ATI Fundamentals Questions #2

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? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. Position the client on his right side C. Insert the tip of the tubing 8 cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum

Insert the tip o fhte tubing 8 cm (3.1 in) *The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa

A nurse on a medical-surgical unit is caring for a client who devlops deep, rapid respirations. Arterial blood gas analysis includes the following valuesL pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

Metabolic acidosis *A pH of 7.25 indicates acidosis. ROME. Respiratory opposite. Metabolic equal. pH is low. (7.35-7.45) HCO3- is low (22-26). PaCO2 is withing normal limits (35-45)

A nurse is evaluating the development of a group of clients. The nurse should understand that, according to Erikson, the developmental task of intamacy vs isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence C. Childhood D. Young adulthood

Young adulthood *The developmental task of young adulthood is intamacy vs. isolation *The developmental task of middle adulthood is generativity vs self-absorption and stagnation *The developmental task of adolescence is identity vs role confusion *The developmental task of school-aged children is industry vs inferiority

A nurse is collecting data during a neurological examination of a client. When asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? A. Cranial nerve XII B. Cranial nerve X C. Cranial nerve VIII D. Cranial nerve V

Cranial nerve XII *Cranial nerve XII (hypoglossal), innervates the tongue by observing a range of tongue movements *Cranial nerve X (vagus), by asking the client to ocalize *Cranial nerve XIII (vestibulocochlear) by using the Rinne and Weber tests and asking the client if he can hear a whisper *Cranial nerve V (trigeminal) by asking the client to clench his teeth and palpating the masseter muscles for contraction

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease passage of the catheter throught the urinary meatus? A. "Bear down." B. "Perform Kegel exercises." C. "Hold your breath." D. "Raise your head off of the pillow."

"Bear down." *The nurse should ask the client to "bear down" gently as if to void. This can enable the nurse to better visualize the urinary meatus and promote relaxation of the external urinary sphincter. Additionally, this will ease the passage of the catheter through the urinary meatus.

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake? (Round the answer to the nearest whole numer. Use a leading zero if applicable but do not use a trailing zero.)

660 mL 1.) what is the unit of measurement the nurse shouold calculate? mL 2.) set up an equation and solve for X 1 oz/30 mL = 22 oz/X mL (22 x 30) X = 660 mL

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 of water should the nurse document as intake for the 3 separate medications the client receives during a 12 hour night shift? (Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)

90 mL 1.) What is the unit of measurement the nurse should calculate? mL 2.) Set up an equation and solve for X 1 oz/30 mL = 3 oz/X mL 3x30=90 mL X=90 mL

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 perform when working with the interpreter? A. Face away from the cloent to avoid creating a distraction B. Pace speech to allow time for the intepreter 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

Pace the speech to allow time for the interpreter to convey the words *The nurse should speak distinctly and at a rate that allows time for the interpreter to convey the message and for the client to receive it

A nurse is preaparing to administer a tap water enema to a client. Which of the following actions should the nurse take? A. Raise the enema bag if the client experiences cramping B. Lubricate 2.54 cm (1 cm) of the tip of the rectal prior to insertion C. Place the client in a left Sims' position D. Don sterile gloves prior to the procedure

Place the client in a left Sims' position *The nurse should place the client into 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.

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? A. Tie a secure knot with the restraint straps B. Attach the restraints' straps to the bed's side rails C. Make sure 3 fingers fit beneath the restraints D. remove the restraints at least every 2 hours

Remove the restraints at least every 2 hours *The nurse should remove the restraints at least every 2 hours to reposition the client, provide fluids and nutrients, assist with range-of-motion exercises, and evaluate the client's overall wellbeing. *The nurse must attach the restraint with a quick release buckle or a knot that does not tighten when pulled *The nurse should attach the restraints' straps to a part of the bed frame that moves when raising and lowering the bed, not to the side rails *The nurse should make sure 2 fingers fit under the restraints

A nurse is caring for a client who has xerostomia with a lack of saliva. The nurse should identify that which of the following nutrients will be affected by the lack of salivary amylase? A. Fat B. Protein C. Starch D. Fiber

Starch *xerostomia means dry mouth *amylase breaks down starch *Lipase breaks down fats *Pepsin breaks down proteins *Fiber is not digestible

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? A. Allows minimal treatment B. Benefits the client's family C. Offers hope of a cure D. Supports self-determination

Supports self-determination *The nurse must honor the client's autonomy and ability to make health care decisions. The client has the right to refuse treatment; as the client's advocate. the nurse must support that right.

A nurse is collecting data from a female client who reports abdomnial pain. Further findings reveal a temperature of 39.2 C (102.6 F), a heart rate of 105.min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. Heart rate of 105 B. Soft nontender abdomen C. Temperature D. overdue menses

Temperature *Elevated temperature is an emergent physiological need that requires priority intervention by the nurse.

A nurse is preparing to instill a vaginal mediation in suppository form to a client. Which of the following action should the nurse take during this procedure? A. Don sterile gloves B. Use the dominant hand to retract the labia C. Use the index finger to insert the suppository D. Ease the suppository along the anterior vaginal wall

Use the index finger to insert the suppository *To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible.