ATI Fundamentals Review
The nurse is caring for a client who is receiving fluid through a peripheral IV catheter.. Which of the following findings at the IV site should the nurse identify as indicating infiltration?
Skin blanching
A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?
-relief of urinary retention -measurement of residual urine after urination -presence of an open perineal wound
A nurse is assessing a client's readiness to learn about insulin 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 is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
"The pain is like a dull ache in my stomach."
A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?
Allow extra time for the client to respond to questions.
short term < 4 weeks enteral feeding?
nasogastric of nasointestinal tubes
lubricate the distal 6-8 cm of suction catheter with a water-soluble lubricant for?
nasopharyngeal and nasotracheal suctioning
Suction pressure?
no higher than 120mmHg
when gastric residual exceeds 100mL?
withhold feeding and notify provider---maintain semi-Fowler's position
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?
"I can see that this is upsetting you."
Rectal temperature?
Sims position---inserted 3.5cm or 11/2 in for adults
a community health nurse is checking BP for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension?
a client who smokes one pack of cigarettes each day
Neurosensory checks and ROM in restraints?
every 2 hours
Blood glucose check on enteral feedings?
every 6 hours until max administration rate is reached and maintained for 24 hours
how often providing tacheostomy care?
every 8 hours
when to flush IVs?
every 8-12 hours when not in use
A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?
Impaired peristalsis of the intestines
A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include?
People who practice Judaism stay with the body of the deceased until burial.
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 having difficulty sleeping and is pacing the floor. The client's head is down, and he is wringing his hands. Which of the following actions should the nurse take?
Remain with the client
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?
The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.
A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?
"It must be difficult to care for someone who is confined to bed."
A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?
"This is a difficult time, but we are helping each other through this."
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
Assess the client for orthostatic hypotension.
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.)
B) Pupil clarity D) Visual fields E) Visual acuity
A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?
Fill the bag two-thirds full with ice.
A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?
Gloves
Rinne test?
Tuning fork against mastoid bone AC > BC 2-1 ratio
Insert catheter how?
Using the sterile hand
delivers most precise oxygen concentration?
Venturi Mask: 24-55% at flow rates of 2-10L/min---Humidification not required
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?
Walking briskly
A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?
Wear cotton clothing to avoid static electricity.
Change IV site?
according to facility policy (usually 72 hours)
a nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure
add 30 mm Hg
Tracheal cuff pressure?
between 14-20 mmHg
Dehiscence?
partial or total rupture of sutured wound
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
Gently shake the container of medication prior to administration.
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
Rapid heart rate
Assessment of respirations?
Rate, Depth (deep or shallow), and Rhythm (regular)
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?
Sit at the bedside while feeding the client.
Fidelity?
agreement to keep one's promise to the client about care that was offered
surgical asepsis for what suctioning?
all but suctioning of the mouth
Insert catheter?
bevel up at angle of 10-30 degrees----flash back of blood---lower hub of catheter close to skin to prepare for threading into vein 1/4 in---advance catheter into vein until hub rests against the insertion site
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which manifestations of Hypoglycemia
blurred vision / tachycardia / moist clammy skin
Cellulitis?
pain, warmth, edema, induration, red streaking, fever, chills, and malaise-----Treat: D/C and remove IV, elevate extremity, warm compress, culture
Infiltration?
pallor, local swelling, dec skin temp, damp dressing, slowed infusion----Treat: stop infusion and remove IV, elevate extremity, warm compress
Droplet precautions?
protect against droplets larger than 5mcg---streptococcal pharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia/sepsis, pneumonic plague
Contact Precaution?
protect visitors and caregivers against direct client/environment contact infections---respiratory syncytial virus, shigella, enteric diseases caused by micros, wound infections, herpes simplex, scabies, multidrug-resistant organisms
Purulent drainage?
result of infection---thick and contains WBCs, tissue debris, and bacteria
Risk for infection at what injection site?
subcut and IM
A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent?
surgeon
a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse
the caregiver insists on remaining in the room
Percussion on chest?
use cupped hand to clap rhythmically on chest to break up secretions
Discontinue hot or cold applications?
usually 15-20 minutes
Parenteral site for infants and children < 2 years of age?
vastus lateralis site recommended
After age 2, what site can be used for parenteral injections?
ventral gluteal
a nurse is caring for a client who has a terminal diagnosis and whos health is declining. Advanced directives.
we can talk about advanced directives brochures
how to take apical pulse?
