ATI Fundamentals Final Exam
which diseases have contact precautions?
C.diff, MRSA, scabies, vancomycin resistant enterococci
a nurse in the 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 client's HIV infection status. Which of the following actions should the nurse take?
Instruct the guard to ask the inmate
examples of tertiary prevention
Management of an established disease. Goal is to minimize disease associated complications, improve disease, minimize symptoms Rehabilitation programs Lifestyle modification to normalize wt, glucose, BP. Support groups Education related to preexisting disease Teaching proper use of equipment (wheelchair, CPAP) Exercise programs Cardiac rehab PT/OT Education about medication, avoidance of interactions
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?
Place the wheelchair at a 45° angle to the bed.
A nurse is caring for a client who has peripheral edema. The nurse should identify that what nutrient regulates extracellular fluid volume?
Sodium sodium regulates E.C fluid balance, nerve impulse transmission, acid-base balance
which diseases have droplet precautions?
rubella, influenza, meningoccal, pneumonia, streptococcal pharyngitis
a nurse is assessing a clients incision and observes the drainage to be blood-tinged. Which term should the nurse use to document this finding?
sanguineous
palpation vs percussion
palpation: touch to detect unusual or expected sensations including texture, temp, masses, or moisture percussion: helps the nurses locate organs or masses and determine their dimensions
a nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"I can still use my transcutaneous electrical nerve stimulation unit while im pushing the PCA button" the nurse should encourage nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation (TENS). PCAs have a timing control lock out mechanismthat usually allows dosing every 6-8 mins.
a nurse is teaching a client who has low back pain about heat therapy. which of the following statements by the client indicates an understanding of the teaching?
"I need to place a towel between the heating pad and my skin" For heat therapy, instruct the client to not sleep on top of the heating pad or increase the temperature for risk of burns. Apply heat for 30 mins at a time
a nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication the client has completed Erikson's developmental task for her age group
"I think I have done a good job with my children since they are all independent now" middle-aged is generativity vs. stagnation. Middle adults help shape future generations through community involvement, parenting, mentoring, and teaching
a nurse is teaching a post op pt about the importance of turning, coughing, and deep breathing. Which statement identifies correct understanding?
"If i do this, I wont get pneumonia" turning, coughing, and deep breathing prevent resp. comp. like pneumonia by promoting lung expansion and secretion removal
A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying?
"It sounds like your pain is intermittent"
A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include?
"Sit with your back supported" "Keep your knees at hip level" "Use an ergonomically designed computer keyboard" keeping the knees at hip level helps reduce the risk of lordosis
alternations of the heart:
- Tachycardia: heart rate over 100/min in adults; abnormally fast - Palpitation: subjective feeling of the heart "skipping a beat" or fluttering - Bradycardia: heart rate under 60/min in adults - Dysrhythmia- irregularly or erratic heart rhythm
Rhonci
-Loud, low pitched rumbling primarily detected over the trachea and bronchi. Encourage client to cough to clear the sound. -Disappears with cough
expected reference range for blood glucose:
70 to 110 mg/dL for fasting and less than 200 mg/dL for a casual blood draw.
* A nurse is preparing to insert an ng tube for a client. Which actions will help facilitate the insertion of the tube?
1. Coat the tip of the tube with water-soluble lubricant 2. Ask the client to swallow water while the tube enters the throat 3. **Tell the client to tilt her head backward as insertion begins. ***
Not on ATI: The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for developing? 1. intracellular fluid deficit 2. intracellular fluid overload 3. extracellular fluid deficit 4. interstitial fluid deficit
1. intracellular fluid deficit Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.
a nurse is assessing a clients nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habit does not change, how long will it take for the client to gain 4.5 kg (10 lb)
10 weeks because 1 lb of body fat is equivalent to 3,500 calories, consuming 500 extra calories each day for 7 days would lead to a total of 3,500 calories and a 1 lb gain per week. At a rate of 1 lb per week, the client would gain 10 lb in 10 weeks.
a nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4°C. Above what Fahrenheit temperature should the nurse administer acetaminophen to the client?
101.1 C° --> F° = (C x 9/5) + 32 F° --> C° = (F x 5/9) - 32
expected reference range for hemoglobin:
12 to 18 g/dL
The nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose?
2
A nurse is teaching the parent of a child who is to take 30 mL of a liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct the parent to give to the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing 0.)
2 15 mL/ 1 tbsp = 30 mL/ X tbsp 15X = 30 X = 2 (if 15 mL=1 tbsp then, 30 mL=2 tbsp)
a nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
29 vol (ml)/time (mins) x drop factor=IV flow rate 700 ml/ 1440 mins x 60= 29
expected reference range for potassium:
3.5 to 5 mEq/L
a nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters (mL) of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hr night shift?
90
* A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse see first?
A client who has HF and receiving 100% o2 via partial rebreather mask.
a nurse is teaching a client who is post-op following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint?
Antagonistic the antagonistic muscle group is responsible for movement of the knee joint by contracting with other muscles relax.
a nurse is in the urgent care is caring for a 15-yr-old whose symptoms suggest an STI. The clients parent is unavailible, but the grandma accompanied. What action should the nurse take?
