ATI Funds
dysphagia following CVA. Which action
offer tart or sour foods first
which muscle group is responsible for movement at knee joint
antagonist
client has dysrhythmia. Assessment technique for pulse deficit
apical and radial rates simultaneously
ultrasound bladder scanner
apply light pressure to scanner head
Eye drops for glaucoma
apply pressure to the puncta
which of the following environments should the nurse manager identify as an acceptable place for discussing clients' info
areas with no public access
client requires ventilatory assistance which part of brain in injured
brainstem
client who asks the nurse to leave the medication at bedside. Which response
call me when you are ready, and i will return with the medication
progress toward which of the following developmental tasks
ceasing to compare personal identity with others
difficulty in muscle coordination indicates injury to which area
cerebellum
Implementing cold therapy for client with ankle sprain
check cap refill before applying an ice pack
client is receiving TPN, Which action?
check client's capillary BG Q4h
after admin tuberculin skin test
circle injection area w a pen
Proper care to a client who has a new colostomy
cleanse the skin around stoma w warm water
Teaching about straight-legged cane
client holds cane of unaffected side
Supination of the hand
client holds hand with the palm up
right sided weakness ambulating using cane
client keeps 2 points of support on the ground
Which client should be seen first with O2 therapy
client who has heart failure and is receiving 100% o2
4 clients which should nurse see first
client who is 2 days postoperative following a colectomy due to colorectal cancer and has an stony bag full of red bloody drainage
Admission interview with a client. Which should nurse collect during introductory phase
client's level of comfort and ability participate in the interview
Clients 65 years and older about pain management
clients are reluctant to report pain
imminent death
cold extremities
wound should be cleansed n which of the following directions
from the wound toward the surrounding skin
Braden scale to predict risk of pressure ulcer
nutriton
client reports SOB and requests help in changing positions
observe rate depth of resps
Infant's expected physical development during the first year of life
10 month infant can pull up to standing position
500 calories more per day how long to gain 10 lbs
10 weeks
1+ pedal edema bilaterally size
2 mm
Admin oral phenytoin who has seizure disorder.
Check the med dose and client's identification
A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify contributing
Client watches TV in bed during day
A nurse is planning care for a client who has a prescription for collection of sputum specimen for culture and sensitivity.
Collect specimen in the morning
AP how to obtain a capillary finger-stick blood sample. Which action intervene
Elevating finger above heart level
Client has hearing impairment. Which interventions should nurse use
Face the client when speaking
2 Penrose drains near an abdominal incision. Which adhering device?
Montgomery straps
RDA definitions
RDA defines the level of nutrient intake that meets the needs of healthy people in various groups
NPWT Order
Turn off vacuum, Remove soiled dressing, apply sterile gloves/irrigate, Apply skin protectant, place prepared foam, connect tubing
by asking the client to stick out his tongue which of the following cranial nerves is tested
XII
tap water enema
left sims
Sign client has developed delirium
reduced LOC
abdominal assessment, Which following positions should nurse tell client to assume
supine
Straight urinary catheterization for female client who has urinary retention
wiping labia minora in an anteroposterior direction
test ROM motions of wrist
with palm facing down, move wrist sideways towards thumb
BG glucose procedure but does not obtain an adequate amount of blood.Which action
wrap the client's finger in a warm washcloth
pH of gastric fluid to confirm placement of NG tube
2
One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which action
Accompany client bac to room
Client is restless and sports severe pain but refuses the prescribed opioid pain medication
Ask why client is refusing
VerifyNG tube placement
CXR, measure length of exposed tube, determine ph of aspirated fluid
During the completion of a health hx w a nurse, a client reports intermittent chest pain for the past week
Can you tell me what the pain felt like and show me exactly where it was
NG Tube actions
Coat tip, ask the client to swallow, tell client to tilt her head back
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated
Cover incision with moist sterile dressing
A nurse is caring for a client who is unstable and has vital signs measured Q15 Minutes. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?
Disconnect the machine and measure the BP manually every 15 minutes
HOB elevated 45 angle w knees flexed. which position?
Fowlers
communicates unmet spiritual need. which indicates spiritual distress
God is punishing me
dehydration who has developed hypovolemic shock. Which lab value reflects
Hct 55%
Inhaler steps
Hold mouthpiece, tilt head back, depress canister, hold breath
Vaginal hysterectomy and asks for a drink.
