ATI

A nurse is providing teaching for a client who has a new prescription for a continuous positive airway pressure ( CPAP ) machine to treat obstructive sleep apnea . Which of the following statements should the nurse include ?

" Cover your nose with the CPAP mask . "

A nurse is providing teaching to an assistive personnel ( AP ) about the use of sterile gloves . Which of the following instructions regarding the open gloving method should the nurse give ?

" Grasp only the inside of the glove with your ungloved hand . "

A nurse is planning care for a group of clients on a cardiopulmonary unit . Which of the following clients should the nurse plan to see first ?

A client who reports dyspnea when walking to the bathroom

A nurse is preparing a sterile field . The nurse should identify that which of the following actions contaminates the sterile field ? ( Select all that apply . )

A cotton ball dampened with sterile normal saline is placed on the field is correct The nurse turns to address the client's question concerning the procedure is correct The procedure is postponed for 30 min to accommodate the client is correct A liquid is poured into a sterile container from a distance of 25 cm ( 10 in ) is correct

A nurse is obtaining a health history from a client . Which of the following findings should the nurse identify as risk factors for heart disease ? ( Select all that apply . )

A diet high in saturated fats A history of smoking for 25 years A sedentary lifestyle is correct .

A nurse is suctioning a client's tracheostomy using an open system . Which of the following actions should the nurse tak

Administer 100 % oxygen before the procedure .

A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding . Which of the following types of dressings should the nurse select to help promote hemostasis ?

Alginate

A nurse is discussing ventilation and perfusion with a newly licensed nurse . The nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations ?

Alveoli

A nurse is planning care for a client who has multiple wounds . During the initial stage of wound healing , which of the following should the nurse include in the plan of care ?

Apply oxygen at 2 L / min via nasal cannula . CORRECT

A nurse is caring for a client who has a tracheostomy . Which of the following pieces equipment should the nurse use when administering oxygen to this client

Atracheostomy collar

expect to use ? A nurse is caring for a client who requires 1 L of oxygen . Which of the following oxygen delivery devices should the nurse

Nasal cannula

A nurse is caring for a client who has a history of asthma and is wheezing . Which of the following actions should the nurse take first ?

Obtain the oxygen saturation

Administering oxygen therapy with a nonrebreather mask has which of the following advantages

Offers the highest oxygen concentration of the low - flow systems

A nurse should recognize that which of the following findings is an indication for oxygen therapy ?

Oxygen saturation ( SaO₂ ) 90 %

A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy . Which of the following instructions should the nurse include ?

Place the oxygen tank in a clutter - free environment . "

A nurse is preparing to open a sterile package of instruments . Identify the order in which the nurse should perform the following steps . ( Move the steps into the box on the right , placing them in the order of performance . Use all the steps . )

Position the tray so that the top flap is farthest away from their body is the first step . Open the flap furthest from their body is the second step Open the side flaps is the third step Open the flap closest to their body is the fourth step .

A nurse is providing teaching for a client who has a prescription for home oxygen . Which of the following instructions should the nurse include ? ( Select all that apply . )

Post a " No Smoking " sign inside the home Attach oxygen containers to a fixed object Notify the fire department that oxygen is used in the home home

A nurse is caring for a client who has been receiving oxygen via nasal cannula for 4 hr . Which of the following assessment findings helps indicate that oxygen therapy has been effective ?

Respiratory rate 14 / min

A nurse is assessing a client who is receiving oxygen therapy . The nurse should identify that which of the following findings can indicate oxygen toxicity ?

Ringing in the ears

A nurse is explaining the sequence of electrical conduction in the heart to a newly licensed nurse . What should the nurse include as the correct sequence of the transmission of electrical impulses ? ( Move the steps into the box on the right , placing them in the selected order of performance . Use all the steps . )

SA node is the first step AV node is the second step Bundle of His is the third step Right and left bundle branches is the fourth step Purkinje fibers is the fifth step

A nurse is documenting data about a healing wound on a client's lower leg . The predominant exudate in the wound is watery in consistency and light red in color . The nurse should document which of the following types of wound drainage ?

Serosanguineous

A nurse is caring for a client who requires 7 L of oxygen to maintain oxygen saturation . Which of the following oxygen delivery devices should the nurse expect to use ?

Simple face mask

A nurse is documenting data about a deep necrotic wound on a client's left buttock . The nurse observes a yellowish - tan , soft , stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed . Which of the following assessment findings should the nurse document ?

Slough

A nurse is caring for a client who is receiving supplemental oxygen for hypoxia . The nurse should identify that which of the following can cause hypoxia ?

Smoke inhalation

A nurse is staging a pressure injury over a client's right heel area . The pressure injury has no eschar or slough and no exposed muscle or bone . The nurse should identify that this pressure injury is classified as which of the following ?