Ask the adolescent to sign the consent form minors are allowed to sign consent forms for treatments such as STIs and substance use disorders
a nurse rates a clients biceps reflex as 2+. Which of the following characteristics should the nurse document about the clients reflexes?
Average reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+ - diminished reflexes: 1+ or less - brisk reflexes: 3+ or more - hyperactive reflexes: 4+
NOT ON ATI The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.
B) A lactating woman nursing her 3-day-old infantA lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation
A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding?
Chronic hypoxia Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia (low oxygen supply) such as with COPD. It is a change in the angle between the nail and the nail base, often with enlargement of the fingertips (iron-deficiency anemia can cause koilonychia aka spoon nails) (trauma or severe infection can cause Beau's lines, or transverse depressions in the nails)
NOT ATI The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.
D) Re-oxygenate the client before attempting to suction again.
a nurse is performing a mental-health exam on a client who has manifestations of dementia. Which of the following directions should the nurse give when evaluating the clients ability to think abstractly?
Discuss the meaning of a common proverb asking a client to subtract by 7 serially, starting at 100 evaluates: clients attention span asking to describe a previous illness evaluates: remote memory asking to explain what to do if a fire happened in this bedroom evaluates: clients judgment
a nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?
Edema at the infusion site Edema due to fluid entering the subcutaneous tissue is an indication of infiltration. - phlebitis: warmth, redness at infusion site, stop and remove IV catheter then apply warm compress to the site - system not intact: oozing at infusion site
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurses religious beliefs related to death and dying. Which of the following statements should the nurse make?
Encourage the client to express thoughts about death and dying
a nurse is teaching a client how to self-administer insulin. Which action should the nurse take to evaluate the clients understanding of the psychomotor domain of learning?
Have the client demonstrate the procedure - affective domain: ask the client if he wants to self-administer his insulin - cognitive domain: having the client list the steps of the procedure or ask if he understands the purpose of insulin
a nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?
Hyperglycemia stress causes an overload of cortisol, which can lead to hypertension and hyperglycemia
I-SBAR
Identify Situation- gives info about problems client is experiencing Background- pertinent medical history, lab finding, allergies, and code status Assessment- vital signs, pain assessment, changes in assessment findings Recommendation- nurse makes recommendations about treatment and asks the provider about additional treatment
a nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take?
Identify the client using 2 identifiers
a nurse is caring for a client who has a temp of 38.7°C (101.7°F). Which of the following actions should the nurse take?
Keep the patients bed linens dry maximize the clients heat loss by keeping the clients clothes and bed linens dry. Reduce external coverings on the client without causing shivering. Satisfy the clients increased metabolic needs by providing at least 1893 mL (64 oz) of fluid per day.
a nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?
Lentils incomplete proteins are missing one or more of the essential amino acids necessary for synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds. complete proteins are foods such as eggs, soybeans, and yogurt which contain all the essential amino acids necessary for synthesis of protein
a nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take?
Place the client in a supine position with the hips and knees flexed Cover the wound and intestine with a sterile, moistened dressing Monitor the client for manifestations of shock The nurse should place the client ina s supine position with hips and knees flexed to prevent further tearing of the incision and wound evisceration by lessening tension on the wound. Cover the protruding intestine with a sterile dressing that is moistened with 0.9% sodium chloride to prevent further contamination and keep the protruding intestine from drying out. The nurse should stay with the client to observe for further complications such as shock. Delegate another person to notify the surgeon immediately
a nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following?
Purulent exudate purulent exudate on the clients dressing includes thick yellow, green, or brown drainage and usually indicates wound sloughing or infection
a nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?
Raise the level of the bed to prevent the risk of aspiration, the nurse should raise the clients head to 30° or turn the client to a side-lying position
a nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?
Raise your index finger if you need to pause during the insertion the nurse should instruct the client to breathe through the mouth and swallow
The nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take?
Record the amount of medication wasted on the controlled substance inventory log two nurses should sign the controlled substance inventory log to document the amount of medication wasted
A nurse is planning to perform passive ROM exercises for a client. Which of the following actions should the nurse take?
Repeat each joint motion 5 times during each session to maintain the clients joint mobility, the nurse should repeat each motion 3-5 times. Move the joint to the point of slight resistance and stand at the side of the bed closest to the joint being exercised. Exercise the large joints first
a home health nurse is visiting an older client with severe dementia. The clients son, who serves as the primary caregiver, reports being "exhausted" from working part-time and caring for his mom at home. Which of the following options should the nurse suggest to the caregiver?
Respite Care respite care is a service for caregivers who need time to rest from multiple responsibilities related to care of a family member who needs assistance. - assisted living: for clients who need limited personal care. Dementia requires total care - adult day care: provide care and supervision for clients who need minimal assistance (taking meds, physical therapy, or counseling). - rehab: return clients to optimal functioning after illness or injury
a nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests?
Romberg A Romberg test evaluates standing balance, first with the client's eyes open and then with them closed. The nurse should remain nearby because the client could easily fall during this test.
A nurse is caring for a client who has xerostomia with a lack of saliva. Which nutrient will be affected by the lack of salivary amylase? A. Fat B. Protein C. Startch D. Fiber
Starch Salivary amylase begins the process of digestion in the mouth with the initial breakdown of starches. The majority of starch breakdown occurs in the small intestine with pancreatic amylase. Additional info: - Lipase breaks down fats - Pepsin breaks down proteins
* As part of a neurological exam, a nurse instructs a client to keep his eyes closed, placed object in hand. And asks to identify. Which of the following abilities is the nurse evaluating with this technique?