I am going to listen to your abdomen
injuries resulting from a motor-vehicle crash. Which statement
I can't sleep well bc whenever i move in my sleep the pain wakes me up
Erickson's developmental task for college students
I go home on weekends to be with my family because I do not have any good friends her on campus
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer
I keep having nightmares about my upcoming surgery
Older adults about age-related changes Which of the following statements indicates effective teaching
I should expect my heart rate to take longer to return to normal after exercise
Removing sutures from a client's laceration
I will clip each suture close to the skin and pull it though the other side
Teaching about proper use of albuterol inhaler. Which shows understanding
I will shake the inhaler well right before i use it
Nurse is caring for a client who requires a CXR. Prior to the client being transported what should nurse do
Identify using 2 identifies
client who is 48 hr postop following small bowel resection. Reports gas pains in the periumbilical area
Impaired peristalsis of intestines
A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis.
Increased BP
Admin Assessment. Which reflects the communication technique of clarifying
It sounds like your pain is intermittent
Adverse side affect for acetaminophen
Liver damage
A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside
Lower client to the floor
Pt has tracheostomy and gastrostomy tube for enteral feeding.
New prescriptions, ABG results, tracheal secretion characteristics
Charge nurse is observing newly licensed nurse perform teach care. Which requires intervention
Obtaining cotton balls
Client's son who serves as primary care giver is "exhausted" from working part time
Respite care
Delegation. Axillary temp, wanted oral, which of the following rights of delegation should have prevented?
Right communication
A nurse is caring for a client who has bilateral casts on her hands. Action with feeding
Sit at the bedside while feeding the client
Endotracheal tube. Inflating the cuff doses what
Stabilizes position, preventing aspirations of secretions, preventing air leaks
Caring for a client who is at risk of experience seizures. Which of the following pieces of equipment must be available at the client's beside
Suction equipment
A nurse in the ER is caring for a client who has abdominal trauma. Which of the following assessment findings indicates hypovolemic shock
Tachycardia
A nurse is caring for a client who reports using several herbal medicines
Verify herbal supplements do not interact with meds
PostOP and has paralytic ileus. Which of the following abdominal assessments should nurse do
absent bowel sounds with distention
Clients acquire HAI. Which of the following routes of infection should the manager identify as iatrogenic
acquired from diagnostic procedure
child who is postop following tonsillectomy
admin analgesic to the child on a routine schedule throughout the day and night
dysphagia at meal time
advise client to tuck chin downward
Rinne test
air conduction is less than bone conduction in left ear
MRSA infection. Precautions
don glove when entering and use sanitizer when exiting
client expresses concern about risk of acquiring infection from the blood transfusion
donate autologous blood before surgery
which clear liquid food
gelatin
swabbing form least contamination to greater contamination
keeping microorganisms from entering the wound
Various dietary practices
kosher diets have restrictions regarding how the food must be prepared
incomplete protein
lentils
which neuro test assesses balance
romberg
Auscultate the aortic valve
second intercostal space to the right of the sternum
pt is unconscious and family members answers question
secondary source data
overweight IM injection
side hip between iliac crest and anterior iliac spine
nurse is witnessing a client sign an informed consent. Nurse's role
signature on the preoperative consent form is the client's
what should nurse do when client is crying
sit and hold clients hand
child temp source
temporal
Middle aged female client dx test
eye exam every 2 years
impaired skin integrity
faint pedal pulses
In service about nutrition. Which should be included
fats provide energy
ice bag for ankle following sports injury
fill bag with 2/3 full of ice
Post ob arthroplasty
foot and leg excerises every 1-2 hurst's while awake to rent thrombophlebitis
experiencing obstruction to flow of vitreous humor in the eye
glaucoma
healing by secondary intention
granulation tissue fills the wound during healing
Pt reports flank pain, and reddish brown urine
hemolytic
recovering from gallbladder surgery how to use incentive spirometer
hold breath for 5 sec after goal volume is reached
Admin otic antibiotic
hold dropper 1cm above ear canal
changing bed linens for a client who is on bed rest
hold linens away from the body and clothing
admin liquid med from bottle
hold med bottle with the label against the palm of the hand
stage II pressure ulcer
hydrocolloid
Caring for a client who has tracheostomy and requires suctioning
hyper oxygenate the client before suctioning
A nurse is caring for a client who has a gastric ulcer, the nurse should explain that prolong exposure of the body to stress can also cause which of the following to occur
hyperglycemia
Pt understands PCA instructions
i can still use my transcutaneous electric nerve stimulation unit wile pushing PCA button
who has lower back pain about heat therapy
i need to place a towel between the heating pad and my skin
Erickson's developmental tsk for middle aged client
i think i have done a good job with my children since they are all independent now
His partner who has been caring for him at home is embarrassed and apologizes for the smell
it must be difficult to care for someone who is confined to bed
religious practices to newly licensed nurse
judaism stay with the body of deceased until burial
My child has suddenly become disinterested in certain foods
keep diary of foods your child eats each day
Teaching about crutches who has fractured right foot
keep rubber crutch tips securely in place
WBC count of 3600
leukopenia
Client who has measles. Which transmission precaution?
