ATI Fundamentals - Practice A
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
Compare the client's home medications with the provider's prescriptions.
A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
*image with the device being used on the front of the knee*
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?
A mole with an asymmetrical appearance.
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
Abdominal cramping
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
Acupuncture
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instruction should the nurse include in the teaching?
Administer the medication into the abdomen.
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?
Advocacy ensures clients' safety, heath, and rights.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
Ask another nurse to observe the medication wastage.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
Make sure the client wears a mask when outside her room if there is construction in the area.
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
Place the client's arm in a dependent position.
A nurse is caring for a client who is expressing anger about the diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Reassure the client that this is an expected response to grief.
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
Situation, background, assessment, and recommendation (SBAR)
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?
Wear a gown when caring for client.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
Administer the medication with the needle at a 45* angle.
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse use?
Droplet
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
Place a client who has a tuberculosis in a room with negative-pressure airflow.
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear.
Press gently on the tragus of the client's ear.
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following should the nurse take?
Turn the client every 2 hr.
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
"I am available to talk if you should change your mind."
A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? "I am not worried because I still have hope that he will be okay." "I am relying on support from our family during this time." "We can plan our family reunion once he recovers and comes home." "We don't see any reason to start discussing funeral arrangements right now."
"I am relying on support from our family during this time."
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)
assist the client with a partial bed bath, measure the client's BP after the nurse administers an antihypertensive medication, use a communication board to ask what the client wants for lunch
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)
pupil clarity, visual fields, visual acuity
A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
"I can concentrate best in the morning."
A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?
Check the IV tubing for obstruction.
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
Stand close to the cabinet when lifting it.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Subtract the amount of irrigant used from the client's urine output.
A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
Calf swelling
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? Use a bed exit alarm system. Raise four side rails while the client is in bed. Apply one soft wrist restraint. Dim the lights in the client's room.
Use a bed exit alarm system.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? "Is your pain constant or intermittent?" "What would you rate your pain on a scale of 0 to 10?" "Does the pain radiate?" "Is your pain sharp or dull?"
"Is your pain sharp or dull?"
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? "Use the complete name of the medication magnesium sulfate." "Delete the space between the numerical dose and the unit of measure." "Write the letter U when noting the dosage of insulin." "Use the abbreviation SC when indicating an injection."
"Use the complete name of the medication magnesium sulfate."
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?
"We would give you oxygen through a tube in your nose."
A nurse is caring for a client who has COPD Nurses' Notes 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Vital Signs 1000: Temperature 38.6° C (101.5° F) BP 114/56 mm Hg Heart rate 99/min Respirations 32/min Oxygen saturation 85% on room air Diagnostic Results 1200: Chest x-ray shows lung hyperinflation and left upper lobe pneumonia. What 3 findings need a follow up -Breath Soundns -BP -O2 -Temp _HR
-Breath Sounds -O2 -Temp
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if if applies. Do not use a trailing zero.)
107 mL/hr
A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, in hurts so much." Which of the following interventions is the nurse's priority action?
Administer pain medication 45 min before changing the client's dressing.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
Apply intermittent suction when withdrawing the catheter.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions in the nurse's priority?
Determine the reasons why the client is refusing to use the incentive spirometer.
A nurse is admitting a client who is having an exacerbation of heart failure. In planning the client's care, when should the nurse initiate discharge planning?
During the admission process
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
Examine personal values about the issue.
A nurse in a provider's clinic is caring for a client who has diarrhea. Vital Signs Temperature 36.2° C (97.2° F)Pulse rate 116/minRespiratory rate 24/minBP 102/68 mm HgOxygen saturation 95%Weight 52.2 kg (115 lb) Nurses' Notes 1000: Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. Weight at previous visit was 56.2 kg (124 lb). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100: Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching provided for managing diarrhea. Physical Examination 1015: Oriented to person, place, and time; lethargic, reports headache Tachycardia, hypotension, thready pulse, dry mucous membranes, tenting present. Respirations slightly labored, chest clear. Bowel sounds x 4 quadrants hyperactive. Reports urine is dark, minimal amount. The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. Increase intake of high-calcium foods. Eat probiotic foods, such as yogurt. Avoid alcohol while experiencing diarrhea. Eat raw vegetables. Eat three large meals a day. Avoid caffeine while experiencing diarrhea. Drink hot liquids several times a day. Drink carbonated beverages to replace lost fluids. Follow a low-fiber diet.
Increase intake of high-calcium foods is incorrect. The nurse should instruct the client to increase intake of high-potassium foods. Eat probiotic foods, such as yogurt is correct. Probiotic foods, such as yogurt, contain live bacterial cultures, which can help to reduce diarrhea. Avoid alcohol while experiencing diarrhea is correct. Alcohol is a substance that stimulates gastrointestinal (GI) motility. Eat raw vegetables is incorrect. Raw vegetables contain fiber. The nurse should instruct the client to eat vegetables that are well-cooked and do not have skins or seeds. Eat three large meals a day is incorrect. The nurse should instruct the client to eat small meals throughout the day to manage diarrhea. Avoid caffeine while experiencing diarrhea is correct. Caffeine is a substance that stimulates GI motility. Drink hot liquids several times a day is incorrect. Hot liquids can stimulate peristalsis and should be avoided while the client is experiencing diarrhea. Drink carbonated beverages to replace lost fluids is incorrect. Items such as milk, fruit, and carbonated beverages can contain simple sugars that stimulate GI motility. Follow a low-fiber diet is correct. Foods that are high in fiber stimulate GI motility and should be avoided while the client is experiencing diarrhea.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
Make sure two fingers can fit under the sleeves.
A nurse is a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Obtain the pronouncement of death from the provider. Remove tubes and indwelling lines. Wash the client's body. Ask the client's family members if they would like to view the body. Place a name tag on the body.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
Pad the client's wrist before applying the restraints.
A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?
Role overload
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? The top of the cane is parallel to the client's waist. When walking, the client moves the cane 46 cm (18 in) forward. The client holds the cane on the stronger side of her body. The client moves her stronger limb forward with the cane.
The client holds the cane on the stronger side of her body.
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
Use the planning step of the nursing process to prioritize client care delivery.
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in teaching?
Use tracheostomy covers when outdoors.
A nurse is caring for a client who has pneumonia. Vital Signs 0800: Heart rate 109/min Respirations 26/min BP 125/65 mm Hg Temperature 39.2° C (102.6° F) Oxygen saturation 95% 1200: Heart rate 94/min Respirations 18/min BP 115/65 mm Hg Temperature 37.8° C (100° F) Oxygen saturation 96% Medication Administration Record 0.45% sodium chloride IV at 125 mL/hr Vancomycin 1 g intermittent IV bolus every 12 hr Acetaminophen 650 mg PO every 6 hr PRN temperature greater than 38.3° C (101° F) Codeine 20 mg PO every 4 hr PRN cough Nurses' Notes 0800: Oriented to person, place, and time. Appears fatigued. Diaphoretic, febrile. Reports not sleeping well last night due to "coughing a lot." Moves all extremities well. Tachycardia. All pulses palpable. Reports chest discomfort with coughing. Respirations 26/min, shallow. Auscultation reveals diminished breath sounds and bilateral crackles. Pulse oximetry 95% on O2 2 L via nasal cannula. Hypoactive bowel sounds present in all four quadrants. States tolerating diet with no nausea or vomiting but has no appetite. Client states voiding using the bedside commode with no difficulty. Output of 500 mL clear, yellow urine flushed. IV infusing to right arm, no noted redness or irritation at site. Acetaminophen administered for temperature. 1200: States feeling better following administration of acetaminophen. Vancomycin infusion started. Client voices no discomfort at this time. 1300: Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified. The nurse should identify that the client might be experiencing Select... -UTI -Seizurs -Extravasation as evidenced by the client's Select... -Urine appernace -IV site -Temp .