Stereognosis
a nurse is planning care for a client who reports abdominal pain. The clients has a temperature of 39.2°C (102.6°F), a heart rate if 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurses priority?
Temperature elevated temp is an emergent physiological need that requires priority intervention by the nurse. Fever and pain can contribute to tachycardia
a nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?
Test for the presence of the client's gag reflex use a soft-bristled toothbrush with nonabrasive fluoride toothpaste, water or alcohol-free mouthwash, use a padded tongue blade, pt in semi-fowlers with head turned towards the person providing oral care
a nurse is preparing to administer an afternoon dose of ampicillin to a client who appears upset and refuses to take the mediation before throwing the pill on the floor. Which of the following entries should the nurse enter into the clients medical record?
The client threw the medication on the floor Document exactly what took place. Always include: 1. name of the medication 2. the dose 3. the time client refused to take
a nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique?
The nurse holds her hands higher than her elbows while washing this is so the water and soapsuds can drain away from the clean area toward the dirty area. Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes
which diseases have airborne precautions?
Varicella, TB, and measles
A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use?
Vastus lateralis the nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants or children. the ventrogluteal site is safe for children older than 7 months
a nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first?
a client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage an ostomy bag full of blood indicates that the client's bowel is hemorrhaging, and the nurse must report this finding to the surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the threat to the client's circulation
a newly licensed nurse is supervising a new nurse who is suctioning a clients tracheostomy. Which action indicates understanding of the procedure?
administering high-flow oxygen prior to the procedure use sterile technique to suction a tracheostomy. Lubricate the suction catheter with sterile saline to reduce the risk of aspiration pneumonia. Administer 3-4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia
magnesium
affects enzyme and neurochemical activities and the excitability of cardiac and skeletal muscles
potassium
affects storage of glycogen, nerve impulse transmission, cardiac conduction, and smooth muscle contraction
a nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?
airway
examples of broad-spectrum anti-infective agents
ampicillin and cefixime
instruct clients about using the incentive spirometer to prevent the development of
atelecatasis, or lung collaspe
a client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? a) encourage the client to take deep breaths b) observe the client's rate, depth, and character of respirations c) prepare to administer oxygen d) give the client a backrub to promote relaxation
b) observe the client's rate, depth, and character of respirations
* nurse is caring for a client who has major fecal incontinence and reports irritation in the perineal area. Which actions should the nurse take first?
check the clients perineum
* A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene. Which action should nurse take?
circle the injection area with a pen
serous drainage
clear, watery blood
a nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube?
coat the tip of the tube with water-soluble lubricant ask the client to swallow water while tube enters throat tell client to tilt head backwards as insertion begins
purulent drainage
containing pus, thicker than other drainage
synergistic muscle group
contract in sync to cause the same movement. Therefore, 2 muscles contact as other muscles relax. (does not occur within a joint)
a nurse is caring for a client who is post-op following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the clients wound has eviscerated?
cover the dressing with a moist sterile dressing
a nurse manager is providing teaching to a group of newly licensed nurses about the ways that clients acquire healthcare-associated-infections (HAI's). Which of the following routes of infection should the manager identify as an iatrogenic HAI? a) infection required from improper hand hygiene b) infection acquired by drug resistance c) infection acquired by inappropriate waste disposal d) infection acquired from diagnostic procedure
d) infection acquired from diagnostic procedure Iatrogenic HAIs directly result from diagnostic or therapeutic procedures
a nurse is assessing a client who has a total calcium level of 12.7 mg/dL. what findings should be expected?
depressed deep-tendon reflexes hyperglycemia manifestations include depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness hypoglycemia= muscle tremors and numbness/tingling around the mouth, are positive Chvosteks and Trousseaus signs
Foods high in fiber
dried peas and beans, including black beans, whole grain bread
a nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding?
elevate the head of the clients bed clients who have had a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Elevate to prevent risk for aspiration. Flush the tube with water prior to initiating the feeding to ensure the patency of the tube. The pH of gastric secretions should be below 4, a pH above 4 suggests that the end of the tube is not in the stomach
kyphosis
excessive outward curvature of the spine (hunch back)
a nurse should administer oxygen to a client who is:
experiencing SOB or displaying an O2 sat below 95%
caring for a post-op following vascular surgery on the left femoral artery. The wound should be cleansed in which direction?
from the wound toward the surrounding skin
obstruction of the flow of the vitreous humor in the eye
glaucoma leads to increase in intraocular pressure
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) The client should lay on their left side in the Sims position to allow the solution to flow downward into the sigmoid colon and promote retention of the enema. The nurse should lubricate 5-8 cm (2-3 in) of the tip of the rectal tube before inserting and insert the tip of the tubing 7-10 cm (3-4 in) along the rectal wall to prevent dislodging of the tube during the procedure and avoid injury to the rectal mucosa. Hold the enema container a maximum of 45 cm (18 in) above the rectum to prevent painful distention of the colon.
a nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?