5th intercostal space at left midclavicular line--place stethoscope on chest and always count for 1 minute----used to assess HR of infant, rapid rates > 100, irregular rhythms, and prior to cardiac meds
A nurse is calculating a client's fluid intake over the past 8 hour. Which of the following items should the nurse plan to document on the client's intake and output record as 120ml of fluid?
8 oz of ice chips
Normal pulse oximetry?
95%-100%---<85% is abnormal
Causes concern with UO < ___mL/hr?
< 30 mL/hr for more than 2 hours
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?
Assist the client to an upright position.
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?
Auscultate lung sounds.
Palpation of the thorax and lungs?
Chest excursion: thumbs move outward 5cm and Vocal (Tactile) Fremitus: client says 99 each time--vibration symmetrical
A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?
Cold extremities
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
Educating clients about the recommended immunization schedule for adults
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?
"You should have a fecal occult blood test every year."
A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?
"You should receive a pneumococcal immunization every 10 years."
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
Cleanse the wound from the center outward
Simple Face Mask?
40-60% at flow rate of 5-8L/min
Apical pulse?
5th intercostal space at left midclavicular line
Intermittent feeding?
60mL syringe---formula instilled via gravity until done followed with 60-100mL tap water
A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?
Liver Damage
Phlebitis/thrombophlebitis?
edema, throbbing, burning, or pain at site, inc temp, erythema, red line up arm with palpable band at vein site, slowed infusion----Treat: D/C infusion and remove IV, elevate extremity, warm compress
Hyperglycemia? Hypoglycemia?
greater than 250mg/dL---Less than 70mg/dL
A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?
The client holds his breath for 10 seconds after inhaling the medication
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 client holds the cane on the stronger side of her body.
A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question?
The dose
A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?
Tie the restraint with a quick-release knot.
Cane instructions?
2 points of support on ground at all times---Keep cane on stronger side---Move cane 6-10 in, then move weaker leg then stronger leg
Unused formula after 24 hours?
discarded
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?
Have the client use a trapeze bar when changing position.
s/s of bradycardia?
hypotension, chest pain, syncope, diaphoresis, dyspnea, altered mental status
Prior to suctioning?
hyperoxygenate with FiO2 of 100%, obtain baseline vitals of O2 and breath sounds
A nurse is admitting a client who has active TB to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for this client?
A room with air exhaust directly to the outdoor environment
Fluids should not hang more than?
24 hours unless closed system
Nasal Cannula?
24-44% at flow rate of 1-6L/min----Humidification for flow rate 4L or >
MDI administration?
hold inhaler 1-2 inches away from mouth
what solutions used to clean trach?
hydrogen peroxide of normal saline
emergency if decannulation occurs?
in the 1st 72 hours
Palpate radial pulse for BP then?
inflate cuff another 30mmHg to hear BP systolic number
Sphygmomanometer?
BP measurement---Width should be 40% of arm circumference--Bladder (inside cuff) should surround 80% of arm circumference of adult and whole arm for child
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
"Are you able to help with your hygiene care?"
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.)
-Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown.
Pulse strength scale?
0-4+---0=absent- 4+= full or bounding
Tonsils grading scale?
1+ barely visible 2+ halfway to uvula 3+ touching uvula 4+ touching each other or midline
A nurse is preparing a heparin solutionA nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
8 mL/hr
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 his condition is a contraindication for which of the following therapies?
Acupuncture
Tympanic temperature--adults? children?
Adult--pull ear up and back; Children younger than 3 pull down and back
high humidification with O2 delivery?
Aerosol mask, face tent, and tracheostomy collar: 24-100% at flow rates of 10L/min or more
Risk tools for Staging Pressure Ulcers?
Braden Scale <18---at risk; Norton Scale 15-16---indicator of risk
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?
Consult the medication reference book available on the unit.
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?
Contact precautions
Wear what clothing while on oxygen?
Cotton b/c synthetic or wool fabrics can generate static electricity
A nurse is planning care for a client who has terminal cancer and a prescription for morphine. Which intervention should the nurse include in the plan of care?
