Practice fundamentals ATI

A nurse in a provider's clinic is teaching a female client about how to collect a clean-catch urine specimen at home. Which of the following information should the nurse include in the teaching? •"Use sterile gloves when collecting your urine specimen." • "You may refrigerate your urine specimen for up to 12 hours before bringing it to the laboratory." • "Collect your urine specimen as soon as you start your stream." • "Clean your vaginal area from the front to the back."

"Clean your vaginal area from the front to the back." The nurse should instruct the client to clean the vaginal area using a front-to back motion two to three times using a fresh towelette, cotton ball, or gauze pad each time.

A nurse at a provider's office is caring for a young adult client. Which of the following information should the nurse provide regarding health promotion strategies? • "Have breast cancer screenings after 40 years of age." • "Schedule a tuberculin skin test every 5 years." • "Have your cholesterol checked every 10 years." • "Schedule a baseline ECG at age 45."

"Have breast cancer screenings after 40 years of age." The nurse should instruct the client to have breast cancer screenings after 40 years of age if they desire. Clients who are 45 to 54 years of age are encouraged to receive annual mammograms

A nurse is preparing to document a prescription from a provider. Which of the following abbreviations should the nurse use? • "U" for "units" • "Q.D." for "daily" • "HS" for "bedtime" • "IV" for "intravenous"

"IV" for "intravenous" ~ CORRECT The nurse should use "IV" because it is an acceptable abbreviation to indicate an intravenous route of administration.

A nurse is performing an admission assessment on a client who has chronic fatigue syndrome and is seeing a practitioner for therapeutic touch therapy. Which of the following statements should the nurse make? • "Your nurses here will be able to provide this therapy while you're in the facility." • "Chronic fatigue is a contraindication for this type of therapy." • " will need to document the equipment settings the practitioner uses in your medical record." • "Tell me about the specific symptoms this therapy relieves for you."

"Tell me about the specific symptoms this therapy relieves for you." As part of understanding the client's use of complementary and integrative health strategies, the nurse should promote open dialogue with the client and should gather information about the reasons the client uses these strategies. This can assist the nurse in planning client-specific care that includes the client's preferred care strategies, when possible.

A nurse is talking with the family of a client who is nearing the end of life. The nurse should identify that agreeing to which of the following requests from the client's family violates the principle of justice? • "Give her a sedative so she will sleep and not wake up." • "We want her to have a feeding tube even though her living will says not to." • "Try to spend more time with her than with your other patients." •"We want you to tell her that she's getting better."

"Try to spend more time with her than with your other patients."~ CORRECT When considering the ethical principle of justice, the nurse has a responsibility to act fairly.

A nurse is teaching a client who has a new diagnosis of diabetes mellitus about how to perform capillary blood glucose testing. Which of the following instructions should the nurse include? • "Choose a puncture site next to a bone." • "Wrap your finger in a cold compress for 5 minutes prior to collecting the specimen." • "Place the lancet at a 45-degree angle to the skin." • "Use a drop of blood large enough to cover the pad on the reagent strip."

"Use a drop of blood large enough to cover the pad on the reagent strip." CORRECT The nurse should instruct the client to place a drop of blood on the reagent strip large enough to cover the pad to ensure an adequate specimen collection and accurate measurement of the blood glucose level.

A nurse is teaching a client who requires the insertion of a feeding tube in the jejunum. Which of the following instructions should the nurse include in the teaching? • "You should tilt your head forward when the tube is first inserted into your nostril." • "You will need an X-ray to check the location of the tube after it is inserted." • "You should cough forcefully as the tube is passed through the back of your throat." • "This tube will be placed in your large intestine."

"You will need an x-ray to check the location of the tube after it is inserted."

