ATI FUNDAMENTALS review

instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitits

A nurse in an acute-care facility is assisting with planning care for a client who is alert but is temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse suggest to prevent a complication of immobility?

Hyper oxygenate the client before suctioning

A nurse is caring fo ra client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take?

Monitor the client at least once every hour

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?

Ceasing to compare personal identity with those of others

A nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward which of the following developmental tassks

Feedback provided

A nurse is communicating w/ a group of clients about what to expect during the POp phase of a total hip arthroplasty. Which of the following elements of hte communication process should the nurse identify as a sign of effective communication

The client has slightly flexed elbows when ambulating w/ the crutches

A nurse is evaluating a clien'ts use of crutches. The nurese should identify that which of the following actions by the client indicates safe usage of teis equpiment?

Sitting

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in whicho f the following positions for evaluation?

place the bladder of the cuff over the posterior aspect of the thigh

A nurse is obtaining the blood pressure in a client's lower extremity. Whcihof the following actions should the nurse take?

The basal metabolic rate could decrease

A nurse is reinforcing teaching about nutrition w/ a middle adult client who has a sedentary job. Which of the following factors should the nurse consider?

I will make sure to replace my pouch around 4 hours after I eat

A nurse is reinforcing teaching w/ a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

The involvement of the client in planning the change

A nurse is reinforcing teaching with a client who has heart failure about reducing his daily intake of sodium. Which of hte following factors is the most important in determining the clien'ts ability to learn new dietary habits?

clamp the tubing below the collection port

a nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Below the medial malleoulus

a nurse is collecting baseline data of a clien'ts peripheral vascular system. in which of the following locations should the nurse palpate the posterior tibial pulse?

decreased bowel sounds

a nurse is collecting data from a client whose potassium level is 2.8 meq/L which of the following findings should the nurse expect?

faint pedal pulses

a nurse is collecting data on a client. The nurse should recognize that which of the following findings places the client at risk for impaired skin integrity?

check capillary refill before applying an ice pack to the affected area

a nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

increased cerumen

a nurse is in a provider's office is collecting data from an older adult client. Which of the following findings should the nurse expect?

place soiled linen in a single linen bag

a nurse is leading an education session about disposing of biohazards materials. Which of the following instructions should the nurse include in the teaching?

Discuss the meaning of a common proverb

a nurse is performing a mental-status examination for a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly?

apply pressure to the bridge of the nose after instillation of the medication - to prevent systemic absorption

a nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

Circle the area of the injection with a pen

a nurse is preparing to admnister a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take?

Warm the irrigating solution to 37 C to minimize discomfort and vascular constriction

a nurse is preparing to irrigate a clien'ts wound. which ofthe following actions should the nurse take?

a nurse will show me how to care for my wound

a nurse is reinforcing discharge teaching with a client who has a prescription for daily wound care via home health care services. Which of the following statements by the client indicates an understanding of the teaching?

Sit w/ your back supported keep your knees at hip level use an ergonomically designed computer keyboard

a nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include?

elevates the finger above heart level

a nurse is reinforcing teaching w/ a client about how to obtain a capillary finger-stick blood sample. Which of the following actions by the client requires the nurse to intervene?

Sit on the toilet 30 minutes after eating a meal

a nurse is reinforcing teaching w/ an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

Antagonistic

a nurse is reinforcing teaching with a client who is postop following a knee arthroplasty about the muscles he will nee d to strengthen in physical therapy. Which of the following muscle groups are responsible for movement at the knee joint?

Antagonisitc

a nurse is reinforcing teaching with a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups are responsible for movement at the knee joint?

apply light pressure to the scanner head once it is in position

a nurse is using a portable ultrasound bladder scanner to measure a clients post-void residual. Which of ht following actions should the nurse take?

F = (C x 9/5) +32

FORMULA F-C

Suction equipment

a nurse ona. medical unit is caring for a client who has a seizure disorder. Which of the following items is the nurse's priorty to keep near the client at all times?

Rhonchi

adventitious (abnormal) breath sounds loud, harsh, gurgling, have a snoring or moaning quality

Cranial nerve V trigeminal

ask client to clench teeth and palpate masseter muscle for contraction to test this cranial nerve

sensorimotor stage

birth-2 years ex- playing in sand

Sanguineous

blood-tinged drainage

Leukopenia

decrease of WBCs

Hypocalciuma

deep tendon reflexes, positive Chvostek's sign (tightening of muscles in face when the nurse taps the client's facial nerve)

Protein-calorie malnourishment

dry, brittle hair edema poor wound healing

Depression

during this stage, the client has realized the full impact of the loss and might express hopelessness and despair

Complete proteins

eggs, meat, poultry, seafood, milk, yogurt, cheese, soybean, soybean products

Hold cane on unaffected side

for cane

Metabolic acidosis

higher ph, paCO2 within expected range

fight-or-flight response

hypertension increased respiratory rate dilated pupils bronchiolar dilation

Leukocytosis

increase in circulating WBC in response to WBC existing from blood vessels- result of inflammation

Cranial nerve XII hypoglossal

innervates the tongue, by observing a range of tongue movements

Vesicular

lung sounds over major part of lungs

generativty vs. stagnation

middle adult hood community involvement, parenting, mentoring, teaching

TENS unit

modulates the transmission of pain impulse

Dorsalis pedis

most distal pulse

serous

mostly serum, clear portion of blood

ROM -neck- flexion

moving neck up and down

moro reflex

newborn extends both arsm and legs outward and thend raws then back inward as a response to a loud noise

