ATI review
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?
rapid heart rate- tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. What action should the nurse take first?
- gently shake the container of medication prior to administration
A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate?
Airborne
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Subtract the amount of irritant used from the client's urine output
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?
- The client holds the cane on the stronger side of her body - the client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and stronger leg.
A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
- Have family members wear a gown and gloves when visiting - Wash hands with soap and water because alcohol-based hand sanitizer doesn't kill C. diff
A nurse is caring for a client who has an NG time and is receiving intermittent feedings through an open system. What action should you take first?
- Tell the client to keep the head of the bed elevated at least 30 degrees Side note: - rinse the feeding bad with water between feedings - make sure enteral formulas is at room temp - wipe the top of the formula can with alcohol
A nurse is caring for a client who has tuberculosis. What actions should the nurse take
- place the client in a room with negative-pressure airglow (airborne precautions) - wear gloves when assisting the client with oral care - wear an N95 mask when providing client care - use antimicrobial sanitizer for hand hygiene
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?
Auscultate lung sounds
Go over lab values
Potassium: 3.5-5
A nurse is caring for a client receiving fluid through a peripheral IV catheter. What finding at the IV site should the nurse identify as infiltration?
Skin blanching - Skin blanching, edema, and coolness at IV site indicate infiltration Side notes: - Warmth indicated phlebitis - Purulent exudate indicated infection