Drop Down 1: Urinary tract infection is incorrect. The client reports no difficulty or discomfort with urination. Seizures in incorrect. The client's neurological assessment is within expected parameters, and the client's temperature is decreasing. Elevated temperature can be a risk factor for seizure activity. Extravasation is correct. The client's report of severe pain and the appearance of the IV catheter site are indications of extravasation. Vancomycin is a medication that carries the risk of extravasation. Drop Down 2: Urine appearance is incorrect. The urine color is within expected parameters. IV catheter site is correct. The appearance of the site is an indication of extravasation. Vancomycin is a medication that carries a risk of extravasation. Temperature is incorrect. The client's temperature is decreasing.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Potassium 5.4 mEq/L BUN 15 mg/dL This value is within the expected reference range of 10 to 20 mg/dL. Creatinine 0.8 mg/dL This value is within the expected reference range of 0.5 to 1.1 mg/dL for women 41 to 60 years of age and 0.6 to 1.3 mg/dL for men 41 to 60 years of age. Even for clients within younger and older age ranges (with the exception of newborn through 9 years of age), 0.8 mg/dL is within the expected reference range for creatinine. Sodium 143 mEq/L This value is within the expected reference range of 136 to 145 mEq/L. Potassium 5.4 mEq/L This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? Alginate Gauze Transparent Hydrocolloid
Hydrocolloid
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Make sure the reservoir bag of a partial rebreathing mask remains deflated. Use petroleum jelly to lubricate the client's nares, face, and lips.
Regulate the oxygen via nasal cannula at a flow rate of no more than 6 L/min.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements indicates an understanding of the teaching?
"I will hire someone to trim the tree that hangs low over the stairs of my front porch."
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing. The nurse is assessing the client. Which of the following actions should the nurse take? Select all that apply. Stop the IV infusion. Elevate the client's left arm. Apply heat to the client's left hand. Place a pressure dressing over the IV site. Start a new IV in the client's left hand.
Stop the IV infusion. Elevate the client's left arm. Apply heat to the client's left hand.
A nurse is caring for a client who has a new diagnosis of seizure disorder. Nurses' Notes 0800: Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. 0900: On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. Medication Administration Record Carbamazepine ER 200 mg PO twice per day Lorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min The nurse should first address the client's Select... -BP -Safety -Privacy followed by the client's Select... -PRN med -Positioning -Inconcnitence .
BP/Positioning
A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?
"Let's talk about how the change in your job status will affect you."
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
Check the client for injuries.
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
Decrease in heart rate
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. Remove the NG tube if the client begins to gag or choke. Apply suction to the NG tube prior to insertion. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Have the client take sips of water to promote insertion of the NG tube into the esophagus.
A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.)
Normal breath sounds
A nurse is caring for a client for a client who is postoperative and is experiencing signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? Document the provider's statement in the medical record. Complete an incident report. Consult the facility's risk manager. Notify the nursing manager.
Notify the nursing manager.
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
The client's caregiver washes out the feeding bag with warm water once every 24 hr.
A nurse in a provider's clinic is caring for a client who has heart failure. Nurses' Notes First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent edema present. Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this a.m. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from 20 mg to 40 mg daily. Client to return in 2 weeks for follow-up. Second Clinic Visit: Client arrives for follow-up visit 2 weeks later. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus rhythm. Pulses to lower extremities weak. +1 dependent edema present. Respirations even. Chest clear. Reports less coughing. Bowel sounds all present. Abdomen slightly distended. Reports last bowel movement previous evening. States voiding without difficulty, clear yellow urine. States urination has increased with increased dose of furosemide. Vital Signs First Clinic Visit: Temperature 36.7° C (98° F) Heart rate 106/min Respirations 26/min BP 162/88 mm Hg Oxygen saturation 93% on room air Weight 83.9 kg (185 lb) Second Clinic Visit: Temperature 36.7° C (98° F) Heart rate 86/min Respirations 22/min BP 142/78 mm Hg Oxygen saturation 94% on room air Weight 81.6 kg (180 lb) A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? "I have been weighing myself every other morning." "I am trying to decrease my intake of foods with potassium." "I am limiting my sodium intake to 2 grams daily." "I am eating fewer potato chips and more fruit for snacks." "I lie down and rest after meals." "I know to call my doctor if I gain 3 pounds or more in 2 days."