Stage 3

A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve . Which of the following findings should the nurse expect ?

Stenosis

A nurse is caring for a client who has atelectasis . The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis ?

Surfactant

A nurse is preparing to flush and change the dressing on a client's central venous catheter . Which of the following should the nurse identify as the primary purpose for performing this intervention using surgical asepsis ?

To control the introduction of micro - organisms at the catheter site

A nurse should identify that which of the following is the goal of surgical asepsis ?

To create and maintain a micro - organism - free environment

A nurse preparing to wash their hands prior to surgery . For which of the following reasons should the nurse keep their hands above their elbows ?

To encourage water and soap to flow away from the clean hands

A nurse is providing teaching for a client who has a new prescription for an incentive spirometer Which of the following instructions should the nurse include

Use the incentive spirometer every hour while awake . "

A nurse is caring for a critically ill client who has COPD and requires delivery of a precise concentration of oxygen . Which of the following types of oxygen - delivery devices is indicated for this client ?

Ventur mask

A nurse is assessing a client who is being discharged . The nurse notes the client has regular and quiet breathing . The nurse should identify this breathing pattern as which of the following ?

Normal breathing

Prior to entering the surgical - scrub area , which of the following personal protective equipment ( PPE ) items should a nurse don ? ( Select all that apply )

Protective eyewear is correct Hair cover is correct . Mask is correct Shoe covers is correct .

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement Which of the following is a form of mechanical debridement that the nurse should expect the client to receive ?

Pulsating lavage

A nurse is planning to measure the cardiac output of a client who had a myocardial infarction . Which of the following data should the nurse use to calculate the client's cardiac output ? ...

Stroke volume

When donning sterile gloves , which of the following explains the method a nurse should use for gloving the dominant hand ?

The inner edge of the cuff will lie against the skin and thus will not be sterile .

While waiting for a sterile procedure to begin , how should a nurse position their hands and arms ?

With hands clasped together in front of the body above waist level

A nurse should identify that which of the following areas of the hands requires special attention during the prescrub wash ?

The area under each fingernail

A nurse is teaching a newly licensed nurse about pulmonary function tests . The nurse should include that which of the following is the vital capacity ?

The maximum volume of air that is expired after a maximum inspiration

A nurse is teaching a client who has an abdominal incision about coughing and deep breathing . In which order should the nurse instruct the client to perform the following steps ? ( Move the steps into the box on the right , placing them in the selected order of performance . Use all the steps . )

" Take a deep breath " is the first step Hold your breath for several seconds " is the second step . Exhale slowly " is the third step Brace the incision with a pillow and try to cough deeply

A nurse is discussing atrial fibrillation with a newly licensed nurse . Which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrillation ?

"Atrial fibrillation is caused by electrical signals outside of the SA node."

A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right ischial tuberosity . Which of the following should the nurse plan to apply to the client's pressure injury ?

Barrier creams

A nurse is assessing a client who has COPD . The nurse should identify that which of the following is an expected finding ?

Clubbing of the fingers

A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound . The nurse should recognize that which of the following types of medications is known to delay wound healing ?

Corticosteroids

A nurse is caring for a client who has left - sided heart failure . Which of the following findings should the nurse expect ?

Crackles in the lungs

A nurse is caring for a client who was admitted with community - acquired pneumonia and has been receiving oxygen therapy for several days . Which of the following findings indicates an adverse effect of oxygen therapy ?

Cracks in the oral mucosa

A nurse is caring for a client who has dyspnea , slight cyanosis , and a nursing process will the nurse determine that the client has impaired gas exchange ? respiratory rate of 28 / min . During which of the following phases of the

Diagnosis

Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia . When assessing this client , a nurse should expect which of the following findings ?

Elevated blood pressure

When opening a sterile pack , which of the following actions by the nurse might compromise the sterility of the instruments and supplies inside the pack ?

Holding the sterile pack below waist or table level

A nurse is selecting dressings for a client who has a full - thickness pressure injury and is experiencing considerable pain during dressing changes despite administration of the prescribed analgesic prior to wound care . Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes ?

Hydrogel

A nurse is performing chest percussion therapy on a client . Which of the following actions should the nurse take ?

Listen for a hollow sound when performing chest percussion therapy

A nurse is caring for a client who has a chest tube , Which of the following actions should the nurse take ?

Monitor the client for subcutaneous emphysema

A nurse is auscultating a client's heart sounds and hears a low - pitched whooshing or blowing sound over the apex of the heart . The nurse should identify that this indicates which of the following ?

Murmur

home health nurse is teaching a client who has just started receiving oxygen therapy via mask . The nurse should emphasize that the client must

reposition the elastic band frequently .

nurse is providing discharge teaching knob on the oxygen flow meter all the way to the right to a client who will continue oxygen therapy at home . The nurse should instruct the client that turning the

stops the flow of oxygen .