record. B. Complete an incident report. C. Complete an incident report. D. Notify the nursing manager.

D. Notify the nursing manager. - The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care. A. - The nurse should document the provider's directions in the medical record for later reference; however, another action is the nurse's priority. B.- The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse's priority. C. - The nurse should discuss the situation with the facility's risk management department to help determine the need for preventive actions; however, another action is the nurse's priority.

A nurse us carng for a patient who is postoperative. When the nurse prepares to change her dressing, the patient says, "Every time you change my bandage, it hurts so much." Whihc of the following interventions is the nurs's priority action? A. Encourage the client to relax and take deep breaths during the dressing change. B. Educate the client about the importance of the dressing change to prevent infection. C. Assist the client to a comfortable position for the dressing change. D. Administer pain medication 45 min before changing the client's dressing.

D. Administer pain medication 45 min before changing the client's dressing. - Moving the client to a comfortable position for the dressing change is important because it can help the client relax and can also reduce strain on the wound. However, there is another intervention that is the priority. A. - Encouraging the client to relax and take deep breaths during the postoperative period is important because relaxation can help reduce the client's anxiety about the procedure. However, there is another intervention that is the priority. B. - Educating the client about the importance of the dressing change is important because understanding the rationale for the procedure can help the client relax. However, there is another intervention that is the priority. C. - Moving the client to a comfortable position for the dressing change is important because it can help the client relax and can also reduce strain on the wound. However, there is another intervention that is the priority.

A nurse is performing medicaiton reconciliation with a client. Which of the following action should the nurse take first? A. Contact the provider about discrepancies in medication dosages. B. Provide the client with a new list of prescribed medications. C. Compare the provider's admission prescriptions to the client's list of home medications. D. Ask the client if she takes any over-the-counter medications.

D. Ask the client if she takes any over-the-counter medications. - The first action the nurse should take when using the nursing process is to assess the client's current use of prescription and nonprescription medications, vitamins, and herbal supplements to obtain a complete list for comparison to the provider's admission prescriptions. A. - The nurse should identify and resolve any discrepancies in the client's medication list and the provider's prescriptions by contacting the provider to avoid a medication error; however, there is another action the nurse should take first. B. - The nurse should provide a complete and reconciled list of prescribed medications to the client to ensure the client continues to take the appropriate medications as prescribed by the provider; however, there is another action the nurse should take first. C. The nurse should compare the client's current list of prescribed medications, herbal supplements, vitamins, and nonprescription medications to the provider's admission prescriptions to ensure medications are not duplicated or omitted and that dosages are accurate; however, there is another action the nurse should take first.

A nurse in a provider's office is collecting info from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? A. Constipation B. Gastric Ulcers C. Respiratory depression D. Liver damage

D. Liver damage - Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment. A. - Constipation is an adverse effect of opioid analgesics. B. - Gastric ulcers are an adverse effect of aspirin and other nonselective NSAIDs. C. - Respiratory depression is an adverse effect of opioid analgesics.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions shoudl the nurse include int he plan of care to promote wound healing? A. Limit total caloric intake to 25 kcal/kg of body weight. B. Provide an intake of 500 mg/day of vitamin E. C. Limit fluid intake to 20 mL/kg of body weight per day. D. Provide a protein intake of 1.5 g/kg of body weight per day.

D. Provide a protein intake of 1.5 g/kg of body weight per day. - A protein intake of 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing. A. - A caloric intake of 35 to 40 kcal/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing. B. - Vitamin E is not essential for wound healing. C. - The nurse should encourage a fluid intake of 30 to 35 mL/kg of body weight per day as water is essential to the wound healing process.

Cream of rice is allowed on what kind of diet?

Full liquid

_________________ are discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways.

Unlike these breath sounds, crackles (also called rales) are discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways.

The reservoir bag should inflate by _________ to _______ If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale.

one-third to one-half with inspiration

Airborne precautions are a requirement for clients who have infections that?

spread via droplet nuclei that are smaller than 5 microns in diameter

Droplet precautions are a requirement for clients who have infections that? what should the nurse wear when providing care?

that spread via droplet nuclei that are larger than 5 microns in diameter The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.

Sepsis occurs when? symptoms?

the blood is contaminated with bacteria. High fever, vomiting, and diarrhea are indications of sepsis.

A hemolytic reaction occurs when? symptoms?

the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.

A febrile reaction occurs when? symptoms?

the client's blood is sensitive to the WBCs and platelets in the donor's blood. Fever, chills, headache, and flushing are indications of a febrile reaction.

For a patient who is on a low sodium diet, the nurse should instruct the client to

to consume processed foods sparingly and to ensure each serving has less than 300 mg of sodium.

babinki reflex is tested by

using an object to strike the sole of the foot - when test is +: all the toes spread outwawrd - when test is -: all the toes blend

Examples of illnesses requiring contact precautions?

vancomycin-resistant enterococci and herpes simplex infections.

Creatinine range

women 41 to 60 years of age: 0.5 to 1.1 mg/dL men 41 to 60 years of age: 0.6 to 1.3 mg/dL Even for clients within younger and older age ranges (with the exception of newborn through 9 years of age), 0.8 mg/dL is within the expected reference range for creatinine.