Fundamentals ATI/NCLEX
A community recreational center offers what level of public health prevention?
Tertiary Prevention
This type of prevention reduces complications and disabilities experienced by clients who already have a medical illness
Tertiary prevention
How should a client walk with a walker?
The client should move the walker forward, followed by the affected (weak) leg, and then the unaffected leg
Where should the nurse stand during a scoliosis screening?
The nurse should stand behind the client, who is bent over at the waist,
This position can promote venous circulation and facilitates postural drainage.
Trandelenburg -lowering the head of the bed with the foot of the bed raised in a straight incline
A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. What actions by the nurse is appropriate when administering the ear drops?
Warm refrigerated drops to room temperature prior to instillation. -pull the pinna down and back Because of the anatomy of internal ear structures, it is important to remember that the ear is sensitive to extremes in temp. Ear drops should be warmed to room temp prior to instillation to reduce the risk of painful stimuli
When the nurse is transferring the client from the bed to the wheelchair, how should the nurse and the wheelchair be positioned?
Wheelchair should be at a 45 degree angle so the client is able to pivot. The nurse should stand in front of the client toward the side that requires more support.
In what order should a client crutch walk when going up stairs?
Good leg (unaffected) crutch bad leg (affected)
In this religious faith, people may place the body with the head facing north following death. Cremation is practiced rather than burial
Hindu faith
In this religious faith, the body of the deceased is washed and wrapped during a ritual and then buried as soon as possible following death
Islamic faith
In this religious faith, a family member often stays with the body until burial occurs
Jewish faith
A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-age child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching?
"I will use my cromolyn inhaler before using my albuterol inhaler."When both cromolyn and albuterol are prescribed, albuterol should be inhaled first to open the airways because it is a bronchodilator. After waiting a few minutes, the cromolyn can then be inhaled and will reach further into the lungs because of the dilatory effects of albuterol.
Management precautions for contact precautions
-Private room (cohort patients) -gloves -gown
Testicular exams should begin at what age and performed how often?
15, monthly
What degree should the clients elbows be flexed when cane walking?
15-30 degrees
What is the distance between the axillea and the arm pieces on a crutch when a client is crutch walking?
2-3 fingerwidths
Blood cholesterol levels should begin at what age and performed how often?
20, 5 years
What degree should the elbows be flexed when a client is using crutches to walk?
20-30 degrees
Pap smears should begin at what age and performed how often?
21, every 3 years
saline solutions and IV bags should be changed after how many hours?
24 hours -after 48 hours they are considered contaminated
How far should a clients cane be placed outside the foot?
4-6 inches (10-15 inches)
Mammograms should begin at what age and performed how often?
40, yearly
Blood glucose testing (screening) should begin at what age and performed how often?
45, every 3 years
Colorectal screening (fecal occult, colonoscopy, sigmoidoscopy) should begin at what age and performed how often?
50 colonoscopy: 10 years Sigmoidoscopy: 5 years barium enema: 5 years
How far should the client place the crutches when ambulating?
6-10 inches (25.5 cm) diagonally in front of the foot
What must be present in order for the client to legally change the client's code status to do-not-resuscitate (DNR)?
A written prescription from the provider A DNR is typically instituted at the request of a client or family member and should be a written order instead of a verbal prescription. Until a DNR prescription exists. every attempts to revive the client should be made in the event of respiratory or cardiac arrest. A written prescription from the provider is necessary to legally change the client's code status to a DNR
Which side should the nurse stand on when a client is using a walker?
Affected (weak)
The nurse should stand on which side when a client is crutch walking?
Affected (weak) side
This is the priority assessment in a client newly diagnosed with quadipalegia?
Airway management and oxygen
What is the nurses first action for a client who is intubated and their oxygen begins to drop?
Auscultate lung sounds bilaterally -this confirms proper tube placement
In what order should the client crutch walk when going down stairs?
