ATI Fundamentals WK6 -2 of 7
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Administer analgesics to the child on a routine schd throughout the day and night. -The nurse can provide the rx rectally or intravenously to avoid the oral route to child
A nurse is caring for a adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress?
"God is punishing me for something." -Spiritual distress is an impaired ability to integrate meaning and purpose in life through various means, including belief systems and relationships. Manifestations of spiritual distress can include a feeling that a higher power is punishing the individual for some behavior.
A nurse is teaching a client how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, what sequence of instructions should the nurse give the client?
"Hold the mouthpiece 1-2 in in front of your mouth." "Tilt head back slightly and open mouth wide." "Depress canister while taking a slow, dep breath." "Hold your breath for 10 sec."
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates the the nurse understands family-centered care?
"Lets set up a meeting time with the doctor to discuss your options for home care." -In family-centered care, the nurse considers the health of the family as a unit; therefore the client & family members help determine their outcomes and goals. setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment.
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
"Sit on the toilet 30 min after eating a meal." -Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?
Face the client when speaking. -face the client who has a hearing impariment and stand or sit at the same level to maximize communication. Many client who are hearing-impaired combine lip reading with their residual hearing when communicating.
A nurse is assessing a client's nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5kg (10lbs)
10 wks. -1 lb of body fat = 3,500 calories. cosuming 500 etxra calories each day for 7 days would lead to a total of 3500 calories and a 1 lb gain per week, thus 1 lb/wk = 10lbs in 10 wks
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
Explain the procedure to the client. -The nurse should apply the LEAST INVASIVE priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client SAFETY. The nurse should take interventions that are not invasive to the client BEFORE interventions that are INVASIVE. This REDUCES the # of organisms introduced into the body, < # facility-acquired INFECTIONS. Informing the client about the procedure REDUCES FEAR & assists in gaining client COOPERATION, which is important for NG insertion and is the priority nursing intervention
A nurse is providing reaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching>
Gelatin. -Foods allowed on a clear liquid diet are clear and liquid at room temperature.
As a nurse is preparing to administer liquid medication from a bottle to a client, which of the following actions should the nurse take?
Hold the medication bottle with the label against the palm of the hand when pouring. -the nurse should hold a multidose bottle with the label against the palm of the hand when pouring to prevent contaminating the label with spilled medication that could cause info on the label to fade or become illegible
A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?
Nutrition. -nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a clients risk of developing pressure ulcers.
A nurse is collecting health hx data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working w/ the interpreter?
Pace speech to allow time for interpreter to convey the words. -The nurse should speak clearly, allow time for interpreter to convey message, and the client to receive it. The nurse should face the client while speaking.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is restraints?
Remove the restraints one at a time. -restraints should be removed and ROM performed q 2 hrs. Restraints CANNOT be PRN, they are only written for 24hrs. Never tie to side rails bc can injure client in rails are lowered.
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?
Repeat each joint motion 5 times during each session. -To maintain the client's joint mobility, the nurse should repeat each motion 3-5 times.
A nurse is assessing a client's incision and observes the drainage to be blood tinged. Which of the following terms should the nurse use to document this finding?
Sanguineous. -This type of drainage contains large amount of RBCs, indicating the damaged capillaries are allowing the escape of RBCs from the plasma.
A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?
Starch. -Salivary amylase begins the process of digestion in the mouth with the initial breakdown of starches. The majority of starch breakdown occurs in the small intestine with pancreatic amylase.
An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?
"Tell me more about how your friend discourage you." -The nurse should ask an open-ended question that encourages the client to elaborate on these problems.
A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene?
Elevating the finger above heart level. -The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.
A nurse in a rehab facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?
Locking the breaks on the bed and the wheelchair before moving the client. -you do not want either to move when shifting the client.
A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk for developing complicated grief?
The death was sudden. -Complicated grief can occur when the death of a loved one is sudden and unexpected.