Instruct client to actively cough to prevent buildup of secretions in airway.
A nurse is reviewing a client's medication prescription that reads "digoxin 0.25 by mouth everyday." Which of the following components of the prescription should the nurse verify with the provider?
Medication dose
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 receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
Skin blanching
A nurse is reviewing a clients ABG lab results. Which of the following should the nurse report to the provider?
Sodium 126 mEq/L
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 caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?
Wear gloves when changing the client's gown.
A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?
When lifting an object, spread your feet apart to provide a wide base of support.
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
Withhold the blood transfusion
monitoring tube replacement?
checking gastric contents for pH 0-4
Postural drainage?
client assumes one or more positions (total of 9) to allow gravity to assist with removal of secretions from specific areas of the lung
Serosanguineous drainage?
contains both serum and blood---watery and appears blood-streaks or blood-tinged
a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?
current medications
Evisceration?
dehiscence that involves the protrusion of visceral organs through a wound opening
A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
evacuate the client
Serous drainage?
portion of the blood (serum) that is watery and clear or slightly yellow
Tracheostomy client permitted to eat?
position upright and tip chin to chest to enable swallowing
Vibration on chest?
move heel of hands to create vibrations as the client exhales---cough after each set of vibrations
how often to remove TED hose?
remove and reapply at least twice a day
Positive test for ketones in urine?
uncontrolled blood glucose
ethical principle of veracity
nurse tells client she has cancer
A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?
"Bear weight on both of your legs."
A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom. After assessing, the nurse notifies the provider. What documentation should the nurse use?
"The provider was notified."
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 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."
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
"What could I have done to deserve this illness?"
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
"When descending stairs, I will first shift my weight to my right leg."
A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
0.3 mg
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
1) Ask the client if he can bear weight 3) Position the chair on the left side of the bed 4) Have the client sit and dangle his feet at the bedside 2) Use the stand-and-pivot technique to move the client to the chair
Limit suction attempt to no longer than?
10-15 sec and 2-3 attempts with 20-30 sec for recovery between sessions
A nurse is caring for a client who has diabetes and a new prescriptions for 14 units of regular insulin and 28 units of NPH insulin to be given subcutaneous at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the syringe?
14 + 28 = 42 units.
Glasgow Coma scale?
15= awake and alert----3=coma
20/20?
1st # is distance pt is standing from Snellen chart--2nd # is distance a normal sighted person can read the line
A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?
A client who has a cast and reports numbness and paresthesia
A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?
A client who has a prescription for a transfusion of packed red blood cells
A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?
A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oil is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?
A client who has asthma.
A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?
A nurse asks a nurse from another unit to assist with her documentation.
a nurse is preparing to delegate client care tasks to an assistive personnel (ap). which of the following tasks should the nurse delegate?
Ambulating a client who is postoperative
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 using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report?
Assessment
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?
Cough deeply after each use.
A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/ 1 mL. How many mL should the nurse administer per dose?
40 / 10 = 4 mL
A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?
Daily weight
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 is the nurse's priority action?
Determine the reasons why the client is refusing to use the incentive spirometer.
A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?
Eggs
Evisceration and Dehiscence requires?
Emergency treatment---cover wound and protruding organs with sterile towels soaked in sterile normal saline---DO NOT attempt to reinsert organs---position client supine with hips and knees bent
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?
Erythema on pressure points
A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
Evacuate the client
A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
Have family members wear a gown and gloves when visiting.
A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning?
Have the client demonstrates the procedure.
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?
Hemolytic
A nurse is assessing a client who is receiving TPN. Which of the following findings should the nurse recognize as a complication to this therapy?
Hyperglycemia
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?
Inspection
Highest O2 concentration possible?
Nonrebreather mask: 80-95% at flow rates of 10-15L/min
A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?
Place the client in a lateral position with the head turned to the side before beginning the procedure.
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
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.
Contact precaution equipment?
Private room OR room with same disease client, gloves and gowns by caregivers and visitors, disposal of infectious dressing material into single nonporous bag
Droplet precaution equipment?
Private room OR room with same disease client, masks for providers and visitors
Airborne precaution equipment?
Private room, N95 or HEPA respirator for TB, Negative pressure airflow exchange
Airborne precautions?
