ATI Fundamentals Final

a nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "everytime you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

administer pain meds 45 min before changing the client's dressing.

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

Abdominal cramping. Can also include weakness, confusion, lethargy, headache and nausea.

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

Administer the medication with the needle at a 45 degree angle.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the providers prescriptions.

a nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client.

Make sure the client wears a mask when outside her room if there is construction in the area. they need at least 12 air exchanges per hour, in a positive-pressure airflow room

a nurse is assessing an older adult client's risk for falls. which of the following assessments should the nurse use to identify the client's safety needs.

Pupil clarity, visual fields and visual acuity.

Role conflict

develops when a person must assume multiple roles that have opposing expectations

Protective precautions

for clients with a compromised immune system, such as those who have received an allogenic stem cell transplant, require a protective environment. This precaution keeps them from acquiring infections from others

manifestation of hyperkalemia

numbness of the extremities

what is biofeedback?

a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders.

Role ambiguity

occurs when people are unclear about the expectations of their role in a given situation

Manifestation of hyponatremia and hypovolemia?

tachycardia

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea.

The client's caregiver washes the feeding tube bag with warm water once every 24 hours. They should be washed out after each feeding and replaced with a new feeding bag every 24 hours to prevent bacterial contamination. The nurse should reinforce this info with client's caregiver to avoid future contamination.

Gauze

Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as the proper safety protocol?

The client uses NON-acetone nail polish remover. Equipment should be inspected daily!!!

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures clients' safety, health and rights.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid. Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

A nurse in a long term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

1. Obtain the pronouncement of death from the provider. 2. Remove tubes and indwelling lines. 3. Wash the client's body 4. Ask the client's family members if they would like to view the body. 5. Place a name tag on the body.

REVIEW LAB VALUES

BUN--10-20 mg/dL Creatinine Sodium: 136-145 mEq/L. Potassium 3.5-5 mEq/L

a nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

I can concentrate best in the morning.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?

I will hire someone to trim the tree that hangs low over the stairs of my front porch.

a nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in the dependent position because the veins will dilate due to gravity. Generally, catheters are inserted at a 10-30 degree angle, however for an older adult client, 10-15 degrees is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue.

a nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly-licensed nurse. Which of the following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min. Flow rate would be aligned with the middle of the silver ball inside the meter. Reservoir bag should inflate by one-third to one-half with the inspiration. If it remains deflated, it indicates that clients are breathing in too much of the CO2 they exhale. Lastly, EBP supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen.

Droplet precautions

Required for clients that have infections spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia and streptococcal pharyngitis. The nurse should wear a mask when providing care of when within 1 m of the client who has a disorder requiring droplet precautions.

Airborne precautions

Required for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload the partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.

a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "what would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?

We would give you oxygen through a tube in your nose. Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

a nurse is caring for a client who has a prescription for a blood transfusion. The child's parents have refused treatment due to their religious beliefs. Which of the following actions should the nurse take?

examine personal values about the issue. Nurses should examine their own personal values about the issue in question in order to provide care that is without bias. contacting a spiritual support is for spiritual needs not physiological ones.

manifestation of hypomagnesemia and hypocalcemia

positive chvostek's sign.

Transparent dressing

promote healing in stage 1 pressure injuries by preventing further friction and shearing.

Sick role

refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver.

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 irrigant used from the client's urine output.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to the assistive personnel?

Assist the client with a partial bed bad, measure the client's BP after the nurse administers an antihypertensive medication and use a communication board to ask what the client wants for lunch.

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as the indication that the treatment was successful?

Decrease in heart rate. Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

Contact precautions

Needed for clients who have infections that spread via direct contact or from environmental contact.

a nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon who tells the nurse to continue to measure the client's vital signs every 15 min and report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

a nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. which of the following actions should the nurse take?

Pad the client's wrist before applying restraints.

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 hold the cane on the stronger side of her body to increase support and maintain alignment. The client will also move her weaker leg forward with the cane which divides the client's body weight between the cane and the stronger leg.

a nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

use tracheostomy covers when outdoors

Alginate dressing

used to treat stage 3 and 4 pressure injuries to absorb drainage which forms a soft gel when it comes into contact with drainage.

Role overload

when a person has more responsibilities within a role than one person can manage.