ati fundamentals questions

Anurse is caring for a client who has an indwelling urinary catheter . which of the following findings require catheter irrigation?

bladder scan shows ml of urine.

A middle adult client tells the nurse, " I feel so useless now that my children don't need me anymore". which of the following responses should the nurse make?

" people in middle adulthood often find satisfaction in nurturing and guiding young people.

A nurse is caring for a client who has TB. which of the following actions should the nurse take?

(Tb is airborne disease) 1) place the client in a negative pressure room(to meet airborne precautions) 2) wear gloves when assisting the client with oral care( to meet standard precaution. wear gloves when at risk of coming in contact with pt's fulids.) 3) use antimicrobial sanitizer for hand hygiene.

A nurse is placing a client in the dorsal recumbent position. which of the following actions should the nurse take?

Arrange a pillow under the clients head and shoulder. rational: the nurse should arrange a pillow under the clients head and shoulders when placing them in the dorsal recumbent position which is back lying position

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. after securing a safe environment. which of the following actions should the nurse take next?

Asses for orthostatic hypotension. rational. using nursing process the nurse should assess. the nurse should determine the clients risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed.

a nurse is providing teaching to a client who has severe weakness in their right lower extremity and is learning to walk using a cane. which of the the following actions by the client indicates an understanding of the teaching?

The client moves the cane forward before taking a step. rational: the client should move the cane forward by about 6inches to 1ft before taking a step with the weaker leg to maintain stability.

A nurse is planning an education program for a group of older adults at a senior living center. which of the following recommendations should the nurse include?

You should receives a pneumococcal immunization every 10 years.

technique for the Romberg test?

have the client stand with their arms at their side and their feet together.

To obtain an accurate blood pressure measurement, the nurse should inflate the ___mm Hg beyond the point at which the nurse last felt a pulse.

30mm Hg

A nurse is calculating a clients fluid intake over the past 8hrs. which of the following items should the nurse plan to document on the clients intake and output record as 120ml of fluid.

8oz of ice chips. rational: the nurse should document half the volume of ice chips when calculating fluid intake to account for the air in between the chips. the nurse should understand that 4 oz of liquid equal 120ml of fluid. 4

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the new nurse requires intervention by the charge nurse.

The new nurse places the cap of the bottle sterile saline solution on the sterile field. rational: the new nurse should place the cap on a clean surface

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In the preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and take them in place. rational: bc many monitors devices and cords contain latex. so the nurse should prevent any cord contact with pt's skin.

A nurse is caring for a group of clinets on a medical surgical unit. In which of the following situations does the nurse demonstrate the ethical principal veracity?

a clinet who is unaware of her recent diagnosis ask the nurse if she has cancer, and the nurse responds affirmatively. rational: the nurse must tall the truth at all times and never decieve others.

A nurse is preparing to administer 0.5 mL of oral single dose liquid medication to a client. which of the following actions should the nurse take?

gently shake the container of medication prior to administration. rational: the nurse should gently shake the liquid medication to ensure that the medication is mixed.

A charge nurse is discussing the responsibility of nurses caring for clients who have c. diff infection. which of the following info should the nurse include in the teaching?

have family members wear gloves and gown when visiting. rational: nurses are responsible for ensuring that family members wear gown and gloves to prevent the transmission of c. diff. staff needs to wear gloves and gowns too.

A nurse is caring for a clinet who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown?

have the client use a trapeze bar when changing positions

a nurse is caring for a client who reports difficulty falling asleep. which of the following should the nurse make?

maintaining a consistent time to wake up each day. rational: the client should maintain a consistent time for waking up and going to sleep. this helps to establish an internal sense of sleep and waking on a daily basis.this will help promote sleep for the client.

A nurse is reviewing a clients medication prescription that reads "digoxin 0.25 by mouth everyday." which of the following components of the prescription should the nurse verify with the provider?

medication dose. rational:The medication dose is not complete. there is no units next to digoxin, such as mg.

a nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning

practice session rational: practice sessions require psychomotor skills when learning.

A nurse is caring for a client who has an NG tube and is receiving intermittent feeding through an open system. which of the following actions should the nurse take FIRST?

tell the client to keep the head of the bed elevated at least 30 degrees.

Home health nurse is completing an admission assessment of an older adult who has their caregiver present. Which of the following statements should the nurse identify as a potential indication of elderly abuse?

the caregiver insist on remaining in the room. rational: the caregivers refusal to leave the room can be an indication of the potential mistreatment of the client.

a nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the clients plan of care?

wrap blankets around all 4 sides of the bed. rational: the nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frquent tonic-clonic seizures.

A nurse is teaching a client whose left leg is in the cast about using clutches. which of the following statements should the nurse identify as an indication that the client understands the teaching?

when descending stairs, I will shift my weight to my right leg( good leg).

order of giving regular insulin and NPH insulin

1) inject 10 units of air into the bottle of Nph insulin 2) inject 5 units of air into regular insulin 3)withdraw the correct dose of regular insulin from the bottle. 4) withdraw the correct dose of NPH insulin into the bottle.

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family?

check the cord routinely for frays or tearing, consider purchasing a generator for power backup, observe for signs of hyoxia.