intraoperative
lordosis
inward or concave curvature of the lumbar spine (sway back)
a nurse is cleaning a clients wound by swabbing from the area of least contamination to the area of greater contamination. Which of the following rationales should the nurse identify for using this technique?
keeping microorganisms from entering the wound
Simple sugars (monosaccharides)
lactose- form of sugar(carbohydrate) found in milk sucrose- table sugar also found in fruits and vegetables maltose- found in germinating cereals, such as barely fructose- found in honey and fruit
Scoliosis
lateral curvature of the spine
A nurse should evaluate a clients popliteal pulse by?
located behind the knee by palpating behind the knee in the area of the popliteal fossa. Best felt with clients knee slightly flexed and foot resting on examination table
A nurse should evaluate a clients femoral pulse by?
located in the inguinal area. Best felt with the client laying down and the inguinal area exposed
Examples of Skeletal Muscle Relaxants
metaxalone and cyclobenzaprine (Flexeril) diazepam (Valium) Methocarbamol baclofen (Lioresal)
a nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?
place the client in a left Sims' position the nurse should place the client in a left Sims' position for the insertion of an enema. This left lateral position facilitates the flow of the enema solution into the sigmoid and descending colon. The anus is exposed by flexing the right leg. - don clean gloves to perform an enema procedure - lubricate 5.08 (2 in) of the tip of the rectal tube - administer the fluids slowly and lower the container for a client who experiences fullness or pain during the administration of the enema.
a nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications?
plasma volume expanders dextran and albumin are plasma volume expanders that help to correct hypovolemia in emergency situations, such as after hemorrhages or burns
a nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take?
position the client for drainage of secretions by gravity postural drainage consists of providing drainage, positioning, and turning the client, The positioning can help to drain secretions from the affected lung segments and bronchi into the trachea
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?
position the client on his left side positioning is an important aspect of administering an enema. Having a client lay on their left side facilitates the flow of enema solution into the sigmoid colon and descending colon. The nurse should wear clean (nonsterile) gloves and insert the rectal tube 7 to 10 cm (3 to 4 in). Hold the solution bag 30 cm (12 in) above the clients rectum for a low enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag too high, the solution might run in too fast, causing discomfort and spasms that make retaining the enema more difficult.
what procedures should be scheduled prior to the client eating a meal to decrease the risk of GI discomfort?
postural drainage, chest physiotherapy, or vibration
examples of beta adrenergic blockers
propranolol and carvedilol
antigravity muscle group
stabilize joints
calcium
supports bone and tooth formation and facilitates nerve impulse transmission
skeletal muscle group
supports posture and produces voluntary movement
a nurse is assessing a clients respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?
vesicular - vesicular sounds: heard over periphery of the major lung fields. - bronchial sounds: over trachea, high-pitched hollow and loud - rhonchi or gurgling sounds: over the trachea and bronchi if airways are narrow due to secretions or swelling - bronchovesicular sounds: either side of the sternal border and between the scapulae posteriorly. Moderately loud with a medium pitch
a nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care?
"Lets set up a meeting time with the doctor to discuss your options for home care" In family centered care, the nurse considers the health of the family as a unit; therefore, the client and family members help determine their goals and outcomes. The family must decide, with the nurse's input, what to do before the client goes home
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. 1) Pain history, including location, intensity, and quality of pain 2) Client's purposeful body movement in arranging the papers on the bedside table 3) Pain pattern, including precipitating and alleviating factors 4) Vital signs such as increased blood pressure and heart rate 5) The client's family statement about increases in pain with ambulation
1) Pain history, including location, intensity, and quality of pain 3) Pain pattern, including precipitating and alleviating factors
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
1. provide frequent oral hygiene 2. measure the amount of drainage from the NG tube every shift 3. secure the NG tube to the client's gown single-lumen NG tubes are used for intermittent suction, and the machine is set to 80 to 100 mmHg. Higher suction settings can traumatize the gastric lining. A water-soluble lubricant should be applied to the nares to help prevent or relieve dry skin.
a nurse is performing a focused assessment of a clients peripheral vascular system. In which location should the nurse palpate the posterior tibial pulse?
Below the medial malleolus the nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus or inner surface of the client's ankle *inner side of ankle best felt with the clients foot relaxed and extended slightly
Not on ATI: The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color? a) Black b) Red c) Dark brown d) Green
Black
a charge nurse is teaching adult CPR to a group of NLN. Which of the following should the charge nurse teach as the first response in CPR?
Confirm unresponsiveness
a nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening?
assume an open position the nurse should sit facing towards the client with arms and legs uncrossed, lean towards the client to convey interest/interaction, establish direct eye contact to convey involvement and willingness to learn,
a nurse is assessing a clients vascular system. Which of the following techniques should the nurse use when evaluating the carotid artery?
auscultation of the arteries for bruits with the bell of the stethescope
a nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take?
check the medication dose and the clients identification
metabolic alkalosis
high pH, high HCO3 pH > 7.45 HCO3 > 26
respiratory alkalosis
high pH, low CO2, hyperventilation (excessive breathing)
examples of primary prevention
immunizations, health education, nutrition, Marriage counseling and sex education, personal hygiene, protection from accidents, avoidance of allergens
respiratory acidosis
low pH, high CO2, hypoventilation (too little breathing)
prone position
lying on abdomen, facing downward
a nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH- 7.25, PaCO2- 40, and HCO3- 18. Which of the following acid base imbalances should the nurse report to the provider?
metabolic acidosis a pH of 7.25 indicates acidosis. If the cause is respiratory, pH and PaCO2 values will deviate in opposite directions. Since the PaCO2 is within the expected reference range, despite the low pH, the cause must be metabolic.