Protect against droplet infections smaller than 5mcg----Measles, varicella, pulmonary or laryngeal TB
A nurse is reviewing the ABG's for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid base balances?
Respiratory acidosis
A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?
Tachycardia
Weber Test
Tuning fork on top of client's head---sound heard equally in both ears---Negative Weber test
A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?
Two nurses using a friction-reducing device
Advance catheter until?
Urine returns then continue to advance it another 2.5-5cm
A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?
Use a clock pattern to describe food on the client's plate.
A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?
Witness the client's signature on the consent form.
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?
Wrap blankets around all four sides of the bed
Fluid Overload?
distended neck veins, increased BP, tachycardia, SOB, crackles and edema----Treat: Stop infusion, raise HOB, VS, adjust rate, Diuretics if prescribed
Client in restraints assessed for food, fluids, comfort, and safety?
every 15-30 minutes
Circadian rhythms?
BP usually lowest in the early morning and peaking during later part of afternoon
body's preferred energy source?
Carbohydrates
A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
"I'll check the wires and cables on my TV to make sure they are in good working order."
SaO2 < 90%?
Hypoxemia---Early: tachypnea, tachycardia, restlessness, pale skin, elevated BP---Late: confusion, cyanotic, bradypnea, bradycardia, hypotension, dysrhythmias
A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?
A 10-month-old infant can pull up to a standing position.
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.)
A) Place the client in a room with negative-pressure airflow. B) Wear gloves when assisting the client with oral care. E) Use antimicrobial sanitizer for hand hygiene.
_____ color is positive for blood in fecal occult blood testing (guaiac test)?
Blue color
A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?
Bounding pulse
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 providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply)
Check the cord routinely for frays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?
Cover the incision with a moist sterile dressing.
A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?
Droplet
Hematoma?
Ecchymosis at site---Treat: No alcohol, apply pressure after IV removal, war compress and elevation after bleeding stops
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
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?
Fidelity
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
Flush the tube with 15 mL of sterile water.
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?
Lock the wheels of the bed and wheelchair
A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?
Loss
Men respirations? Women respirations?
Men--diaphragmatic breathers, abdominal movements more noticeable--Women- thoracic muscles, and chest movements more pronounced
A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client?
N95 respirator
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?
Narrowed arterial lumen
A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?
PC for after meals
The nurse overhears two AP's from the medical surgical unit discussing a hospitalized patient while in the cafeteria. Which of the following is the priority nursing action?
Quietly tell the AP's that that this is inappropriate
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?
Rapid heart rate
Assessment of pulse?
Rate, Rhythm (regular), Strength (amplitude 0-4), Equality (symmetrical)
A nurse is caring for a client who is expressing anger over his 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 talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?
Role overload
Hypoxemia?
SaO2 < 90%--s/s tachypnea, tachycardia, restlessness, anxiety, cyanosis----place in semi-Fowlers or Fowlers position
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?
Washing dishes
Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers?
a client who has a protein calorie malnutrition a client who has right-sided heart failure and 4+ edema to lower extremities a client who has post operative delirium
Beneficence?
agreement that the care given is in the best interest of the client---positive actions
a nurse has just inserted an NG tube for a client. Which of the dollowing findings should the nurse expect to confirm correct tube placement?
an x-ray
a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?
apply an ankle-foot orthotic device to the client's feet
Nonmaleficence?
avoidance of harm or pain as much as possible when giving treatments
a nurse is giving a change of shift report about a client admitted earlier who has pneumonia
breath sounds
Sanguineous drainage?
contains serum and RBCs---thick and appears reddish
signs of dysphagia?
coughing, choking, gagging, and drooling of food
high risk for aspiration?
instruct client to tuck chin when swallowing
aspirate for residual volume?
intestinal should be less than 10mL and gastric should be less than 100mL---every 4-8 hours
Chest physiotherapy (CPT)?
involves chest percussion, vibration, and postural drainage to assist client to mobilize secretions---treatments 1hr before meals or 2hr after meals and at bedtime
Albumin levels < 3.5?
lack of protein puts client at risk for delayed wound healing and infection
position for suppositories?
left lateral position
what is used to cleanse peristomal area?
mild soap and water
Minimum degrees of bed while on enteral feeding?
