ATI Assessment A Review

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration

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. The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?

Acupuncture The nurse should inform the client that the use of acupuncture is contraindicated for a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection.

A nurse is caring for a client 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 position. By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply)

-Place the client in a room with negative pressure airflow (The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions) -Wear gloves when assisting the client with oral care. (Standard precautions: The nurse should wear gloves whenever her hands might come in contact with a client's body fluids, such as saliva, and the mucous membranes in the mouth) -Use antimicrobial sanitizer for hand hygiene. (The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis)

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries The first action the nurse should take when using the nursing process is to assess the client for injuries.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have a blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

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

Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is caring for a client who requires bed rest and has a prescription for anti embolic stockings. Which of the following actions should the nurse take?

Remove the stockings at least once per shift The nurse should remove the stocking once per shift to check the client's circulation and skin integrity.

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

"I'll check the wires and cables on my TV to make sure they are in good working order." Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks.

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

Tell the client to keep the head of bed elevated at least 30 degrees. Elevate HOB because ABC's come first.

A nurse is caring for a client who asks about the purpose of advanced directives. Which of the following statements should the nurse make?

"They indicate the form of treatment a client is willing to accept in the event of a serious illness" Advance directives include a living will, which permits the client to direct treatment in the event of a terminal illness.

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of following actions should the nurse take?

Reassure the client that this is an expected response to grief During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reaction to a cancer diagnosis.