ATI Fundamentals 61.9%

a nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the clients death is imminent?

urinary incontinence (not retention) cold extremities hypotension slow, weak pulse

a nurse is using a portable ultrasound bladder scanner to measure a clients post void residual volume. Which of the following actions should the nurse take?

-apply light pressure to the scanner head once it is in position -have them urinate 10 minutes before procedure -supine positioning w/ HOB slightly elevated (not semi fowlers) -position the scanner head 2.5-4 cm (1-1.6 inches) above the symphysis pubis (not at the symphysis pubis)

a nurse is assessing a client who has fluid volume excess. which of the following findings should the nurse expect?

-crackles in the lung fields -dependent edema -full neck veins when the client is upright -elevated BP -sudden wt gain

SOME health alterations for a patient who is immobile

-decrease cardiac output= increased HR to compensate for increased venous pooling, reduction in circulating volume increases the workload of the heard= orthostatic hypotension and decreased CO - decrease in intestinal motility and peristalsis -decreased respiratory movement= poor oxygenation and carbon dioxide retention= respiratory acidosis -hypercalcemia d/t lack of weight bearing, excess calcium deposits in joints causing stiffness and pain

SIADH (increased ADH)

-hyponatremia - Holding on to fluids and not releasing (little output) - Change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, headache - Administer Declomycin, diuretics, Tolvaptan (vasopressin antagonist)

a nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the cannister what sequence of instructions should the nurse give the client?

1. Tilt your head back slightly and open your mouth wide 2. Hold the mouthpiece 1 to 2 inches in front of your mouth 3. Depress the canister while taking a slow deep breath 4. Hold your breath for 10 seconds

name the age group for each of these thought processes on death: 1.death is unacceptable under any circumstances 2.magical thinking helps avoid thoughts of death 3.death is viewed as an interruption of what might have been 4.death is a natural consequence of a deteriorating body

1. adolescents: tend to reject the end of life, esp. their own 2. preschoolers: avoid thoughts of death by employing magical thinking 3. young adults: see a whole life ahead of them, so death is often seen as interrupting that life. they typically don't welcome death at this time 4. older adults: could view death a relief from chronic or terminal illness

by what age can an infant turn from abdomen to back

5 month

a nurse is caring for a client who has protein malnutrition. which of the following foods should the nurse identify as a source of complete protein?

Eggs meat poultry seafood yogurt cheese soybeans/ soybean products (peanut butter w/ whole wheat bread) (pasta w/ cheese)

PROLONGED stress can do what to a person?

Gastric ulcers Hyperglycemia essential hypertension weak immune response--> various/ worsening infections platelet aggregation and increase risk of MI/ stroke

ability to taste is assessment is called?

Gustation

DI manifestations and med tx

HALLMARKS: A urinary specific gravity of 1.005 or less and a urinary osmolality of less than 200 mOsm/kg are the hallmark of DI. (both low) BUT SERUM OSMOLARITY IS HIGH >/= 300 (means more particles in serum) -hypernatremia, low potassium - Polyuria - Urine output 5-20 L/day - Polydipsia - Drinking 4-30 L/day - Dehydration - Poor skin turgor, dry mucous membranes, hypotension, tachycardia, wt. loss, headache, dizziness, constipation - Hypovolemic shock - hypotension, tachycardia, decreased CO, decreased cerebral perfusion med tx: desmopressin vasopressin chlorpropamide

a hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of the teaching? jewish faith islamic faith hindu faith buddhist faith what happens when someone dies?

Jewish faith: a family member often stays w/ the body until burial occurs Islamic faith: deceased body is washed and wrapped during a ritual and then buried asap after death Hindu faith: cremation rather than burial is practiced buddhist faith: male family members prepare the body following death

playing in the sand is an example of which piaget stage? what age does this kind of play characterize?

Sensorimotor stage: birth to 2 y/o

as part of a neurological exam, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. which ability is the nurse evaluating with this technique?

Stereognosis ability to identify the size, shape, texture via tactile sensation

a nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse make? a. establish client outcomes b.collect information about past health problems c. determine whether the client has met specific goals d. identify the clients specific health problems

a. establish client outcomes b.assessment c.evaluation d.analysis

a nurse is teaching a group of young adults. which of the following should the nurse identify as an expected developmental task for this age group? a. independent moral development b. acceptance of body changes c. strengthening ties w/ the family of origin d. development of concrete reasoning

a. independent moral development b. acceptance of body changes= adolescence c.young adults need develop intimacy outside of fam d. concrete thinking= middle childhood abstract thinking= adolescent

a nurse is collecting a urine specimen for culture and sensitivity for a client who has a UTI. the client has an indwelling urinary catheter in place. which of the following actions should the nurse take? a. withdraw specimen from the drainage bad b.cleanse the collection port w/ soap and water c. place the specimen in a clean specimen cup d. clamp the tubing below the collection port

d. clamp the tubing below the collection port a. the nurse should use a fresh urine specimen obtained near the indwelling urinary cath to prevent contamination b. cleanse port w/ ANTIMICROBIAL SWAB c. use STERILE SPECIMEN CUP

a nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health associated infections (HAIs) which of the following routes of infection should the manager identify as an iatrogenic HAI? a. infx acquired from improper hand hygiene b.infx acquired by drug resistance c. infx acquired by inappropriate waste disposal d. infx acquired form a diagnostic procedure

d.Infection acquired from a diagnostic procedure (iatrogenic HAIs= from diagnostic/ therapeutic procedures

a nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the clients fluid status?