30 degrees
Percussion of thorax and lungs?
Normal= resonance---Dullness= fluid or solid tissue, pneumonia or tumor---Hyperresonance= presence of air, pneumothorax or emphysema
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?
Use progressive relaxation techniques at bedtime.
Venturi Mask?
24-55% at flow rate of 2-10L/min via different size adaptors---most precise O2 concentration--humidification not required
A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate?
Airborne
Diaphragm of stethoscope?
Used for high-pitched sounds (heart sounds, bowel sounds, breath sounds)---placed firmly on the body
with continous-drip feeding, what must be done every 4-6 hours?
flush enteral tubing with 30-60mL of irrigant (tap water) and check tube placement
Partial rebreather mask?
60-75% at flow rate of 6-11L/min---reservoir bag attached with no valve which allows client to rebreathe up to 1/3 of exhaled air
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
Bell of stethoscope?
Used for low-pitched sounds (abnormal heart sounds, bruits)---placed lightly on the body
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?
Tell the client to keep the head of the bed elevated at least 30 degrees
Position for suctioning?
high-Fowlers or Fowlers position
Catheter embolus?
missing catheter tip when D/C, severe pain at site----Treat: tourniquet high on extremity to limit venous return, X-ray
s/s of tachycardia?
pain, anxiety, restlessness, fatigue, low BP, and low O2 sat
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
3) Inject 10 units of air into the bottle of NPH insulin1) Inject 5 units of air into the bottle of regular insulin4) Withdraw the correct dose of regular insulin from the bottle2) Withdraw the correct dose of NPH insulin from the bottle
A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
8 mL/hr
Nonrebreather mask?
80-95% at flow rate of 10-15L/min to keep reservoir bag 2/3 full during I and E----one way valve allows client to inhale max O2 from reservoir bag
A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?
A nurse asks a nurse from another unit to assist with documentation for a client
A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?
Semi-Fowler's
A nurse is assessing a client who has been on 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 reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?
Decreased calcium
A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?
Gelatin
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.)
Narrowed arterial lumen (Bruit)
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
Select a suction catheter that is half the size of the lumen.
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?
The AP hangs the collection bag at the level of the bladder.
selecting vein for IV insertion?
distal veins first on nondominant hand--soft and bouncy feeling when palpated
a nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
distended neck veins
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?
practice sessions
A nurse at an extended-care facility is instructing a class of AP's about the use of assistive devices during ambulation. Which of the following should the nurse give the AP's about the clients' use of a cane?
"When the client moves, he should move the cane forward first."
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?
Place the client in Trendelenburg's position.
A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?
Provide a protein intake of 1.5 g/kg of body weight per day.
indwelling urinary catheter
bladder scan
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.
Instillation of drops?
above conjunctival sac 1-2 cm, drop med into center of sac and hold pressure on nasolacrimal duct
Oxygen-induced hypoventilation?
develop in clients with COPD bc high levels of O2 can decrease or eliminate their respiratory drive
A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?
Have the client stand with her arms at her side and her feet together.
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?
Have the client take sips of water to promote insertion of the NG tube into the esophagus.
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?
Remove the stockings at least once per shift.
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?
Lower the client to the floor and place a pad under the client's head.
A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?
Observe the rate, depth, and character of the client's respirations.
Crutch instructions?
Position crutches on unaffected side when sitting or rising from chair---support body weight at the hand grips with elbows flexed 30 degrees
A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?
Oil retention
A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?
"All of this equipment can be frightening."
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
"Client found lying on floor"
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?
"I can take echinacea to improve my immune system."
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?
"I will be sure to remove my hearing aid before taking a shower"
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." which of the following responses should the nurse make?
"People in middle adulthood often find satisfaction in nurturing and guiding young people."
An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?
"Tell me more about how your friends discourage you."
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process.
Compare prescriptions with medications the client received while at the facility.
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
Initiate an enteral feeding through a gastrostomy tube.
The nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take?
Instruct the family to refrain from pushing the button for the client while she is asleep.
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.
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?
Repeat each joint motion five times during each session.
A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?
Romberg test
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?
Ventrogluteal
A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?
WBC 15,000 mm3
A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
Wrap monitoring cords with stockinette and tape them in place.