A nurse should evaluate a clients brachial pulse by?
palpating in the groove between the biceps and triceps muscles in the area of the antecubital fossa.
A nurse should evaluate a clients dorsalis pedis pulse by?
palpating the dorsum of the foot
a nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching?
place soiled linens in a single linen bag
supine position
lying on back, facing upward (also called dorsal recumbent position)
a nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states that she no longer wants to have the surgery. Which of the following actions should the nurse take?
Notify the provider about the client's decision
A nurse is preparing to administer a unit of packed RBC's to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take? a) Return the blood to the laboratory b) Place the blood in the medication room c) Place the blood in the refrigerator d) Leave the blood at the client's bedside
a) Return the blood to the laboratory -Because the nurse knows that the delay will be more than a few minutes, she should return the unit of packed RBCs immediately to the laboratory where the technician will maintain it at the appropriate temperature until the client is ready to receive it. - b) Place the blood in the medication room: The unit of packed RBCs should not be at room temperature for any length of time because the lack of temperature control could damage the blood. - c) Place the blood in the refrigerator: Blood products require specific temperature regulation, which is not consistently possible in a standard nursing unit refrigerator. - d) Leave the blood at the client's bedside: The nurse should never leave blood products or medication at the bedside due to the potential for loss, misuse, or contamination.
a nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions shut the nurse take first? a) remove the sleeve of the gown from the arm without the IV line b) slow the infusion using a roller clamp c) disconnect the IV line from the pump d) bring the IV solution and tubing from the outside to the inside of the sleeve of the gown
a) remove the sleeve of the gown from the arm without the IV line
A nurse is preparing to administer an intramuscular injection to a young adult client which of the following injection sites is the safest for this client? a) Vastus lateralis b) Dorsogluteal c) Deltoid d) Ventrogluteal
d) Ventrogluteal According to the evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains the gluteal muscles and it does not contain major nerves or blood vessels - a) the fastest ladder is safe for adults because it is thick in away from major blood vessels or nerves. However, according to evidence-based practice, it is not the safest injection site. - b) the dorsogluteal site is close to the sciatic nerve as well as the superior gluteal nerve and artery therefore according to EBP it is not the safest injection site c) the deltoid is easy to access however according to EBP it is not the safest site because the muscle is small and sometimes poorly developed. Additionally it is close to numerous blood vessels and nerves
serous exudate drainage on a clients dressings indicates:
plasma from the blood and appears watery are clear to light yellow in color
sanguineous exudate drainage on a clients dressings indicates:
accumulation of RBCs from the plasma that appears bright red on the dressings
sims position
client lies on a side with the leg on that side slightly flexed and the opposite leg more acutely flexed. The lower arm is behind, with the opposite arm flexed at the shoulder and the elbow
a nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client?
Fowlers low fowlers= 30° elevated semi fowlers= 45° to 60° high fowlers= 60° to 90°
A nurse is talking with a client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of this diagnosis, the nurse identifies that the client is in which of the following stages of dying? a) anger b) bargaining c) depression d) acceptance
c) depression during this stage of depression, the client has realized the full impact of the loss in might express hopelessness and despair - anger: during the stage of anger the client shows resistance or blames other people, a higher power, or the situation - bargaining: stalls awareness of the loss by trying to keep it from occurring - acceptance: integrate the loss (ex. by making final arrangements)
a nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? a) Sodium 123 mEq/L b) Blood glucose 100 mg/dL c) Potassium 3.5 mEq/L d) Hemoglobin 13 g/dL
a) Sodium 123 mEq/L the expected reference range for sodium is 136 to 145 mEq/L. Low sodium can cause confusion and lead to seizures, coma, and death
a nurse is preparing to administer eyedrops for a client who has glaucoma . When instilling the medication, which action should the nurse take?
apply pressure to the puncta after instilling the medication puncta= inside corner of the eye the nurse should instill the medication into the conjuctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication
Serosanguineous exudate drainage on a clients dressings indicates:
plasma mixed with light bloody drainage, which is typically pale yellow and blood-tinged. Watery drainage may also be evident
a nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include?
Protein serves as an energy source when other sources are inadequate
a nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in teaching?
Clients who are age 65 and older are reluctant to report pain
During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data?
corneal light reflex
a nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and 1/2 pint of milk. What is the total 8-hr fluid intake in milliliters (mL) that the nurse should document for this client?
1560
a nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?
absent bowel sounds with distention paralytic ileus is an immobile bowel. In this disorder, bowel sounds are absent, and the abdomen is distended
A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"I will clip each suture close to the skin and pull it through from the other side"
a nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?
"Keep a diary of the foods your child eats each day"
a nurse is providing discharge teaching to a client who has a prescription for wound care via home health services. Which of the following statements made by the client indicates an understanding of the teaching?