daily weight

being able to describe interpersonal relationships requires abstract thinking. which piaget stage does ths? what age is that?

formal operational: reasoning stage for ages 11 and beyond

a nurse is removing PPE after performing a procedure for a client who required isolation precautions. Which of the following items of PPE should the nurse remove first?

gloves goggles/face shield gown mask (most dirty to least) (most contaminated to the least)

what order is PPE donned?

gown mask goggles/ face shield gloves

ability to sense the position and movement of body parts without visualizing them

kinesthesia

awareness of the position of the body?

proprioception

at what age can an infant sit up without support?

6-8 months

by what age can an infant pull up to a standing position/ crawl on hands and knees

8-10 months

a nurse is caring for a client who is scheduled to recieve transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how TENS unit helps relieve pain. Which of the following responses should the nurse make?

it modulates the transmission of the pain impulse applies low voltage electric stimulation directly over a location of pain at an acupressure point. can also cause release of endorphins to assist with pain relief.

a nurse is planning to perform passive ROM exercises for a client. which of the following actions should the nurse take? a. repeat each joint motion 5 times during each session b.move the joint to the point of considerable resistance c. sit approximately 2 ft from the side of the bed closest to the joint being exercised d. exercise the smaller joints first

a. repeat each joint motion 5 times during each session to maintain the joints mobility, repeat each motion 3-5 times b. move the joint to the point of slight resistance c. stand at the side of the bed closest to the joint being exercised d. exercise the large joints first

a nurse is caring for a client who is postop following abdominal surgery. which of the following actions should the nurse take first after discovering the client's wound has eviscerated? a.cover the incision w/ a moist sterile dressing b. have the client lie on their back w/ knees flexed c. call the surgeon d.reassure the client

a.cover the incision w/ a moist sterile dressing

a nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish brown urine in the clients catheter bag. the nurse recognizes these manifestations as which of the following types of transfusion reactions? a.hemolytic b.febrile c.circulatory overload d.sepsis

a.hemolytic: chills, lower back pain, hypotension, tachycardia b: febrile: fever, chills, flushing c: circulatory overload: dyspnea, cough, htn d: sepsis: high fever, vomiting, diarrhea

a nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

air conduction is less than bone conduction in the left ear.

a nurse is preparing to administer a cleansing enema to a client. what should the nurse plan?

insert rectal tube (3-4 inches) (not more) wear clean gloves (non sterile) position client on left side hold the solution bag 12 inches above the rectum for a low enema and 18 inches for a high enema (not more)

a nurse is providing teaching about proper care to a client who has a new colostomy. which of the following pieces of info should the nurse include in teaching? a. change the colostomy bag following breakfast b. cleanse the skin around the stoma with warm water c. change the pouch every day d. place an aspirin in the ostomy pouch to decrease odor

b. cleanse the skin around the stoma with warm water (using soap can leave a residue on skin and cause poor adherence of the pouch) a. change colostomy bag BEFORE a meal b/c drainage from ostomy is less likely to occur c. change pouch every 3-7 days (to avoid skin breakdown around stoma) d. aspirin = stoma bleeding don't do it

a nurse is teaching a client who is postoperative how to use a flow oriented incentive spirometer. which of the following instructions should the nurse include? a. blow into the spirometer to elevate the balls in the device b. cough deeply after each use c. clean the mouthpiece with an alcohol swab after each use d.use the spirometer q8h

b. cough deeply after each use a. INHALE deeply to elevate the ball!! c. clean mouthpiece w/ water and dry it after each use d. use several times every hour while awake

a nurse is performing a physical examination of a client. the nurse should use percussion to evaluate which of the following parts of the clients body? a. heart b.lungs c. thyroid gland d. skin

b. lungs percussion creates a vibration that helps the examiner determine the density of the underlying tissue. The lungs are hollow organs that can produce sounds such as resonance (a hollow sound over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm) also auscultate and palpate the lungs. heart= inspection, auscultation, palpation thyroid gland= inspection, palpation skin= inspection, palpation

a nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take? a. auscultate over the stomach while injecting air b. request an x ray of the clients stomach c. place the head of the clients bed in a flat position d. administer the feeding if the pH of the aspirated content is >6

b. request an x ray of the clients stomach should verify NG tube placement prior to administering a bolus feeding c. The nurse verify tube placement then ELEVATE HOB before administering feeding to reduce risk of aspiration d. the pH of gastric content should be </= 5

a nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. which piece of information are critical to communicate to the next nurse who will be caring for this client? a. room temp b.new prescriptions c.number of visitors d. arterial blood gas results e.tracheal secretion characteristics

b.new prescriptions d. arterial blood gas results e.tracheal secretion characteristics the nurse should report any changes in the clients treatment in the nursing handoff report. a/c: dont report unless it affects client care/ specific concern about visitors

