Med Surg ATI Assessment A

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. A. Inject 5 units of air into the bottle of regular insulin B. Withdraw the correct does of NPH insulin from the bottle C. Inject 10 units of air into the bottle of NPH insulin D. Withdraw the correct does of regular insulin from the bottle

1. Inject 10 units of air into the bottle of NPH insulin 2. Inject 5 units of air into the bottle of regular insulin 3. Withdraw the correct does of regular insulin from the bottle 4. Withdraw the correct does of NPH insulin from the bottle Rationale: The nurse should first inject air into the vial of NPH (cloudy) without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin, and then withdraw the correct amount of the regular (clear) insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with the NPH insulin.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication fro a 2 mL vial. Which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage B.Notify the pharmacy when wasting the medication C. Lock the remaining medication in the controlled substance cabinet D. Dispose of th vial with the remaining medication in a sharp container

A. Ask another nurse to observe the medication wastage Rationale: A second nurse must witness the disposal of any portion of a dose of a controlled substance. This ensures that it does not "go missing" and that it is confirmed that it was disposed of properly.

A nurse iin a surgical suite notes documentation on a clients medical record that he has a latex allergy. In preparation for the clients procedure which of the following precautions should the nurse take? A. Ensure sterilization of non disposable items with ethylene oxide B. Wrap monitoring cords with stockinette and tape them in place C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medications D. Wear hypoallergenic latex gloves that contain powder

B. Wrap monitoring cords with stockinette and tape them in place Rationale: Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the clients skin by covering them with a non latex barrier material, such as stockinette, and using non latex tape to secure them

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? 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 therapy in the veins of the hand

B. Place the clients arm in a dependent position Rationale: The nurse should place the clients arm in a dependent position because the veins will dilate due to gravity and make them easier to find and insert the IV.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A. Rinse the feeding bag with water between feedings. B. Tell the client to keep the head of the bed elevated at least 30 degrees C. Make sure the enteral formula is at room temperature. D. Wipe the top of the formula can with alcohol.

B. Tell the client to keep the head of the bed elevated at least 30 degrees Rationale: The first action the nurse should take when using the ABC approach to client care is to prevent aspiration of the enteral formula; therefor, the priority intervention is to keep the head of the bed elevated at least 30 degrees to prevent reflux of the formula backward into the esophagus

A nurse is caring for a client who requires bed rest and has a prescription for anti embolic stockings. Which of the following actions should the nurse take? A. Apply the stockings so the creases are on the front side of the leg B. Apply the stockings while the clients legs are in a dependent position C. Remove the stockings at least once per shift D. Remove the stockings while the client is sitting in a reclining chair

C. Remove the stockings at least once per shift Rationale: The nurse should remove the stockings once per shift to check the clients circulation and skin integrity.

A nurse is caring for a client receiving a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? A. Purulent exudate B. Warmth C. Skin Blanching D. Bleeding

C. Skin blanching Rationale: Skin blanching, edema, and coolness at the IV site indicate infiltration. Exudate indicates infection rather than infiltration. Warmth indicates phlebitis rather than infiltration. Bleeding is common with IV insertion and not indicative of infiltration.

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? A. The top of the cane is parallel to the client's waist. B. When walking, the client moves the cane 46 cm (18 inch) forward C. The client hold the cane on the stronger side of her body D. The client movers her stronger limb forward with the cane

C. The client holds the cane on the stronger side of her body Rationale: The client should hold the cane on the stronger side of her body to increase support and maintain alignment

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? A. Ill get a blood sample from you and send it for a screening test B. Beginning at age 60 you should have a colonoscopy C. You should have a fecal occult blood test every year D. The recommendation is to have a sigmoidoscopy every 10 years.

C. You should have a fecal occult blood test every year Rationale: Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete and incident report? A. A nurse tied a clients restrain straps to the moveable part of the bed frame B. An assistive personal placed a surgical mask on a client who has tuberculosis before transporting her to radiology C. A nurse administers a medication to a client 30 minutes before the dose is due. D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid Rationale: The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further similar incidents. Medication error.

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurses priority before beginning the procedure? A. "When do you usually bathe, in the morning or in the evening?" B. "Do you prefer a bath or a shower?" C. "At what temperature do you prefer your bath water?" D. "Are you able to help with your hygiene care?"

D. Are you able to help with your hygiene care Rationale: The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care; therefore, the nurse's priority is to asses the clients ability to assist with her hygiene care.

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

D. Have the client take sips of water to promote insertion of the NG tube into the esophagus Rationale: Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tubes passage in to the trachea.

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

D. Reassure the client that this is an expected response to grief Rationale: It is important to validate the patients feelings and make sure that they know they are not the only ones feeling this way.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?

Auscultate the lungs Rationale: The priority assessment the nurse should make when using the ABC approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and SOB.