ATI Foundations Exam

Flow rate of O2 nasal canula range:

1-6 L/min

At home O2 equipment should be at least __ ft away from open flames such as a fireplace or gas stove.

10

Flush the enteral feeding tube with ____ to ____ ml of sterile water before med administration and between each med.

15;30

8oz of ice chips actually equals 4oz to account for air.

1oz = 30ml

Do not use an oral thermometer with a child under the age of _____.

3

A subcutaneous injection is given from a __ to __ degree angle.

45; 90

A nurse is evaluating a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Assess for leg pain

A. Evaluate pedal pulses Nurse should do this FIRST

A nurse is planning to insert a peripheral IV catheter in an older adult client. Which of the following actions should the nurse plan to take? A. Insert the catheter at a 45 degree angle B. Place the clients arm in a dependent position C. Shave excess hair from the insertion site D. Initiate IV thereapy

A. WRONG the nurse should insert the catheter at a 10-30 degree angle. B. C. D.

A nurse is providing teaching to an older client who has constipation. Which of the following statements should the nurse include in the teaching? A. "Drink a minimum of 1,000 mL of fluids daily." B. "Increase your intake of refined fiber foods." C. "Sit on the toilet 30 minutes after eating a meal." D. "Take a laxative every day to maintain regularity."

C. "Sit on the toilet 30 minutes after eating a meal." -Increased peristalsis occurs after food enters the stomach. This is recommended method of bowel retraining to treat constipation. B. is not correct because you want to increase the intake of course fiber and whole grains.

A nurse is measuring vital signs for a client and notes an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope. B. Check the clients pedal pulses. C. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. D. Take the pulse at each peripheral site and count the rate for 30 seconds.

C. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. A. is not correct because that is used for a pulse that is non-palpable or very hard to palpate. C. pedal pulses are used to check circulation in the lower extremities.

T/F: A client who is experiencing severe pain can concentrate to learn.

FALSE

If the BP cuff is too small for the client, the BP will read as very _______.

High

Use ______ ________ for a penrose drain

Montgomery straps

What type of mask do you wear with airborne precautions?

N95 TB, varicella, measles

T/F: A cane should be held on the strong side of the body.

TRUE

T/F: A whistling sound in a hearing aide means there is cerumen buildup or that it does not fit.

TRUE

T/F: The nurse can inform the patient about an advanced directive.

TRUE

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 to the clients skin by covering them with a not latex barrier material such as stockinette using non-latex tape to secure them.

hyponatremia

abdominal cramping, weakness, headaches, nausea

When correctly inserting an NG tube for a client, the end of the tube should be:

above the pylorus as evidence by an xray.

Complete proteins contain:

all 9 essential amino acids that maintain and promote nitrogen balance. ex. cheese, fish, poultry

What food contains no cholesterol?

avocados

When cleaning a wound, move from the ______ ________ to prevent the introduction of new microorganisms.

center; outward

Major wound infections are ________ precaution.

contact

C. diff is

contact precaution

A second nurse must witness the disposal of any ___________ ________.

controlled substances

Fluid volume excess CM:

crackles in the lung field, dyspnea, and shortness of breath

Diptheria is _________ precautions.

droplet

Discharge planning starts

during admission

How often do you rinse out a feeding bag? How often do you change a feeding bag?

every 4-8 hours every 24 hours

shigella transmission

fecal-oral route (contact precautions)

When suctioning secretions from a client with a tracheostomy, what size should the suction catheter be?

half the size of the lumen

positive Chvosteks sign

hypomagnesemia hypocalcemia

Allogentic stem cell transplant compromises the clients ________ ________.

immune system, they must wear a mask to leave the room

Friction rub

-scratching or squeaking sound

Make sure electrical equipment in the room is working properly when someone is on oxygen so avoid sparks.

...

Oxygen can provide comfort and is not recitative when it is delivered via nasal canula.

...

Bruits are heard from:

narrowed or occluded arteries

A nurse is caring for a client who is post operative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

paralytic ileus is an immobile bowel. Absent bowel sounds with distention

low albumin (<3.5) indicates protein deficiency placing a client at risk for:

pressure ulcers

Older adults experience decreased cardiac output and increased ___________ , which takes longer to return to normal after exercise.

pulse rate

Only document what you observe!!!!!!!

seriously

Infiltration is noted by:

skin blanching, edema, and coolness at the IV site

use tracheostomy covers when outdoors at home

...

Urinary catheter provides constant flow of urine so...

... irrigate if there is a blockage (lots of urine in the bladder) so urine can flow.

IV infiltration is evident by:

swelling and cooling of the side

T/F: Stockings should be removed at least once per shift to check the clients skin integrity and circulation.

true

T/F:Always tie the restraint to the bed frame (using loose knots that are easily removed).

true

The QRS interval on the electrocardiogram (ECG) represents the electrical impulses passing through the ventricles.

true

Crackles

-air bubbles in the airway

Fidelity:

keeping promises

Veracity:

truthfulness

thrombophlebitis

-common effect of immobility -blood clot in a vein -caused inflammation and pain

Rhonchi

-dry, low pitches, snoring noises made due to partial obstructions

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand towards the clients stronger side. B. Instruct the client to lean backwards from the hips. C. Place the wheelchair at a 45 degree angle to the bed. D. Assume a narrow stance with feet 15 cm (6 in) apart.

C. Place the wheelchair at a 45 degree angle to the bed.

tonic clonic seizure:

loss of consciousness and violent muscle contractions

medication reconciliation

make a list of all medication (px and over the counter) that the patient is on currently