Packed RBCs (administration of blood products)

- Time completed: 2-4 hours - Action/Use: increase available RBC, severe anemia, hemoglobinopathies, hemolytic anemia, erythroblastosis fetalis - Monitor for reaction: acute hemolytic, febrile, anaphylactic, mild allergic, and sepsis

A nurse is assessing an older adult client during a home visit. Which of the following findings should the nurse report to the nursing supervisor? -Brown macules distributed over the backs of both hands -Ecchymosis on the torso in various stages of healing -Flesh-colored cutaneous tags in the axillary regions -Absence of skin tenting over the client's sternal region

-Brown macules distributed over the backs of both hands INCORRECT The nurse should identify brown macules distributed over the backs of both hands as senile lentigines, which is an expected age-related change associated with sun exposure. -Ecchymosis on the torso in various stages of healing CORRECT The nurse should identify ecchymosis in various stages of healing as a possible indication of physical abuse. The nurse is required to report suspected elder maltreatment to a supervisor for further investigation. -Flesh-colored cutaneous tags in the axillary regions INCORRECT The nurse should identify flesh-colored cutaneous tags, also called skin tags, in the axillary or neck regions as an expected age-related change. -Absence of skin tenting over the client's sternal region INCORRECT The nurse should identify the absence of skin tenting over the client's sternal region as a finding suggestive of adequate hydration status. Skin turgor should be checked on the sternum rather than hands due to age-related loss of skin elasticity.

How is a transdermal patch containing a controlled substance such as an opioid be discarded?

-Fold transdermal patch (med side is on the inside) -Dispose according to facility policy

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

Tuberculosis precautions

-place client in negative pressure airflow room -wear gloves when assisting with oral hygiene -nurse should wear N95 respirator mask -use antimicrobial sanitizer for hands

Nurses and therapeutic touch therapy

-requires specialized training -nurses use touch as communication form -not part of standard nursing practice

At what rate while taking BP should a nurse release the air so the pressure decreases

2-3mm Hg per sec.

The nurse should instruct the client that she may refrigerate the specimen for no more than ____ before bringing it to the laboratory.

2hrs

bladder cuff size should be what % of circumference of arm?

40%

The lancet should be placed at what degree angle to the skin when performing capillary blood glucose test?

90 degree

A client with hearing loss can purchase a door bell, alarm system and smoke detector system to amplify sounds with

A low pitch buzzing

Who serves as a co-signer when recording the waste of controlled substances such as an opioid?

A nurse should have a 2nd nurse to witness the wasting. The 2nd nurse co-signs within the electronic medication dispensary system with the 1st nurse.

A nurse is teaching a group of newly hired nurses about incident reports. Which of the following examples should the nurse use as a situation that requires completion of an incident report? • A client vomits after receiving an oral medication. • A provider prescribes a medication for a client who has a known allergy to it. • A client receives cefotaxime 25 min after it is scheduled. • A nurse withholds propranolol for a client who has a heart rate of 48/min.

A provider prescribes a medication for a client who has a known allergy to it. ~ CORRECT An incident report is required for a circumstance that leads to injury or poses a risk of injury to a client. An incident report should be completed when a provider prescribes a medication to a client who has a known allergy to that medication, even if the medication was not administered.

continuous IV infusion

A type of intravenous infusion, where large volumes of solution are infused over several hours to days at a slow constant rate

When taking BP the cliff should be placed ...

Above antecubital space to allow room for the bell of the stethoscope

A nurse is caring for a client who has fecal incontinence. Which of the following actions should the nurse take? Wash the client's anus before washing the client's buttocks. Apply a moisture barrier to the client's skin. Use soap and hot water to clean the client's skin. Wash the client's perineal area from back to front.

Apply a moisture barrier to the client's skin. The nurse should apply a thick layer of moisture barrier over clean, dry skin to prevent breakdown of the area contaminated with fecal material.

A nurse is placing a client in the dorsal recumbent position. Which of the following actions should the nurse take? Rotate the client's legs externally. Position the client's head flat on the bed. Place the client's heels on the mattress. Arrange a pillow under the client's head and shoulders.

Arrange a pillow under the client's head and shoulders. The nurse should arrange a pillow under the client's head and shoulders when placing them in the dorsal recumbent position, which is a back-lying position.

At what age should a nurse instruct to schedule a baseline ECG

At 35 years of age

A nurse is planning care to prevent plantar flexion for a client who is in a coma. Which of the following intervention should the nurse include in the plan of care? • Internally rotate the client's ankles and feet. • Place pillows under the client's ankles. • Apply elastic wraps to prevent hyperextension of the client's ankles and feet. • Brace the client's feet with ankle-foot orthotics.