"a nurse will show me how to care for my wound"
NOT ATI The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. Which action should the nurse take first? 1. Clean the insertion site and redress the area. 2. Document assessment findings in the client's chart. 3. Obtain a culture specimen of the drainage. 4. Notify the physician.
3. The nurse should first obtain a culture specimen. The presence of drainage is a potential indication of an infection and the catheter may need to be removed. A culture specimen should be obtained and sent for analysis so that treatment can be promptly initiated. Since removing the catheter will be required in the presence of an infection, the nurse would not clean and redress the area. After the culture report is obtained, the nurse should notify the physician and document all assessments and client care activities in the client's record.
A nurse is caring for a client whose intake and output flowsheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2tsp; and emesis 2 oz. What total output in millimeters should the nurse document for this 8 hr period? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing 0.)
770 convert tsp to mL: Step 1: what is the unit of measurement the nurse should calculate? mL Step 2: set up an equation and solve for X 1 tsp/5 mL = 2 tsp/ X mL x= 10 Step 3: round if necessary Step 4: Determine if the conversion to mL makes sense. If 1 tsp= 5 mL, then 2 tsp= 10 mL. convert oz to mL: Step 1: what is the unit of measurement the nurse should calculate? mL Step 2: set up an equation and solve for X 1 oz/30 mL = 2 oz/ X mL x= 60 Step 3: round if necessary Step 4: Determine if the conversion to mL makes sense. If 1 oz= 30 mL, then 2 oz= 60 mL. For the total intake, calculate: 350 mL + 200 mL + 150 mL + 10 mL + 60 mL = 770 mL
a nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (select all that apply) a)Allowing the client to speak b)Stabilizing the position of the tube c)Preventing aspiration of secretions d)Preventing air leaks e)Preventing tracheal injury
B.Stabilizing the position of the tube C.Preventing aspiration of secretions D.Preventing air leaks An inflated cuff helps prevent movement of the endotracheal tube, reduces the risk of aspiration of oropharyngeal secretions, and keeps air from leaking around the outer portion of the endotracheal tube. Incorrect Answers: - A. The client cannot speak when an endotracheal tube is in place. - E. An inflated cuff does not prevent tracheal injury. If the cuff is overinflated and exerting a pressure that exceeds 25 mmHg, it can cause tracheal ischemia and necrosis.
A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching?
Fats provide energy Fats serve as a stored energy for the body providing 9 cal/g of energy. - proteins play a role in tissue repair and are primarily responsible for regulating fluid balance. The presence of protein also prevents interstitial edema. An appropriate amount of albumin in the blood keeps interstitial edema from occurring.
NOT ATI A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from the bed to a wheelchair. Which action taken by the AP indicates to the nurse an understanding of the proper technique to use for this type of transfer? a) Locks the brakes on the bed and the wheelchair before moving the client b) Tells the client to reach for the side arms of the wheelchair while transferring c) Lowers the bed so that it is lower than the wheelchair seat d) Places the wheelchair on the client's weaker side prior to the transfer
a) Lock the brakes on the bed and the wheelchair before moving the client
A nurse is planning care for a client who has a wound infection following abdominals surgery to promote healing and fight infections which of the following vitamins and minerals should the nurse plan to increase in the claims diet a) Vitamin C and zinc b) Vitamin D c) Vitamin K and iron d) calcium
a) Vitamin C and zinc the client's body needs both vitamin C and zinc to fight a wound infection. The client should receive a multi-vitamin and mineral supplement of both these substances. In addition, vitamin E supplements are also needed to promote skin and wound healing - b) Vitamin D is used with calcium to prevent osteoporosis; however, it does not assist with wound healing. The main function of vitamin D is to maintain normal calcium and phosphorus levels in the blood, and it may protect against cancer - c) Vitamin K is important for normal blood clotting and for impaired intestinal synthesis caused by antibiotics. Iron is needed to rebuild red blood cells; however, neither is needed directly for wound feeling - d) calcium is administered to prevent osteoporosis when used with vitamin D; however, it does not aid with wound healing
A nurse is caring for a postoperative client who has mental and urinary catheter for gravity drainage. The nurse notes no urine output in the past two hrs. Which of the following actions should the nurse take first? a) check to determine if the catheter tubing is kinked b) palpate the bladder c) obtaining prescription to irrigate the catheter with 0.9% sodium chloride d) encourage the client to drink more fluids
a) check to determine if the catheter tubing is kinked
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 take? a) establish client outcomes b) collect information about past health problems c) determine whether the client has met specific goals d) identify the client's specific health problem
a) establish client outcomes The planning phase includes developing goals and outcomes that help the nurse create the client's plan of care. The nursing process: step 1. assessment phase- collect information about past health problems (vitals, age, height) step 2. analysis phase- identify the client's specific health problem step 3. planning phase- establish client goals and outcomes and selects interventions that will help to achieve them. Also involves setting care priorities. step 4. implementation- provides client care and uses interpersonal/technical skills when implementing nursing interventions step 5. evaluation phase- use critical thinking skills to determine whether the client has met a specific goal. examines results, compares the data, identifies errors, and considers pt's situation
A nurse in a provider's office is measuring a client & notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? a) osteoporosis b) scoliosis c) kyphosis d) lordosis
a) osteoporosis A loss of height is often an early indication of osteoporosis with occurs due to a loss of calcium in the vertebrae which can cause them to fracture and collapse. - scoliosis does not precipitate a decrease in the height of the client. It is an abnormal lateral curve of the sign - kyphosis does not precipitate a decrease in the height of a client. It is an exaggerated posterior curvature of the thoracic spine hunchback - lordosis does not precipitate a decrease in the height of a client. It is an exaggerated lumbar curvature way back
a nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of falls? a) use a gait belt during ambulation b) ensure the client is wearing socks before ambulating c) instruct the client to sit on the edge of the bed for 15 secs before ambulating c) walk 2 feet behind the client during ambulation
a) use a gait belt during ambulation The nurse should use a gait belt to keep the client center of gravity midline to decrease the risk of a fall - b) the nurse should ensure the client is wearing nonskid shoes or slippers when ambulating to decrease the risk of a fall from slipping - c) the nurse should encourage the client to dangle their legs on the edge of the bed for 60 seconds before attempting to ambulate to decrease the risk of a fall due to orthostatic hypotension - d) the nurse should walk beside the client to provide physical support while ambulating and exceeds the risk of a fall
a nurse is caring for a client who has Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? a) wear gloves when changing the clients gown b) use alcohol-based sanitizers to cleanse the hands c) wear a mask when assisting the client with his meal tray d) place the client on a complete bed rest
a) wear gloves when changing the clients gown -alcohol-based sanitizers are ineffective against the spores of C.difficile -nurse should wear a mask when working within 3 ft of a patient with droplet precautions -the nurse should not place the client on complete bed rest because this places him at risk for the hazards of immobility, such as impaired skin integrity and retained respiratory secretions. The nurse should instruct the patient to stay in his room but to move, cough, and deep breathe at least every 2 hours
a nurse is performing an admission assessment for a client who has asthma and several food allergies. Which of the following actions should the nurse take first? a) document the clients food allergies b) ask the client to identify the specific food allergies c) monitor the client for signs of anaphylaxis d) have epinephrine available for administration
b) ask the client to identify the specific food allergies The nurse should apply the nursing process priority-setting framework in order to plan client care and prioritize nursing actions. Each step the nursing process builds on the previous steps beginning with an assessment or data collection, before the nurse can formulate a plan of action implement a nursing intervention or notify the provider of a change in the client status. the nurse must first collect adequate data from the client assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore the nurse should first assess the client's allergies and identify specific allergens to ensure the specific foods are not ordered to the client during meals
nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? a) change the colostomy bag falling breakfast b) cleanser skin around the stoma with warm water c) change the pouch everyday d) place an aspirin in the ostomy pouch to decrease odor
b) cleanser skin around the stoma with warm water the nurse should instruct the client to cleanse the skin around the stoma with warm water, as using soap can leave a residue on the skin and cause poor adherence of the pouch. a) the nurse instruct the client to change the colostomy bad before a meal because drainage from the ostomy is less likely to occur c) question instruct the client to change the pouch every three to seven days to avoid skin breakdown around the stoma d) the nurse will instruct the client to not place an aspirin in the ostomy pouch to decrease odor as this can cause stoma bleeding
a nurse is collecting health history data from a client who is deaf and uses American sign language(ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? a) face away from the client to avoid distractions b) pace speech to allow time for the interpreter to convey the words c) make eye contact with the interpreter when explaining the procedure d) stand in the background while the interpreter translates the message
b) pace speech to allow time for the interpreter to convey the words
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? a) lower medial quadrant of the buttock near the coccyx b) side hip between the iliac crest and anterior iliac spine c) tissue of the posterior upper arm d) lower inner thigh 4 finger-widths above the patella
b) side hip between the iliac crest and anterior iliac spine the side head between the iliac crest and the anterior iliac spine forms the boundaries for a ventrogluteal injection therefore this is an appropriate site for the nurse to select. This site is preferred for intramuscular injections for an adult-client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (right hand on left hip) with the first 2 fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. - a) to administer an intramuscular injection of an intramuscular medication using the dorsogluteal site the nurse should select the upper lateral quadrant of the buttocks. However, this site can increase the risk of energy injury to the client because the medication is more likely to be injected into subcutaneous tissue and there is an increased risk of piercing the sciatic nerve - c) the nurse should select the outer posterior tissue of the upper arm when preparing to administer a subcutaneous injection. For intramuscular injections that are < 1mL, the nurse may select the deltoid muscle by placing four fingers on the deltoid muscle with the top finger on the acromion process. The injection site then is 3 finger-widths below the acromion process, or about 5 cm (2in). - d) to administer intramuscular medication using the vastus lateralis site, the nurse should select the middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh. The nurse can place a hand below the greater trochanter, and the other hand just above the knee to locate the middle portion of the muscle for the injection site
a nurse is reviewing the use of side rails with an A.P. Which of the following statements by the A.P indicates that further teaching is required? a) "I should not leave all 4 side rails up unless there is a prescription for restraints" b) "an alert client will be the safest if I raise the 2 upper side rails at the head of the bed" c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself" d) "if a client is sedated, I should raise all 4 side rails to prevent a fall out of bed"
c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself"