Bad leg (affected leg) crutches good leg (unaffected leg)
In this religious faith, male family members prepare the body following death
Buddhist faith
These types of gloves should be used when removing a dressing on a clients skin
CLEAN -when applying a new dressing a sterile glove should be used
What is an indication of a basilar skull fracture?
CSF (clear fluid) coming from the nares or ears
Management precautions for droplet precautions
Mask (within 3 feet) Private room -mask on client when they leave the room
The client should place a cane on which side of the body?
Strong (unaffected) side, so that the cane and the weaker leg can work with eachother
True or False An advanced directive form needs to be notarized
False; it does not need to be notarized and CAN be completed in the healthcare setting if here are two witnesses
A nurse is caring for a client who is having difficulty breathing, the nurse should assist the client into which of the following positions?
Fowlers -this is an upright position that promotes full expansion of both lungs and facilitates ventilation and perfusion
This action by the nurse can help prevent or resolve clogging in the tube of a client with an NG?
Irrigating the tubing
A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness?
Dark urine Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the liver and being excreted in the urine. The nurse should teach the parent that dark urine is a clinical manifestation associated with the illness
This type of therapy can draw attention away from a clients pain and help decrease the perception of the clients pain
Distraction -methods can include visual, auditory, tactile and intellectual distraction
A nurse who is caring for a client who has an NG in place has a prescription for continuous enteral feedings. What action by the nurse will reduce the clients risk for aspiration?
Elevating the head of the bed to 30 or 45 degrees
This type of therapy promotes increased circulation to a painful area and elicits a relaxation response, helpful in pain management of a client
Massage -decreases muscle tension. It can decrease pain intensity by increasing superficial circulation to an area of the body experiencing pain.
How should the nurse verify a medication prescription with a client who is unconscious?
Must use 2 identifiers -compare the medical record number and the name on the MAR with the clients ID band
are listing only last names on a whiteboard a breach in confidentiality?
No
Where should the nurse stand when a client is cane walking?
On the affected side
A nuclear family consists of who?
Parents and offspring -mother, father, child
Patients with this disease should not use a rolling walker
Parkinsons
When providing oral care for a an unconscious client, what should the nurse do?
Position the client in a lateral position with the head turned to the side. This prevents aspiration -do not use lemon glycerin swabs (drying) -use water or alcohol FREE mouthwash to rinse the clients mouth
A day care center offers what level of public health prevention?
Primary prevention
Immunizations are an example of what kind of prevention?
Primary prevention
Manifestations of a tension pneumothorax
Respiratory distress, assymetrical chest wall movement, trachea deviated to unaffected side, distended neck veins, decreased or absent breath sounds on affected side, hypotension, cyanosis
A crisis center, which has the goal of early detection and treatment, is an example of what level of public health prevention?
Secondary Prevention
Testing for exposure of TB is an example of what kind of prevention?
Secondary prevention
Memantine is a medication prescribed for which diagnosis?
Severe alzheimers
What type of test is used to confirm a client with active TB?
Sputum culture for acid-fast bacillus Once infected, the bacteria multiply freely after reaching the bronchi or alveoli. Typically, acquired immunity protects individuals from attaining active tuberculosis. Infection is most common among those who are immunocompromised and those who have been in repeated, close contact with someone who has an undiagnosed case of active tuberculosis. The lungs are primarily involved, but the infection can spread to other organs. Symptoms of pulmonary tuberculosis include productive cough, fever, fatigue, weight loss, hemoptysis, and night sweats. In cases of active pulmonary tuberculosis, the organism is transmitted through the air because it is found in the sputum and secretions. The presence of acid fast bacillus in the sputum, secretions, or tissues of the client is the only method to confirm the diagnosis of active tuberculosis.
a chest tube that is located in the higher portion of the thorax will do what?
allow for removal of air
Clients with nausea are at high risk for what immediately post operative?