Blood transfusion: circulatory overload s/s

blood administered too quickly for a client's circulatory system to handle. -dyspnea -coughing -h/a hypertension

a nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? a. BT for bedtime b. SC for subcutaneous c. PC for after meals d. HS for half strength

c. PC for after meals all others can be interpreted as different things.PC is rarely mistaken as anything else

a nurse is caring for a client who has a stage III pressure ulcer on the heel. when preparing to irrigate the wound, which of the following actions should the nurse take first? a. obtain the prescribed irrigation solution b.don personal protective equipment c. check the client's pain level d. place a waterproof pad under the clients extremity

c. check the client's pain level

a nurse in a same day procedure unit is caring for several clients who are undergoing different types of procedures. the nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI) a. coronary artery stents b.aneurysm clip c. hearing aids d. automated internal defibrillator

c. hearing aids they are safe because they can be removed and should be prior to undergoing MRI

The nurse in an emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the clients HIV infection status. Which of the following actions should the nurse take? a. inform the guard that the warden must request this info b.ask the guard to sign a release of information form c. instruct the guard to ask the inmate d. complete an incident report

c. instruct the guard to ask the inmate nurse can't give this info out. especially not without the pts consent

a nurse is providing teaching to an older adult client who has constipation. which of the following statements should the nurse include in the teaching? a. drink a minimum of 1,000 mL of fluid daily b. increase your intake of refined fiber foods c. sit on the toilet 30 mins after eating meal d.take a laxative every day to maintain regularity

c. sit on the toilet 30 mins after eating meal (recommended method of bowel retraining to tx constipation) a. (consume minimum of 1,500 mL of fluid to prevent constipation) b. increase consumption of coarse fiber and whole grains

a nurse is teaching a client who has urinary incontinence about bladder retraining. which of the following instructions should the nurse include? a. wake up every 2 hr to urinate during the night b.drink citrus juices throughout the day c. try to block the urge to urinate until the next scheduled time d. limit fluid to no more than 1L (34 oz) during waking hours

c. try to block the urge to urinate until the next scheduled time if urge to void before the next scheduled time, trto slow, deep breath and do 5-6 strong and quick pelvic muscle exercises. d. limit fluids 4 hours before bedtime, during the day, encourage fluid intake. a.the client should wake up every 4 hours to urinate during the night, for most ppl this occurs just once during sleeping hours b. citrus juices can irritate the bladder and increase likelihood of incontinence episodes

a nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? a. use a 10 mL syringe b. attach a 22 gauge cath to the syringe c. warm the irrigation solution to 30C (98.6F) d. administer an analgesic 10 min before irrigation

c. warm the irrigation solution to 30C (98.6F) a. use a 30ML syringe b.use 18 or 19 gauge cath, a small cath will exert too much pressure on the wound d. admin analgesic 20 to 30 mins before

a nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? a. place the client supine b.keep both side rails up c.raise the level of the bed d. inspect the clients mouth using a finger sweep

c.raise the level of the bed reduces the risk of self injury. a. to prevent the risk of aspiration, the nurse should raise the clients head to 30 degrees or turn the client to a side lying position b. to reduce the risk of self injury, lower the near side rail before performing mouth care. d. never do that

Blood transfusion reaction: Hemolytic

clients blood is incompatible with the donors blood: -chills -lower back pain -hypotension tachycardia

collecting and trading cards is what stage of piagots theory? what age does this kind of play?

cognitive development: 7-11 y/o

a nurse is caring for a client who had a mastectomy and has a self suction drainage evacuator in place. which of the following actions should the nurse take to ensure proper operation of the device?

collapse the device to remove air after emptying the contents periodically. This will create enough suction to pull fluid exudate into the collection area of the device note: -the device compressed to maintain suction and prevent clotting of sanguineous drainage. The drainage system is NOT made for irrigation. (one answer suggested this) -clean drain opening with an alcohol wipe to decrease the entry of microorganisms -the nurse should maintain the drainage tubing below the level of the incision to enhance drainage

a nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first a. instill proparacaine hydrochloride eye drops b.perform ocular irrigation of the right eye c. place the client in a supine position with the head turned toward the affected side d. ask the client about first aid performed at the scene

d. ask the client about first aid performed at the scene

a nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? a.health hx b.physical exam c.review of systems d.interview

physical exam physical findings are objective and the nurse should collect this info in a systematic way. all else is a mix and interview is subjective info

Playing dress up involves pretending, which reflects which Piaget stage? what age does this kind of play?

preoperational thinking stage: 2-7 y/o

Blood transfusion: febrile reaction s/s

sensitive to the WBCs and platelets in the donor blood. fever chills h/a flushing

a nurse is preparing to administer an IM to a young adult client. which of the following injection sites is the safest for this client?

ventrogluteal deltoid(too small, poorly developed, not safe) dorsogluteal(too close to sciatic nerve and arteries) vastus lateralis (safe for adults, but not the safest injection site)