airborne
client arrives postop from post anesthesia unit
airway
which lab value indicates adequate protein uptake and synthesis
albumin
eye pain from sawing wood
ask about first aid at the scene
administering a controlled substance
asking other nurse to observe the disposal
beginning therapeutic relationship with a client. Therapeutic communication though active listening
assume open position
assessing client's vascular system
auscultation of the arteries for bruits with the bell of the stethoscope
bicep reflex as 2+, which document
average
lower extremity weakness how to use a 4 point crutch gait.
bear weight on both of your legs
palpate posterior tibial pulse
below the medial malleolus
Foods high in fiber
black beans, whole grain bread
Radial pulses 4+ bilateral is what quality
bounding
testing trigeminal nerve equipment
cotton wisps
which of the following concepts of death should the nurse consider for this client
death is viewed as an interruption of what might have been
which is risk for developing complicated grief
death was sudden
Client has calcium of 12.7
depressed deep tendon reflexes
Client understands full impact of diagnosis. which stages of dying
depression
BMI 29 and expresses a desire to lose weight
determine client's intention to change current eating habits
instilling eyedrops
drop eye med in lower conjunctival sac
protein calorie malnourishment
dry brittle hair, edema, poor wound healing
Document of who can make health care decisions for me when i am not able
durable power of attorney document
IV therapy via peripheral catheter. Identify as infiltration
edema at infusion site
New licensed nurse is admin meds. Notes an unfamiliar medication. Which action
Consult medication reference book available on unit
Insert nasogastric tube for a client after explaining the procedure. Clint states "you are not putting that hose down my throat"
I can see that this is upsetting you
Digital removal of the mass, which type of enema
oil retention
NG tube POC
oral hygiene, measure drainage, secure NG tube to client's gown
client uses ASL. Which action
pace speech to allow time for the interpreter to convey the words
nurse is performing physical exam How to evaluate skin moisture
palpation
Auscultates high-pitched scratching sound during both systole and diastole with diaphragm of stethoscope at left sternal border
pericardial friction rub
Obtaining objective data about a client. which method
physical examination
preparing to remove an NG tube for client who had partial colectomy
pinch NG tube while removing
BP cuff in lower extremity
place bladder of cuff over the posterior aspect of the thigh
Oral care for unconscious pt
place client in lateral position with head turned to the side before beginning the procedure
physiotherapy for client who has left lobe atelactisis
place client in trendelenburg
A home health nurse enters a client's home and fins a used insulin syringe without a cap on the table. Which action
place syringe in a puncture proof disposal
splinting abdominal incision
place the client in a supine position, cover the wound and intestine, monitor the client for manifestations
Dextran is what functional classification
plasma volume expander
A nurse is preparing to perform a postural drainage. Which action
position the client for drainage of secretions by gravity
Training session about nutrition
protein serves a san energy source when other sources are inadequate
Enteral feedings though an NG tube. Specific gravity of the client's urine is 1.035
provide more water
which pt can the nurse delegate to AP
provide oral care to a client who cannot take oral fluids
Nurse is inserting NG tube into a client who begins to cough and gag. Which action?
