ATI

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and ask for a drink. Her postoperative diet prescription states clear fluids, advanced diet as tolerated. Which of the following responses should the nurse make?

"I am going to listen to your abdomen" A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the clients abdomen to determine the presence of bowel sounds before clear liquids can be administered

The nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take

-raise the level of the bed to allow do use of proper body mechanics and reduce the risk of self injury -to prevent the risk of aspiration, the nurse should raise the clients had to 30° return the client to a side lying position -to prevent straining and reduce the risk of self injury the nurse should lower the near side rail before performing mouth care -to reduce the risk of caregiver injury, the nurse should never insert fingers into the mouth of an unresponsive client

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client

An elevated hematocrit 55% Elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output Low urine specific gravity indicates hypervolemia

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have a client perform just before insert in the catheter?

Bear down gently Bearing down helps the nurse visualize the urinary meatus and relaxes the external sphincter, which facilitates the insertion of the catheter

Intraoperative Care

Begins when the patient enters the surgical suite & ends at the time of transfer to the postanesthesia recovery area/ends when client is admitted to PACU

Paralytic ileus is ...

Can immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended.

a nurse is planning to obtain the vitals of a 2 yr old who is experiencing diarrhea and who may have an ear infection. which route for temp taking should the nurse use?

The rectal route is very accurate for obtaining body temperature in young children; however, it should not be used for clients who have diarrhea The tympanic route can be used in young children, but should be avoided in a child who has an active ear infection or who has tympanostomy tubes in place The oral route is not appropriate for use with children under the age of 3 The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair

A nurse is obtaining the BP in a clients lower extremity, which action should the nurse take?

This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.

The client is being discharged home with oxygen therapy delivered through nasal cannula. Which of the following instructions to the nurse provided to the client and family members?

Wear cotton clothing to avoid static electricity Avoid oils and petroleum products No smoking

When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death

When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death. Oliguria, or decreased urine production, is a finding consistent with peritonitis and can indicate the client is experiencing an anastomotic leak.

----------- and ----------- can reduce the antihypertensive effects of captopril, which is an ACE inhibitor. The nurse should reinforce to the client that --------------- has the potential to reduce the antihypertensive effect of captopril and should be avoided.

aspirin and other NSAIDS

If the peripheral pulse is irregular, the nurse should

auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record

Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if

the cuff is too small for the client.

A nurse is teaching a group of older adults about expected changes of aging. which of the following statements by a group member indicates that the teaching has been effective?

-Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise (CORRECT ANSWER) -Although bladder capacity decreases in older adults, urinary incontinence is not an expected finding and older adults should report incontinence so that it can be investigated and treated -Older adults have an increased buildup of cerumen in the ears, which may increase expected incidence problems with hearing loss -Decreased gastric emptying is an expected finding in older adults.

the nurse is providing teaching to an older client regarding constipation, what should she include?

-The nurse should instruct the client to consume a minimum of 1,500 mL of fluid to prevent constipation. -The nurse should instruct the client to increase consumption of coarse-fiber and whole grains, rather than refined-fiber foods -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 -The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation habits and can cause constipation, rather than cure it

A nurse is caring for a client who has a nasogastric tube for intermittent enteral feelings. Which of the following actions should the nurse take

-elevate the head of the clients bed 45° before the feeding -auscultate Paul sounds before each feeding to ensure the client has peristalsis a bowel activity for the digestive system to digest or absorb the enteral nutrition -The nurse should ensure the formula is at room temperature before administering because cold formula might cause intestinal cramping and discomfort -The nurse should flush the tubing with at least 30 ML's of water after the enteral feedings to maintain patency of the feeding tube

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?

-hold the breath for five seconds after goal volume is reached -instruct the client to inhale slowly to reach the goal volume and to decrease the collapse of alveoli in the clients lungs -instruct the client to breathe normally for short periods of time between each cycle and breath to reduce hyperventilation and fatigue -instruct the client to repeat the pattern spread 10 to 20 rats every hour while a week to prevent atelectasis and pneumonia

A nurse in an emergency department is caring for a client who reports developing severe right by pain with a gritty sensation while sawing wood. Which actions should she take first?