"I am limiting my sodium intake to 2 grams daily" is correct. "I am eating fewer potato chips and more fruit for snacks" is correct "I know to call my doctor if I gain 3 pounds or more in 2 days" is correct.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? "I think I should take my pain medication more often, since it is not controlling my pain." "Breathing faster will help me keep my mind off of the pain." "It might help me to listen to music while I'm lying in bed." "I don't want to walk today because I have some pain."
"It might help me to listen to music while I'm lying in bed."
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
"They indicate the form of treatment a client is willing to accept in the event of a serious illness."
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? Protective environment Airborne precautions Droplet precautions Contact precautions
Contact precautions
A nurse is caring for a client who is receiving a unit of packed RBCs. Nurses' Notes 0800: Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815: Client reports itching and anxiety. Client's face is flushed and has hives. Vital Signs 0800: BP 112/64 mm Hg Heart rate 80/min Respirations 18/min Temperature 37.1° C (98.8° F) Oxygen saturation 97% on room air 0815: BP 106/54 mm Hg Heart rate 100/min Respirations 22/min Temperature 37° C (98.6° F) Oxygen saturation 95% on room air The client has manifestations of allergic reaction febril reaction fluid overload as evidenced by the client's itching .temp O2
Drop Down 1: Allergic reaction is correct. The nurse should identify the client has manifestations of an allergic reaction as evidenced by itching, flushing of the face, anxiety, and urticaria. The nurse should stop the transfusion and notify the provider. Febrile reaction is incorrect. A febrile reaction has manifestations of fever, chills, headache, flushing of the face, and muscle pain. Fluid overload is incorrect. Fluid overload has manifestations of cough, crackles heard in bases of the client's lungs, shortness of breath, and distended neck veins. Drop Down 2: Itching is correct. The nurse should identify that itching, flushing of the face, anxiety and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider. Temperature is incorrect. The client's temperature is within the expected reference range. An increase in temperature is a manifestation of febrile or hemolytic reaction to blood administration. Oxygen saturation is incorrect. The client's oxygen saturation is within the expected reference range.
A nurse in an emergency department is caring for a client. The nurse should first.... A Review meds that might be causing confusion B Obtain a prescription from the provider for restraints C Assess where the restraint will be placed on the client Followed by.... A Padding bony prominences under the restrain B Monitoring the client in restraints every 2 hr C Using other methods to keep the client safe
The nurse should first A followed by C .
A nurse is caring for a client who is postoperative following abdominal surgery. Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200: Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort. Medication Administration Record Morphine 4 mg IV bolus every 4 hr PRN pain Metoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting Vital Signs 1100: Temperature 36.2° C (97.2° F) Heart rate 76/min Respirations 18/min BP 122/68 mm Hg Oxygen saturation 95% on room air 1200: Temperature 36.8° C (98.2° F) Heart rate 116/min Respirations 20/min BP 112/68 mm Hg Oxygen saturation 93% on room air the assessment findings below that the nurse should report to the provider. Neurological assessment Incisional drainage Urinary output Reported pain level Gastrointestinal assessment Vital signs
Urinary OP Pain Vital SIgns
A nurse is admitting a client to a health care facility. Nurses' Notes 1100: Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed. Vital Signs 1100: BP 138/72 mm Hg Heart rate 80/min Respirations 22/min Temperature 38.3° C (101.1° F) Oxygen saturation 90% on room air Diagnostic Results 1400: Chest x-ray positive for inflammation and infiltrates in upper lobes QuantiFERON-TB positive (negative) Tuberculosis culture positive (negative) The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply. Wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room. Place the client in a negative airflow room. Remove mask after exiting the client's room. Wear a sterile, water-resistant gown if within 3 feet of the client.
Wear an N95 mask when caring for the client is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection. Place the client in a negative airflow room is correct. The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system. Remove mask after exiting the client's room is correct. The nurse should remove their mask after leaving the room of a client who is in airborne precautions for tuberculosis to prevent exposure to the infection.