pull back NG tube slightly
client begins to cough who has tracheostomy
pull suction catheter back 1 cm
3 days postop following cholecystectomy. Yellow thick draining is
purulent exudate
IV site is red and feels warm
remove IV catheter
PROM motions
repeat each joint motion 5x each session
client with NG tube develop diarrhea
request a prescription for an isotonic enteral nutrition formula
nurse is preparing to admin unit of packed RBCs and discovers IV line is no longer patent which action
return blood to laboratory
neurological assessment of a client. To promote safety the nurse stands nearby the client follows the instruction for which test
romberg
older adult has constipation
sit on toilet 30 mins after eating a meal
Examining signs of costovertebral angle tenderness. Which position
sitting
which organ loses 500-600 ml of fluid
skin
evaluating client's use of crutches. Which is safe
slightly flexed elbows when ambulating w crutches
Tracheostomy care
soak inner cannula of the tracheotomy tube in NS
client who has peripheral edema, Which nutrient regulates extracellular fluid volume
sodium
which lab report can cause confusion
sodium 123
expected lab report of fever and watery diarrhea
sodium 150
Which inter-professional team to evaluate the client for dysphagia
speech-language pathologist
client who has xerostomia with lack of saliva
starch
prescription to administer the medication once and ASAP
stat prescription
neurological exam, nurse instructs a client to keep his eyes closed and places an object on hand and is asked to identify
stereognosis
sign of infiltration at IV infusion site
taut skin round IV catheter site and cool to touch
102.6, 105/min, overdue menses
temperature
type 2 DM. Expresses concerns about preparing appropriate diet
the dietitian will help you chose foods you are used to that also meet your health needs
Which of the following facts is most important in determining the clients ability to lean new dietary habits
the involvement of the client in planning the change
assessing thyroid gland
tilt head back and swallow
AP proper hand hygiene
times i should use soap and water rather than alcohol based
urinary incontinence about bladder retraining
try to block urge to urinarte until the next scheduled time
admitted to long-term care facility for rehab after total hip arthroplasty
upon client's admission to care facility
Nurse is planning to administer pain med to client following abdominal surgery. Which action
use pain scale to determine pain level
IM injection to 5 moth infant
vastus lateralis
injection site to young adult client
ventrogluteal
expected lung sounds
vesicular
Promote healing and fight infection vitamins
vitamin C and zinc
irrigate a client's wound. Which action
warm the irrigating solution to 37 degrees
recovering from lung cancer, Which lower intensity activities of daily living
washing dishes
Middle aged adult future plans Erickson's developmental task
we miss our daughter so much that we are going to move closer
C Diff contact isolation
wear gloves when changing client's gown
spiritual assessment of a client
what is your source strength and hope
client lacks vitamin D
whole milk
Erkinson's developmental task of intimacy vs. isolation is which stage
young adulthood
eye irrigation for a client who was exposed to smoke and ash
exert pressure on the bony prominences when holding eyelids open
Mastectomy self suction drainage evacuator
collapse the device to remove air after emptying
Piaget's Theory of Cognitive Development
collecting and trading game cards
meds to unconscious. MAR to do what
compare med record number and name on MAR with id band
nurse suspects strabismus
corneal light reflex
provide health promotion activities for group of clients in community. Which is primary prevention
education about immunization
NG tube for intermittent enteral feedings. Which action
elevate 45 before feeding
identifies phonic over trachea and bronchi
encourage client to cough
client asks questions about religion beliefs
encourage the client to express thought abut death and dying
crainiotomy. during planning phase which action
establish outcomes
What finding indicates toddler has airway obstruction
inability to cry or speak
nutritious diets to adult women
include 2.5 cups of veggies in daily diet
fight or flight response
increased BP
indication of FVD
increased HR
teaching group of young adults. which is expected developmental task
independent moral development
cleansing enema to client scheduled for dx procedure. which action
insert tip of tubing 8 cm
timolol eye drops by looking at ceiling
instruct the client to apply pressure to the inside corner of the eye after instillation
Cop asks about inmate laceration and HIV infection
instructions guard to ask the inmate
Terminal illness, Nurse understands family-centered care
lets set up a meeting time with the doctor to sinus your options
anorexia and nausea due to cancer treatment
limit drinking liquids with food
Which of the following concepts should the nurse and client discuss in the termination phase of the relationship
loss
client who no longer requires care. which concert in termination phase
loss
Client who starts to experience a seizure while sitting in a chair. Which action
lower client to floor and place pad underneath head
Nurse should use percussion to examine what body part
lungs
when planning care for a client that is culturally congruent
meaning of disease can vary widely across cultures
radial pulse is 55/min, Which action
measure the client's apical pulse rate
sedentary job
metabolic rate could decrease
Change hospital gown with IV infusion
remove sleeve of the gown form the arm WITHOUT the iv line