ATI practice exam for NPC final

A nurse is ready to insert an indwelling catheter for a female client. What instructions should the nurse give to the client as the catheter is inserted?

Bear down- as if to void relaxes the external sphincter and eases catheter insertion

A nurse is preparing to administer a medication to a client who states "that looks different from the pill I usually take", what response should the nurse make?

"Describe what the pill looks like"- the nurse must collect more data prior to administering the medication. The nurse should clarify the prescription with the provider in order to ensure safe and effective administration of therapy.

Identify the correct sequence the nurse should follow to initate the enteral feeding via nasogastric tube.

1. Verify tube placement 2. check the residual feeding contents and follow agency protocol about reinstilling the contents into the stomach 3. administer the feeding 4. evaluation of the client's tolerance to the feeding

Identify the squence of steps the nurse should take to perform wound irrigation.

1. place a waterproof pad under the client's leg to prevent soiling the bed linen 2. apply clean gloves 3. remove and discard the old dressing 4. Clean the puncture site using a circular motion, moving from the cleanest area in the center, outwards 5. Prepare equipment necessary for irrigation by opening a sterile dressing set and supplies 6. irrigate the wound until the solution becomes clear to ensure that exudate is no longer present

200ml over 30 min. Drop factor of the iv tubing is 15 gtt/ml. How many gtt/min?

100 gtt/min

A nurse is preparing to administer .3mg at bedtime. The amount available is .1mg/tablet. How many tablets?

3

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?

Dribbling of urine- dribbling of urine or overflowing continents, is an indicator of bladder distention. The nurse should perform intermittent catheterization when this occurs to prevent bladder trauma or infection. A regular schedule to drain the flaccid bladder should be established, with no longer than 8 hours between catheterizations.

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickend toe nails. The nurse should apply the pulse oximiter to what location?

Earlobe- least affected by decreased blood flow, and has greater acuracy when measuring oxygen saturation.

A nurse is preparing to administer a cleansing enema to a client. What action should the nurse take?

Hold the container of solution 30-45cm (12-18in) above the anus- to allow for a continuous, slow instillation of solution to promote evacuation of feces in the bowel.

A nurse is preparing to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take?

Inject the medication at a 90 degree angle- to reduce the risk of injecting the medication into subcutaneous tissue.

A nurse is preparing to obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. What site should the nurse plan to use to obtain the blood specimen.

Left forearm- this site is in the anecubital fossa, which allows for easy access and does not interfere with the client's IV catheter and infusion.

A charge nurse is observing a newly-licensed nurse insert an indwelling urinary catheter for a male client. What action by the new nurse requires intervention by the charge nurse.

Lubricates the first 2.5-5cm (2in) of the catheter- that lubrication is correct for a female client, the nurse should lubricate the first 15-17.5 cm (6-7) in when inserting a catheter into a male client.

A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. What nursing intervention is the highest priority?

Maintain immobilization and alignment- keeps the fracture fragments in close anatomical proximity, therby promoting functional fracture healing.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. What action should the nurse take first?

Raise the head of the bed- elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway.

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority?

Schedule a follow up visit by a home health nurse for dressing changes- the greatest risk to this client is injury from a wound infection. Wounds healing by secondary intention are open and have edges that are not approximated, which increases the risk for infection.

A nurse is caring for a client who needs a stool specimen collected. What action should the nurse take when obtaining the specimen?

Send the specimen container immediately to the lab- the nurse should label the container and send it immediately since a delay in transport can result in altered laboratory findings.

A nurse is caring for a client who has stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing?

Serum albumin 3.2g/dL- a serum albumin level is a good indicator of the nutritional status of a client. A value less than 3.5 g/dL is an indication of poor nutrition, can delay would healing, and lead to infection.

A nurse on a med-surg unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel?

random stool specimen- because it does not require the skills of a licensed nurse. However, the nurse should collect if the using of a sterile swab is required.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

Cover the area with a sterile dressing, moistened with .9% sodium chloride irrigation.- to protect the client's internal organs. The nurse should not attempt to reinsert the client's organs or viscera.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect?

1. Contractures of the extremitis- because of disuse of muscles and joints 2. Crackles in the lungs- because of the muculs that collects in the dependent airways. The client cannot cough effectively and oxygenation status declines 3. Pressure ulcers- because of increased pressure on skin and bony prominences, which affects tissue metabolism

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following taks should the nurse wear protective eye equipment?

1. Irrigating a client's abdominal wound- because exudate and fluids could splash into her eyes 2. Suctioning a client's new tracheostomy tube- because the client's secretions could splash into her eyes

A nurse is preparing to administer 150mg PO daily to a client. The amount available is 100mg/tablet. How many tablets?

1.5

A nurse asks the assitive personnel (AP) to take a specimen to the laboratory and the AP refuses. What action should the nurse take?

Ask the AP about her concerns with the assignment- reviewing the incident with the AP allows the nurse to understand the delegated task from the Ap's perspective. The nurse should attempt to determine the underlying problem the AP has with the assignment.

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the cleint to the left sims' position- this position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The nurse should also have the client's right leg flexed to facilitate insertion.

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the saftey of the client what action should the nurse perform.

Check that the client lifts the walker and then places it down in front of her- the client should lift the walker and advance it about 15cm (6in) then set it down. This allows a wide base of support while she moves forward.

A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse do to prevent infection?

Check the catheter tubing for kinks or twisting- these obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder

A nurse is careing for a client who has a wound infection. What action should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with .9% sodium chloride saline irrigation before obtaining the specimen- remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results

A nurse is planning care for a client who has a decreased level of consciousness. The client is recieving continuous enteral feedings via a gastronomy tube due to an inability to swallow. Which of the following is the priority action?

Elevate the head of bed to 30-45 degrees- this client is at risk for aspiration, lying flat increases that risk. This elevation promotes gastric emptying and reduces the risk of aspiration

A nurse is planning care for an older adult client who is at risk for deveoping pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the cleint's skin.

Use a transfer device to lift the client up in bed- prevents dragging the client's skin across the bed linens, which can cause abrasions.