ATI Extra Quizzes
a nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube, which action should the nurse take first
check the pH of the client's stomach contents check pH of aspirate by drawing up 5 mL of gastric fluid should be less than 5 to confirm
Avocados contain no
cholesterol
When performing medication reconciliation, the nurse should create a
current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.
fluid volume deficit causes tachycardia so after IV therapy the patient would
decrease heart rate
a nurse tells a coworker that she believes the client has been unfaithful to he partner
defamation of character
document in which clients designate a health care proxy to make health care decisions for them if they are unable to do so
durable power of attourney
discharge planning begins
during admission process
a nonambulatory client notifies the nurse that his garbage can is on fire what do they do
evacuate the client
when on a home oxygen machine a patient should consider buying a
generator
telephone or vernal prescription guidelines
have another nurse listen to prescription, repeat it back, question things that seem wrong, make sure provider signs prescription in person within 24 hours
a nurse cannot touch a bottle with sterile solution bc
that is breaching sterile field
a client says he may leave the hospital against medical advice, the nurse believes this is wrong and administers a sedative med which the client hasn't requested along with his usuals, this is an example of
false imprisonment
example of tertiary health care involves provision of specialized and highly technical care
ICU, oncology treatment centers, burn centers
a nurse is preparing to check a clients capillary blood glucose level, which actions should the nurse plan to take
allow antiseptic to dry completely before puncturing
administering pain meds before client attempts a potentially painful exercise like ambulation
beneficidence specific and positive action to help the client
unintential torts
malpractice and negligence
An albumin level below 3.5 g/dL indicates
protein deficiency risk for pressure ulcers and poor wound healing
administering a large dose of med due to calculation error, patient has stroke and dies
malpractice
what actions require an incident report
needle sticks, med errors, missed specimen collection of prescribed lab test
state licensing boards are responsible for ensuring that health care
providers and agencies comply with state regulations
An abdominal x-ray showing the end of the NG tube above the
pylorus is correct positioning
what should be followed when documenting in a client's record
record all dates and times document objective data, leaving out opinions
to clean a hearing aid
soft cloth
home care of tracheostomy
use trach covers when outdoors
nurse at long term care facility gathering a nutrition history for a client who has dementia, which components of the nutrition eval is the priority for the nurse to determine from the clients family
any difficulty swallowing
a nurse is caring for a client who has visual impairment, which action should the nurse take
arrange food on tray in like the face of a clock
a nurse is performing med reconsiliation with a client, which action should the nurse take first
ask the client if they take OTC meds
an AP is repremanding a clietn for not using the urinal properly, they tell the patient they will put a diaper on him if he doesn't use it correctly, this is an example of
assault threatening patient
gastrostomy tubes should be washed out
at each refilling throughout the day (4-8 hours) and replace it with a new feeding bag every 24 hours to prevent bacterial contamination
a nurse is preparing the room for a client transferring from the emergency department who is on seizure precautions, which items should the nurse place in the client's room
oral nasal suction reduces risk of aspiration
a nurse is changing an ostomy appliance for a client who has a new colostomy, which action should the nurse take
press then skin barrier against the client's skin for 30 seconds activate the adhesives in the skin barrier
a client is coughing and sneezing when a surgical dressing change is needed to be made, what does nurse do when preparing sterile field
put a mask over client to limit spread of microorganisms
implications for telephone order
repeat details of prescription back to provider, have another nurse listen to the telephone prescription, obtain the providers signature on prescription within 24 hours
a nurse is planning to perform post mortem care for a client, which of the following actions should the nurse plan to take
verify whether the client needs an autopsy
a nurse is caring for a client who has a C diff infection, which action should the nurse take
wear a cover gown when caring for the patient contact isolation
nitrogen sources
= protein cheddar cheese, poultry, fish
home oxygen should be kept
10 feet away from open flames like a fireplace or gas stove
responsible for primary teaching
RN PN can reinforce teaching only
a client returning from surgery must be accompanied by
RN especially if unstable not a AP
a patient dies during the nurses shift what do they do
The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.
includes data from family and staff
objective
a nurse is performing a preop assessment on four clients, the nurse should ID which of the following are at risk for a latex allergy
a client who has spina bifida history of frequent contact with natural latex products like urinary catheter
intentional torts include
assault, battery, false imprisonment
abdominal cramping is continuous with
hyponatremia
a nurse is completing dietary teaching with a client who has heart failure and has a prescription for a 2g sodium diet, which statements made by client indicates an understanding of the teaching
i can have nonfat yogurt as a dessert low sodium and fat
a nurse is teaching a client who has a new hearing aid, which of the following statements by the client indicates to the nurse an understanding of the teaching
i will reinsert my hearing aid if i hear a whistling sound
a nurse is preparing to administer 15 units of regular insulin along with 25 units of NPH insulin, which actions should the nurse take first when mixing the insulin
inject 25 units of air into NPH prevents contamination of the rapid acting regular insulin with the NPH insulin
a nurse is planning care for a client who is postop, which intervention should the nurse include in the plan to decrease the client's risk for venous stasis
instruct pain to elevate legs when sitting in a chair
fairness in care and delivery and in the use of resources
justice
legal doc that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end of life issues
living will
responsibility of nurse at transferring facility
make sure client has possessions, confirm the rehab center has a bed, give verbal transfer report via telephone, complete transfer form
a nurse is preparing to perform a sterile procedure for a client, which actions should the nurse include in the plan
position a bedside table so the sterile field can be seen throughout the procedure at all times
a gastrostomy tube patient will develop diarrhea if
the feedings are infused at a rapid rate
a nurse is preparing to reposition a client in bed, which actions should the nurse taken when using ergoanomic prinicples to move the client
tighten has abs to prevent injury
To descend stairs using crutches, the client should first shift his body weight to his
unaffected leg
Evidence-based practice supports a flow rate of what for nasal cannula
1-6 L/min
a nurse in a providers office is reviewing the lab reports for a client who is at risk for heart disease, which result should the nurse report to the doctor
LDL level at 170
who can reinforce teaching
PN or RN not Ap
a nurse is reviewing a client's ABG lab results, which of the following ABG results should the nurse report to the provider
PaCO2 32 mm Hg 35-45
a nurse is preparing to insert a new IV catheter, which actions should the nurse take
choose a vein that is palpable
a nurse is performing a guaiac testing for a client to screen for colon cancer, the nurse should ID that ingestion of which foods can cause a false negative
citrus fruits vitamin C produces negative
a nurse has received an order to take out a clients sutures, after putting gloves on what should they do
clean sutures along the incision site minimizes infection
a nurse is teaching a client how to perform active range of motion exercises of the lower extremities to improve mobility, which instructions should the nurse include in the teaching
complete each session two times per day reduce risk for injury
a nurse is admitting a client to a unit, which actions are essential steps in admission procedure
explain roles of other care staff, begin discharge instructions, document the client's wishes about organ donation, introduce the client to his roomate
an end of shift report can be given
face to face, audiotaping, presentation during walking rounds in each clients room no visitors
failing to implement safety measure for a client at risk for falls
negligence
incident report documents the
occurrence of an accident or an unusual event med errors, falls, omissions of prescription, needlesticks document facts, do not refer to individual records
a nurseis performing an admission assessment for an older adult client, after gathering the assessment data and performing review of systems what is there priority
orient client to his room
can initiate therapy for clients who have difficulty with feeding due to swallowing difficulties
speech language pathologist