A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give to the client before inspecting and palpating this gland? a) "tilt your head slightly forward" b) "keep your head straight and look ahead of you" c) "tilt your head back and swallow" d) "turn your head to the side against my hand"
c) "tilt your head back and swallow" to examine the thyroid gland the nurse should instruct the client to extend her head backward into swallow the nurse should be able to feel the thyroid gland is ascend as the client swallows in observe any enlargement of the gland - to palpate the supraclavicular lymph nodes, the nurse should instruct the client to tilt her head forward and relax their shoulders - to palpate the trachea for any deviation to the side, the nurse should instruct the client to keep her head in an erect neutral position - to evaluate the strength of the neck muscles the nurse should place a hand on the side of the clients head and ask her to turn her head against the resistance of the hand then there should then repeat this step on the other side of the client said (ROM)
A nurse is planning care for a young adult client has a terminal illness. Which of the following concepts for death should nurse considered for this client? a) death is unacceptable under any circumstances b) magical thinking helps avoid thoughts of death c) death is viewed as an interruption of what might have been d) that is a natural consequence of the age appearance trading body
c) death is viewed as an interruption of what might have been young adults tend to see a whole life ahead of them so that is often seen as an interesting that lies young adults do not typically welcome death at this time - a) adolescents tend to reject the end of life especially their own - b) preschoolers tend to avoid thoughts of death by employing magical thinking - d) accepting the deterioration of the body is more likely among older adults, some of them might consider that relief from a chronic or terminal illness
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following action should the nurse take? a) hold the irrigator 1.25 centimeters (0.5 in) above the eye b) wrap the irrigation solution up to the upper island eyelid c) exert pressure on the bony prominences when holding the eyelids open d) direct the irrigation from the outer canthus to the inter canthus of the eye
c) exert pressure on the bony prominences when holding the eyelids open The nurse should hold the upper lid against the eyebrow in the lower eyelid against the cheekbone when irrigating the eye - a)the nurse should hold the irrigator 2.5 cms (1 in) above the eye to keep the irrigator from touching the eye in to prevent the solution from damaging the eye tissue - b) the nurse should direct the irrigation solution onto the lower conjunctival sac to avoid injuring the cornea and having contaminated fluid flow down the nasolacrimal duct - d) the nurse should direct the irrigation solution from the inner canthus to the outer canthus to avoid injuring the cornea and having continuous fluid flow down the nasolacrimal duct.
A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? a) Right task b) Right circumstance c) Right person d) Right communication
d) Right communication The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations.
a nurse is changing the dressing for a client recovering from an appendectomy following a ruptured appendix. The client surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? a) tenderness when touched b) pink shiny tissue with a granular appearance c) serosanguineous drainage d) halo of erythema on the surrounding skin
d) halo of erythema on the surrounding skin the nurse should report to the provider when a client has a ring of erythema (redness) on the surrounding skin which might indicate underlying infection. This and any other manifestation of infection (ex. purulent drainage, swelling, warmth, or a strong odor) should be reported to the provider - a) tenderness when touched is an expected finding in a postoperative wound that is healing by secondary intention. Severe pain might indicate infection or underlying tissue destruction and should be reported b) pink shiny tissue with a grainy appearance is granulation tissue and indicates the proliferative stage of limb healing this is an expected finding in a post operative wound healing by a secondary intention c)serosanguineous drainage, which is made up of RBCs and plasma is an expected finding in a postoperative wound healing by secondary intention. Purulent drainage suggest infection and should be reported
A nurse is obtaining a clients blood pressure in a client's lower extremity. Which of the following actions should the nurse take? a) auscultate the BP at the dorsalis pedis artery b) measure the clients BP with the client sitting at the side of the bed c) place the cuff 7.6cm (3in) above the popliteal artery d) place the bladder of the cuff over the posterior aspect of the thigh
d) place the bladder of the cuff over the posterior aspect of the thigh This is the correct position for the bladder of the class when the nurse is measuring a lower extremity blood pressure - a nurse should auscultate the blood pressure at the popliteal artery - the nurse should measure the blood pressure with the client prone is possible otherwise the client should lie supine with knee flexed - the nurse should position the cuff 2.5cm (1 in) above the popliteal artery
a nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include?
include 2.5 cups of vegetables in your diet Recommend 2.5 cups of veggies and 2 cups of fruit in daily diets. Drink between 2 and 3 L of water daily
a nurse is preparing to remove an NG tube for a client who has a partial colectomy. Which of the following actions should the nurse take?
pinch the NG tube while removing the tube -the nurse should disconnect the NG tube from the suctions apparatus before removal to decrease risk of injury to the GI mucosa. -the nurse should instill 50 mL of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube -the nurse should instruct the client to take and hold a deep breath during the removal of the NG tube to close the glottis and decrease the risk of aspiration of any gastric contents
examples of secondary prevention
screening groups of older adults in nursing care facilities for early influenza manifestations Pap smear, mammograms, CBC for anemia Screening for STDS-sexual history, partners Screening for alcohol abuse-CAGE Screening for depression---sadness/hopleless question **activities provided to identify and treat asymptomatic persons who have risk factors for a given disease or preclinical disease....example: mammogram,cervical exam with pap, bp measurement,lipid panel**
a nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?
stop the teaching and check with the surgeon about informed consent