Brace the client's feet with ankle-foot orthotics. The nurse should apply ankle-foot orthotics to prevent plantar flexion, which will allow the client to dorsiflex the foot when conscious.

Therapeutic therapy is effective for clients with

Chronic conditions

When cleaning clients skin the nurse should use

Cleaners with non ionic surfactants to decrease skin breakdown

A nurse is preparing to administer an intermittent IV bolus of phenytoin to a client who is receiving a continuous IV infusion of dextrose 5% in water. The nurse is unfamiliar with the administration of phenytoin. Which of the following actions should the nurse take to ensure that the medication and the IV solution are compatible? Consult the facility's pharmacist. Access the facility policies and procedures. Check the client's medication administration record. Review the safety data sheets (SDSs).

Consult the facility's pharmacist. The nurse should consult the facility's pharmacist to check for compatibility of the medication with the existing IV fluid before administering the medication to prevent any interactions between the medication and the IV solution. This medication information can be found in the facility formulary or in a medication resource book.

A nurse is caring for a client who is scheduled for a procedure. Prior to transporting the client for the procedure, the client states, "I don't understand the risks of having this procedure." Which of the following actions should the nurse take? • Delay the surgical procedure and notify the provider. • Speak to the client's family about the client's concerns. • Instruct the client to sign the informed consent form prior to transfer. • Provide the client with a summary of the risks and benefits of the procedure.

Delay the surgical procedure and notify the provider. CORRECT The nurse should advocate for the client by informing the surgical suite of the delay and notifying the client's provider. The provider should explain the risks and benefits of the procedure to the client.

A charge nurse is supervising a newly licensed nurse change the bed linens for a client who is on contact precautions. The charge nurse should identify that which of the following actions by the newly licensed nurse demonstrates proper technique? • Placing the soiled linens on the floor in the client's room • Holding the soiled linen against his body after removing it from the client's bed • Depositing the soiled linens into a covered laundry hamper • Shaking the soiled linens after removing them from the bed

Depositing the soiled linens into a covered laundry hamper ~ CORRECT The nurse should place the soiled linens into a fluid-resistant bag in a covered laundry hamper to reduce the risk of spreading micro-organisms.

How should a nurse dispose of partially filled syringes of controlled substances such a morphine?

Dispose unused med by returning to the pharmacy or according to facility policy.

A client who is experiencing circulatory overload from a transfusion can have

Distended neck veins, dyspnea, cough, and crackles in lungs

A nurse is performing a skin assessment for a client using the Braden scale. Which of the following findings should the nurse identify as increasing the risk for skin breakdown? • The client ambulates independently three times during the day. • The client consumes 75% of each meal. • The client reports pain in the right foot. • The client is incontinent of urine and feces.

The client is incontinent of urine and feces. According to the Braden scale, a client is at risk for skin breakdown due to the frequency of exposure to moisture from incontinence of urine and feces.

When should a nurse instruct client to schedule tuberculin skin test?

Every 2 years or more if at high risk

When should the nurse instruct clients to have cholesterol screening?

Every 5 years or more if results are above expected range

Internal rotation of the clients ankles and feet will prevent plantar flexion — T or F?

False. Will not prevent plantar flexion

A client who is having a febrile reaction to a transfusion can experience

Fever, chills, headache, and nausea

What should always be worn during airborne precautions?

Fitted N95 respirator

To prevent urethral contamination the nurse should wast the client perineal area ...

Front to back

What does not need to worn during airborne precautions

Gown, eye protection, surgical face mask

When should a nurse withhold propranolol for a client?

If HR is less than 50/min withhold and contact provider

Applying elastic wraps can help with...

Improving circulation and preventing edema of the lower extremities

The nurse should asses the safety data sheets (SDSs) when seeking

Information about cleaning up chemical spills. SDSs provides info about the process for cleaning up specific materials as well as first aid guidelines in the event of exposure

A client who is having acute intravascular hemolytic reaction can experience

Low back pain, flushing and tachycardia

A nurse is planning care for a client who has tuberculosis. Which of the following pieces of personal protective equipment should the nurse apply before entering the client's room? • Gown • N95 respirator • Eye protection •Surgical face mask

N95 respirator ~ CORRECT A properly fitted N95 respirator should always be worn when caring for a client who is on airborne precautions. This type of mask protects the nurse from inhaling small micro-organisms and particles in the air.