Braden scale

nutrition, sensory perception, moisture, activity, mobility, friction and shear parameters of this test

to test trigeminal nerves

obtain cotton whisps, safety pain, clench teeth

primary intention

occurs when the provider closes the wound using sutures or staples at the time the incision is made, the suture lines becom ewell approximated when healing

incomplete proteins

pasta, peanut butter, cereal (unless you add milk) lentils, veggies, grains, nuts s, seeds missing 1 or more of the essentail amino acids necessary to support growth and maintain homeostasis

Intraoperative

phase of care begins w/ transferring the client to the surgical suite table and ends with transfer to PACU

initiative vs. guilt

preschoolers guilt, frustration and help control impulses and cooperative w/ others altered development can result from harsh punishment and excessive limits on behavior

Babinski

reflex - newborns toes fan out when the nurse strokes the sole of foot

antigravity muscle group

stabalizing knee joint

second intention expected findings

tenderness to touch, pink, shy tissue with a grainy appearance - granulation tissue, serosanguineous drainage

Leukoplakia

thick white patches found in mucosa of mouth

rooting reflex

touching the newborns cheek makes the head turn ot the side where the touch occurs. disappears after 4 months

Cranial nerve VIII vestibulocochlear

using Rinne and Weber tests, ask client if they can hear whisper

tertiary intention

using sutures to close an open would at a later date after the wound drains and starts to heal placing skin graft

formal operation period

11- adulthood self-conciousness

formal operational reasoning

11-up describing interpersonal relationship- example

confirm unresponsiness

1st CPR step

4mm identation

2+ edema

preoperational thinking

2-7 playign dress up- pretending

PIaget's preoperational period

2-7 yrs old animism- child attributes lifelike feeling and thoughts to inanimate objects play therapy- dolls, , toys

6 mm indentation

3+ edema

head lagging stops between

4-6 months

concrete operational period

7-11 seriation, reversibility

Respiratory alkalosis

ABG's, high Ph. PaCO2 below expected range

diuresis

AKA polyuria (excessive urination)

Depressed deep tendon reflexes, nausea, vomiting, bone pain, lethargy, weakness

Calcium level EXCESS expected findings

intimacy vs. isolation

Erickson's stage for young adults - finding partner, adjust to living w/ partner, making plans to start family, raising/nurturing children, managing a home, establish an affiliation w/ a social group, civic responsibility

infection acquired from a diagnostic procedure

Iatrogenic HAIs directly result from diagnostic or tehrapeutic procedures

Albumin

a nurse caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. a laboratory result w/in the expected reference range for which of the following substances is an indication that the client has adequate protein uptake and synthesis?

Physical examination

a nurse employs a through , systematic method for obtaining objective data about the client. Which of the following method should the nurse use to collect information?

pocketing food

a nurse in a long-term care facility is feeding a client. Which of the following observations should the nurse identify as an indication that the client requires an evaluation for dysphagia?

Have another nurse witness the disposal of the medication

a nurse is administering a controlled substance to a client who is postop. The IM dosage requires the nurse to use only part of the amount of the medication in the vial. Which of the following actions should the nurse take?

I'll wash my hands before I remove the old dressing and again before putting on the new one

a nurse is assisting with preparing a client for discharge and providng instructions about performing dressing changes at home. WHich of the ofllowing statements indicates that the client understands medical asepssis?

monitor the client's blood glucose level

a nurse is carign for a client who is receiving continous enteral feedings. WHich of the following actions should the nurse take?

clean the drain site from the center outward

a nurse is caring fo ra client who requires a dressing change. which of the following actions should the nurse take?

collapse air from the device before emptying

a nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation fo the device?

collapse air from the device after emptying

a nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?

elevate the client's head of bed 45 degrees before the feeding

a nurse is caring for a client who has a NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Hyperglycemia cortisol-increase

a nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which ofthe following to occur?

starch

a nurse is caring for a client who has xerostomia with a lack of saliva. the nurse should identify that which of teh following nutrients will be affected by teh lack of salivary amylase?

HCT 55%

a nurse is caring for a client who is dehydrated. Which of the following lab values shoudl the nurse expect for this client?

Provide more water with feedings

a nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?

identify the client using 2 identifiers

a nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take ifrst?

Advise the client to perform ROM exercises in bed

a nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?

supports self-determination

a nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

montgomery straps

a nurse is changing the dressings for a client who has 2 penrose drains near an abdominal incision. Which of the followin gadhering devices is the best choice fo rthe nurse to use to decrease skin irritation?

Taut skin around the IV catheter site that is cool to the touch

a nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which ofh the following findings should the nurse identify as infiltration of hte IV infusion site?

Cleanse the wound with 0.9% sodium chloride irrigation

a nurse is collecting a specimen for culture from a clien'ts infected wound. Which of the following actions should the nurse take?

Tell me more about how you feel about dying

while in a hospital, a client who has a terminal illness tells the nurse, "I can't believe i'm dying. there are a lot of bad people in the world who are healthy, and here I am dying!" which of the following responses should the nurse offer?