aspitation (vomit) -clients who feel nauseous should be placed on their side to prevent aspiration of vomit
A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. The client reports a burning pain in his chest. Which of the following actions by the nurse is appropriate?
assist the client into a side lying position
a chest tube that is located on the lower portion of the thorax will drain what?
blood
Clients with unilateral weakness related to a stroke should dress which side of the body first?
the affected side of the body first
This type of solution should never be used to flush a clogged feeding tube
carbonated soda/cranberry juice -this can worsen the obstruction and the dark color can mask GI bleeding
these are wet popping sounds heard when auscultating the clients lungs. -these are often a manifestation of pneumonia
crackles aka rales
This is a course crackling sensation that can be felt under the clients skin. This is due to an air leak into subq tissue and often a manifestation of a pneumothorax
crepitus
How does a client cane walk?
the client should move the cane at the same time as the affected leg
this is a scratching or squeaking sound heard when auscultating the clients lungs. -this is due to plural surfaces rubbing together
friction rub
order of doffing PPE
gloves, goggles, gown, mask
Order of donning PPE
gown, mask, goggles, gloves
Where should the handle of a cane be placed when a client is cane walking?
great trochanter
What is a post complication from a lumbar puncture
headache A headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture that results from cerebrospinal fluid leakage at the puncture site. These headaches are managed primarily with analgesics, hydration, and bed rest
An NG tube to suction puts the client at risk for what electrolyte imbalance?
hypokalemia
manifestations of a respiratory obstruction
intercostal retractions stridor (high pitched inspiratory noises)
How should the nurse respond when a client asks how a TENS unit helps relieve pain?
it modulates the transmission of a pain impulse a TENS machine applies low voltage electrical stimulation directly over a location of pain at an accupressure point
This side lying position facilitates expansion of a single lung
lateral
Management precautions for airborne precautions
n-95 -Private room -Negative air pressure room with 6-12 exchanges per hour -HEPA filtration -mask on client when leaving the room
manifestations of a flail chest
paradoxical chest wall movement dyspnea cyanosis
this type of wound intention involves the closing of a wound using sutures or staples at the time the incision is made. -the suture line becomes well approximated during healing
primary intention
a client with COPD is likely to suffer from which acid base imbalance?
respiratory acidosis -clients are unable to exhale carbon dioxide due to a loss of elastic recoil of the lungs
this type of wound intention involves a beefy, red tissue called granulation tissue to fill the wound during healing -the wound is left open to drain and should heal within 5-21 days
secondary intention
what is the [proper way a client should be positioned for a thoracentesis?
sit on the side of the bed and lean forward over the bedside table
This is a severe complication associated with sickle cell anemia for a client who is experiencing a vaso-occlusive crisis
slurred speech Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of sickle cell anemia. The blockage of blood vessels in the brain by sickled cells results in cerebral infarction, which leads to neurological impairment. Because a CVA threatens the life of the client, this is highest priority finding.
This type of syringe should never be used to flush a clogged feeding tube?
small barrel syringe; this can create too much pressure and rupture the tube
What should the wound from a chest tube removal be covered with?
sterile, airtight, patroluem jelly gauze
asphyxiation
suffocation
Manifestations of pulmonary edema
tachycardia crackles pink frothy sputum
this is a vibration of the chest wall that the nurse can feel when palpating the clients chest as the client repeats a syllable such as "nine, nine" -this is a manifestation of pnemonia
tactile fremitus
What instructions should the nurse give while a physician is removing a chest tube?
take a breath in, hold it, and bear down -this will prevent air from coming back into the pleural space
this type of wound intention involves a graft placed over the clients wound bed after a wound is left open to drain and start healing. -includes sutures to close an open wound at a later date
tertiary intention
This is the first action the nurse should take when a client has a clogged enteral tube feed?
use a large barrel syringe to flush and aspirate warm water in a back and forth motion through the tube -second action: use a digestive enzyme solution and let it sit 30min-1 hour before flushing and aspiration are attempted.
