ATI RN Fundamentals Online Practice 2019 A

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- Administer enoxaparin at a 45 to 90 degree angle. - Discharge planning begins as the client is undergoing the admission process. - Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, complication of immobility. - Pupil clarity, visual fields, and visual acuity = increase risk for falls. - Droplet precautions = rubella, meningococcal pneumonia, streptococcal pharyngitis. - Herpes zoster is a contraindication for the use of acupuncture. - Feverfew = promotes wound healing. - Aloe = improve disorders and wound healing effects. - Biofeedback = stroke recovery, smoking cessation, headaches. - Contact precautions = gown and gloves. - Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers via nasal cannula. - Tuberculosis = negative-pressure airflow room - Medication reconciliation = compare client's home medications with the provider's prescriptions. - When lifting heavy objects = stand close to the cabinet, use arm and leg muscles, wide base of support, and bend knees when lifting. - Role overload = expression of frustration, have more responsibilities within a role than one person can manage. - Place client's arm in a dependent position because veins will dilate due to gravity. - Feeding bas should be washed out after each feeding and replaced with a new feeding bag every 24 hours to prevent bacterial contamination. - Fluid volume deficit causes tachycardia. - Hyponatremia = low sodium level, abdominal cramping, weakness, confusion, lethargy, headache, and nausea. - Advance directives = living will, which permits a client to direct the treatment they will receive in the event of a medical emergency or serious illness. - Nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.

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 an assistive personnel (AP)? - Assist the client with a partial bed bath - Measure the client's BP after the nurse administers an antihypertensive medication. - Test the client's swallowing ability by providing thickened liquids. - Use a communication board to ask what the client wants for lunch. - Irrigate the client's indwelling urinary catheter.

- Assist the client with a partial bed bath - Measure the client's BP after the nurse administers an antihypertensive medication. - Use a communication board to ask what the client wants for lunch.

Identify the sequence in which the nurse should perform the following steps. - Place a name tag on the body. - Wash the client's body. - Remove tubes and indwelling lines. - Ask the client's family members if they would like to view the body. - Obtain the pronouncement of death from the provider.

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

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

1. Examine personal values of the issue.

A nurse is administering an otic medication to an older adult. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? 1. Press gently on the tragus of the ear. 2. Pack a small piece of cotton deep into the ear. 3. Move auricle down and back toward the head. 4. Tilt the head backward for 5 min.

1. Press gently on the tragus of the ear. - Help medication get into inner ear. - Move auricle upward and backward for an older adult.

A nurse is caring for a client who has terminal illness and approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

1. Turn the client every 2 hours.

A nurse is reviewing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? 1. "I can place an extension cord across my living room to plug in my television" 2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" 3. "I will place my alarm clock on my bedroom dresser across the room" 4. "I will replace my old throw rug in my kitchen with a new one"

2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" - Reduces risk of falls

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

2. Apply intermittent suction when withdrawing the catheter. - To prevent injury to mucosa. Suctioning continually for more than 10 seconds can cause compromise.

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?

2. Make sure the client wears a mask when outside her room if there is construction in the area. - Compromises the patient's immune system - increasing risk for infection.

A nurse is teaching a client how to care the tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

2. Use the tracheostomy covers when outdoors.

A nurse is providing teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

3. Administer the medication into the abdomen.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?

3. Make sure two fingers can fit under the sleeve.

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? 1. Place the client in a side-lying position 2. Instill 15 mL of irrigation fluid 3. Subtract the amount of irrigant used from the client's urine output. 4. Perform the irrigation using a 20-mL syringe.

3. Subtract the amount of irrigant used from the client's urine output. - Instill 30 to 40 mL of irrigation fluid - Use a 30 to 50 mL syringe to perform

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? 1. The top of the cane is parallel to the client's waist. 2. When walking, the client moves the cane 46 cm forward. 3. The client holds the cane on the stronger side of the body. 4. The client moves her stronger limb forward with the cane.

3. The client holds the cane on the stronger side of the body. - To increase support and maintain alignment. - Top of the cane is parallel to the client's greater trochanter. - Client should advance cane 15 to 30 cm (6 to 12 in) forward. - Weaker leg + cane = walking

A nurse is planning strategies to manage time effectively for the client care. Which of the following strategies should the nurse implement?

3. Use the planning step of the nursing process to prioritize client care delivery.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing quality of pain?

4. "Is your pain sharp or dull" - Sharp, dull, crushing, throbbing, aching, burning, or shooting helps determine quality of pain.

A nurse receives report on a client who is receiving 0.9% sodium chloride at 125 mL/hr. When the nurse performs the initial assessment she notes that the client has received 80 mL for the last 2 hrs. Which of the following actions should the nurse first take? 1. Reposition the client 2. Document the client's IV intake in the medical record 3. Request a new IV fluid prescription 4. Check the IV tubing for obstruction

4. Check the IV tubing for obstruction - Assess the client first by checking the IV tubing.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? 1. Position the client with the head of the bed elevated to 30 degrees prior to insertion. 2. Remove the NG tube if the client begins to gag or choke. 3. Apply suction to the NG tube prior to insertion. 4. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

4. Have the client take sips of water to promote insertion of the NG tube into the esophagus. - Will help prevent the tube from passing into the trachea. - Client should be sitting in a high-Fowler's position. - Nurse should withdraw the NG tube slightly, not remove it, if the client gags or chocks to reduce risk of injury.

A nurse is preparing to apply a dressing on a stage 2 pressure injury. Which of the following types of dressings should the nurse use? 1. Alginate 2. Gauze 3. Transparent 4. Hydrocolloid

4. Hydrocolloid - Promotes healing in stage 2 injuries' by creating moist wound bed. - Alginate = treat stage 3 or 4 injuries - Gauze = promote healing in stage 4 injuries - Transparent = promote healing in stage 1 injuries'

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L

4. Potassium 5.4 mEq/L - Normal range 3.5 - 5 mEq/L

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? 1. Discuss the risk factors for colon cancer. 2. Focus teaching on what the client will need to do in the future to manage his illness. 3. Provide the client with written information about the phases of loss and grief. 4. Reassure the client that this is an expected response to grief.

4. Reassure the client that this is an expected response to grief. - Nurse should support the client.