Ask the client about first aid performed at the scene The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of change in the client status the nurse must first collect data from the client. Assessing or collecting additional data will provide the nurse of the knowledge to make an appropriate decision. Therefore the first action the nurse should take is to assess the first aid that was performed at the scene to determine if eye irrigation was administered

a nurse is admitting a client who has decreased circulation in his leg. which of the following actions should the nurse take first?

For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client

According to erikson, the stage of psychosocial development for middle aged adults is

Generativity vs stagnation Excepting the independence of adult children is part of the developmental task of middle aged Ex of someone having difficulty with achieving Erikson's developmental task for this age group: "we miss our daughter so much that we are going to move closer to her"

A nurse is changing the dressing is for a client recovering from an appendectomy following a ruptured appendix. The client surgical wound is healing if I secondary intention. Which of the following observations to the nurse report to the provider?

Halo of erythema on the surrounding skin Might indicate underlying infection. This and any other manifestation of infection includes purulent drainage, swelling, warmth, or a strong odor and should be reported to the provider

The nurse is caring for a client who begins having a tonic clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor The nurse should apply the safety and risk education priority setting framework, which assigns priority to the factor or situation posing the greatest safety rest to the client. When is there are several risk to the client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority studying framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore if the client has a seizure while sitting should put them on the floor first

The charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for tracheostomy care -Cotton ball particles can be aspirated into the tracheostomy opening -Half strength peroxide solution is used to clean the inner cannula -tracheostomy care is a sterile procedure requiring the use of sterile gloves -pipe cleaners or a small sterile brush can be used to remove or crusty secretions from the inner cannula

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mask, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil retention The nurse should administer an oil retention enema prior to the removal of a fecal impaction to soft in the stool. This makes the procedure less painful for the client

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting and abdominal incision. On assessment, the nurse notes that the clients moon has eviscerated. Which of the following actions should the nurse take

Place the client in a supine position with the hips and knees flexed Cover the wound and intestine with a sterile, moistened dressing Monitor the client for manifestations of shock

A nurse is planning on in-service training session about nutrition. Which of the following pieces of information should the nurse include

Proteins serves as an energy source when other sources are inadequate Protein breaks down into amino acids Protein breaks down into ammonia. Glucose doesn't produce any products of metabolism Carbs provide 4 cal/g of energy. Fat provides 9 cal/g of energy

The kidneys regulate body fluids as well as assisting in which of the following functions

Regulation of acid base balance by retaining bicarbonate as they excrete hydrogen ions

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites sure the nurse select for the injection

Side hip between the iliac crest and anterior iliac spine The side hit between the iliac crest and anterior iliac spine forms the boundaries for a ventral gluteal injection, therefore this is an appropriate site. This site is preferred for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the clients greater trochanter (right hand on left hip) with the first 2 fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape

the question is asking which sites are associated with health care infections

Urinary tract is correct. Health care associated infections are caused from health care delivery in a health care facility. These result from prescribed antibiotic administration, presence of multi-medication resistant organisms, breeches in infection control practices, and invasive procedures. The urinary tract is a common site for health care associated infections. Surgical wound is correct. Surgical wounds are a common site for health care associated infections. Musculoskeletal system is incorrect. While injuries can occur in the health care setting that affect the musculoskeletal system, this is not a common site for health care associated infections. Respiratory tract is correct. The respiratory tract is a common site for health care associated infections. Blood stream is correct. The blood stream is common site for health care associated infections.

symptoms of acute alcohol withdrawal include

tachycardia, hypertension, diaphoresis, disorientation, and hand tremors. These can progress to visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, and grand mal seizures. Acute alcohol is a medical emergency and can cause death if not treated with the appropriate interventions. Tachycardia indicates the client is in acute alcohol withdrawal and should be reported to the provider.

Autologous blood transfusion is

the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.

While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as

when the hands are visibly soiled with dirt or body fluids