Is a client receiving cefotaxime 25min after scheduled a concern?

No. This is a time sensitive medication and should be administered within 30min of scheduled time. This is not an incident report.

The nurse should instruct what about frayed or damaged electric cords

Not to use because they increase risk of electric shock or fire

Cranial nerve III

Oculomotor (motor)

To examine the structure of the inner ear what is used?

Otoscope

A nurse is preparing to perform a physical assessment of a client. Which of the following pieces of equipment should the nurse select to test the client's oculomotor nerve (cranial nerve III)? Penlight Tongue blade Tuning fork Otoscope

Penlight To test the oculomotor nerve (cranial nerve III), the nurse should check the client's extraocular eye movement and pupil's reaction to light by using a penlight.

Therapeutic touch therapy may be contradicted in clients who

Physical touch might be intolerable or traumatizing, such as someone who has a history of abuse

To decrease the risk of or developing pressure injuries pillows should be placed where? And heels should be kept where?

Pillow under ankles or lower legs and heels off the mattress

A nurse is teaching a class about home safety. Which of the following instructions should the nurse include in the teaching? • Change smoke detector batteries every 2 years. • Place toddlers in rear-facing car seats until they are 2 years old. • Store toxic liquids in plastic soft drink bottles. • Tape frayed electric cords before using them.

Place toddlers in rear-facing car seats until they are 2 years old

What can increase risk of plantar flexion for a client in coma?

Placing pillows under ankles, by allowing toes to point downward

The nurse should access the clients medication record to identify

Prescribed meds, dosages, administration times, methods of administration, and to document meds administered

Pillows are used to prevent the bed mattress from causing

Pressure injuries

A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse plan to take? Place the lower border of the cuff slightly over the antecubital space. Record the diastolic number as the last sound heard. Release the air from the cuff so the pressure decreases at 5 mm Hg per second. Use a blood pressure cuff with a bladder that is 50% of the client's arm circumference.

Record the diastolic number as the last sound heard. The pressure at the fifth and final sound, considered phase 5 of the Korotkoff sounds, is recorded as the diastolic pressure in adolescents and adults.

What can alter readings when taking BP?

Releasing air from cuff too fast A cuff that is too large or small

What kind of report should be done if a client vomits after taking an oral medication?

Report to provider in case further action is required. DOES NOT REQUIRE INCIDENT REPORT

What is required to use a telecommunication device

Requires both the sender and the receiver to have the device for communication

ankle foot orthotics

Stop in 5 degrees of plantarflexion to give knee stability Stop in slight dorsiflexion helps prevent genu recurvatum of the knee Posterior leaf-spring - dorsiflexion assist and prevention of plantarflexion or foot drop Free single-axis ankle joint or "articulated" or "hinged" AFO - limits normal hindfoot and forefoot motion, no rotation except within brace; pistoning can occur

The client should hold the cane on their

Stronger side to obtain maximum support and correct body alignment

To facilitate passage of the tube into esophagus the client should tilt their head forward and ....

Swallow sips of water to facilitate passage of the tube into esophagus

A nurse is providing teaching to a client who has severe weakness in their right lower extremity and is learning to walk using a cane. Which of the following actions by the client indicates an understanding of the teaching? • The client moves the cane forward before taking a step. • The client holds the cane on their weaker side. • The client moves their stronger leg before moving their weaker leg. • The client keeps their elbow straight when holding on to the cane.

The client moves the cane forward before taking a step. CORRECT The client should move the cane forward by about 15 to 30 cm (6 in to 1 ft) before taking a step with the weaker leg to maintain stability.

When inserting a feeding tube how should the client positioned their neck?

The client should hyperextend their neck when the feeding tube is advanced toward the nasopharynx to straighten the nasopharyngeal junction.

A nurse is teaching a client who is preparing to use a telecommunication device for clients who have hearing loss. Which of the following information should the nurse include about the device? The device amplifies sounds with a low-pitch buzzing sound. The device prevents an intruder from entering the home of a client who has a hearing impairment. The device requires the use of a computer and printer. The device only requires the client who has hearing loss to purchase the device.

