Ati fundamentals

A nurse is changing the dressing for a client who has to Penrose drain's near an abdominal incision. Which of the following and hearing devices is the best choice for the nurse to use to decrease skin, irritation?

Montgomery straps: the nurse should apply the least restrictive priority, setting framework.

A nurse is contributing to the plan of care for a client who is confused and requires a prescription for wrist restraints. Which of the following intervention should the nurse include in the plan of care?

Renew the prescription for these restaurants within 24 hours

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following side should the nurse select for the injection?

The side hip between the iliac crest in anterior iliac spine

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and ask for a drink. Her post operative diet prescription read: clear liquids; advanced diet as tolerated. Which of the following responses should the nurse make?

"I am going to listen to your abdomen. "

A nurse is collecting data from a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse asked to encourage discussion with the client?

"What do you think caused the onset of your pain? "

A nurse is caring for a group of clients are receiving oxygen therapy. Which of the following client should the nurse came to see first?

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask.

A nurse is reinforcing teaching with a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water

A nurse is caring for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take a specimen?

Collect the specimen upon rising in the morning

A nurse is performing I irrigation for a client who was exposed to smoke and ash. Which of the following action should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open.

A nurse is preparing to insert an NG tube for a client who has a ball instruction. Which of the following action should the nurse take first?

Explain the procedure to the client

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The clients surgical wound is healing by secondary intention, which of the following observations should the nurse report to the provider?

Halo of your erythema on the surrounding skin

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8 cm (3.1 in)

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following location should the nurse secure the urinary catheter tubing?

Lower abdomen: after inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the clients, upper thigh or lower, abdomen by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the ureter.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing

A nurse is caring for who has dysphasia following a cerebrovascular accident. Which of the following action should the nurse take when assessing a client at meal time?

Offer the client tart or sour foods first: the client who has a pair of pharyngeal swallowing. It should consume, tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?

Turn the stocking inside out up to the heel before applying

A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the clients pain level

The nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing fight infection. which of the following vitamins and minerals should the nurse plan to increase in the clients diet?

Vitamin C and zinc

A nurse is contributing to the plan of care for a client who has fluid volume excess which of the following interventions. Should the nurse plan to include to monitor the clients weight?

Weigh the client on arising

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurses maintaining sterile technique?

Wipes to labia menorah in an anteroposterior direction

A nurse is caring for a toddler at a well child visit when the mother calls to the nurse, "help! My baby is choking on his food. "Which of the following findings indicate the toddler has an airway obstruction

Inability of the toddler to cry or speak

A nurse is caring for a client who has major people, incontinence and reports irritation of the perennial area. Which of the following actions should the nurse take first

Check the client's perineum.

A nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past two hours. Which of the following action should the nurse take first?

Check to determine if the catheter tubing is Kinked.

A nurse is planning to collect a stool specimen for OVA and parasites from a client who has diarrhea. Which of the following action should the nurse take when collecting a specimen?

Place to store specimen collection container in a biohazard bag

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following action should the nurse take?

Pinch the NG tube while removing the tube call Lynn the nurse should pitch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.