The device requires the use of a computer and printer. The client who has hearing loss can purchase a telecommunication device that requires a computer and printer to transfer typed words over the telephone.

The client should move what leg first when using a cane?

Their weak leg before their stronger leg

The nurse should instruct the client to first initiate the stream and then collect 30 to 60 mL of urine. This process avoids the collection of any micro-organisms that might be present on the urethral meatus.

To collect a clean catch urine specimen

When testing the glossopharyngeal nerve (cranial nerve IX) which equipment is used?

Tongue blade (this cranial nerve is responsible for gag reflexes and ability to taste.) During this exam, sweet and salty things can be given with eyes closed to test the nerve.

The nurse should instruct clients not to store what in food or drink containers to reduce risk of accidental poisoning ?

Toxic liquids

A client who is able to consume adequate amounts of nutrients is not at risk for skin breakdown related to nutrition. T or F?

True

urethral contamination places the client at risk for

UTI

A nurse is caring for a client who is receiving 1 unit of packed RBs. Which of the following findings should indicate to the nurse that the client is experiencing an allergic reaction? •Distended neck veins • Fever • Urticaria • Low-back pain

Urticaria The nurse should identify that a client who is experiencing an allergic reaction from a transfusion can have urticaria, flushing of the face, and itching of skin.

Phenytoin used for?

Used for -Status epilepticus -Tonic Clonic Seizure

When assisting to help wash a clients fecal matter what area should be washed first and then after?

Wash the least contaminated area first then the most contaminated area near the anus

When should the nurse asses the facilities policies and procedures regarding medication

When seeking info about types of medications that can be administered within a particular unit. (Do not give info of administration for specific med)

When is a running fork used during a physical assessment?

When testing auditory nerve (cranial nerve VIII). This nerve control equilibrium and hearing. A Romberg test for balance can also be used

The nurse should instruct to change smoke detector batteries every :

Year to ensure proper function

A nurse is conducting an in-service with a group of newly licensed nurses about handling controlled substances. Which of the following information should the nurse include? Discard used transdermal patches containing opioid medications in the trash can. Have the pharmacist serve as cosigner when recording the waste of opioid medications. Verifv the number of available medications with the number indicated in the inventory. Dispose of partially-filled syringes of morphine into a sharps container.

• Verify the number of available medications with the number indicated in the inventory. The nurse should count the number of opioid medications, such as hydromorphone, prior to removing tablets from the computerized dispensing system and investigate any discrepancies.

plantar flexion

bending of the sole of the foot by curling the toes toward the ground

Propanolol

beta blocker

Last sound heard when taking blood pressure is

diastolic pressure

transcutaneous electrical nerve stimulation (TENS)

electrical stimulation of nerves for relief of pain

justice in nursing

equal treatment for all (treating without bias)

Oculomotor

eye movement

"Give her a sedative so she will sleep and not wake up." The nurse should recognize that administering a sedative medication unnecessarily could cause....

harm to the client and violates the ethical principle of nonmaleficence.

urticartia

hives

Dextrose use

hypoglycemia

dorsal recumbent

lying on back with legs bent and feet flat. Arrange pillow under clients head and shoulders

jejunum

second part of the small intestine

Intermittent IV bolus

small amount of solution given intermittently (25-250 mL)

Antecubital

space in front of the elbow

The first sound heard when taking blood pressure is

systolic pressure

"We want her to have a feeding tube even though her living will says not to." The nurse should recognize that not upholding the client's wishes for end-of-life treatment violates

the ethical principle of autonomy.

"We want you to tell her that she's getting better." The nurse should recognize that not telling the client the truth about her condition violates

the ethical principle of veracity.

"Therapeutic Touch Therapy"

therapy based on idea that illness is caused by an imbalance in the body's energy field, places hands slightly above patient's body to stimulate self healing

hemiparesis

weakness on one side of the body

When documenting a prescription from a provider what abbreviations should not be used?

• "U" for "units" : can be mistaken for a zero or four • "Q.D." for "daily" : Can be mistaken for Q.I.D or QID • "HS" for "bedtime" : can be mistaken for half strength