ATI FUNDS Practice A Review
tertiary prevention
focuses on the rehabilitation and restoration of the clients optimal level of functioning. ex rehabilitation therapy
partner
A patients _______________ can sign a consent form only if the client is unable or incompetent to do so.
weight gain of more then ___________ in 24hrs, for a client on continuous enteral feedings, is a manifestation of fluid volume excess and places the client at risk for heart failure
0.91 kg (2lbs)
The nurse should report gastric residual of greater than ________________ for a client who is receiving continuous enteral feedings?
100 mL
HCO3- ref range
21-28 mEq/L
PaCO2 ref range
35-45 mm Hg
Blood glucose range
74 to 106 mg/dL
PaO2 ref range
80-100 mm Hg
Client self determination
An ethical principle in social work that recognizes the rights and need of clients to be free to make their own choices and decisions.
LDL aka
bad cholesterol
A nurse is providing teaching to a client who has severe weakness in their right lower extremity and is learning to walk using a cane. Which of the following actions by the client indicates an understanding of the teaching? a. the client moves the cane forward before taking a step b. the client holds the cane on their weaker side c. the client moves their stronger leg before moving their weaker leg d. the client keeps their elbow straight when holding on to the cane
CORRECT: a. the client moves the cane forward before taking a step - the client should move the cane forward about 15-30cm (6in to 1ft) before taking a step with the weaker leg to maintain stability INCORRECT: b. the client holds the cane on their weaker side - the client should hold the cane on their stronger side to obtain maximum support and correct body alignment c. the client moves their stronger leg before moving their weaker leg - the client should move their weaker leg before moving their stronger leg to maintain stability d. the client keeps their elbow straight when holding on to the cane - the client should flex their elbow slightly while using the cane to maintain correct body alignment
A nurse is performing a preoperative assessment on four clients. The nurse should identify that which of the following clients is at risk for a latex allergy? a. a client who has an allergy to walnuts b. a client who has spina bifida c. a client who has a family history of malignant hyperthermia d. a client who has a history of smoking
CORRECT: b. a client who has a spina bifida REASON: a client who has spina bifida is at risk for a latex allergy because of their history of frequent contact with latex products, such as urinary catheters. The nurse should use latex-free products to reduce the risk for a hypersensitivity reaction.
A nurse is completing an informed consent document for a 16-year-old adolescent who is married and is scheduled for an emergency appendectomy. Which of the following actions should the nurse take? a. Locate the adolescents partner to sign the form prior to the appendectomy. b. Document that consent is implied due to the urgency of the procedure c. Tell the client that a general consent to treatment covers the surgical procedure. d. Ask the client if they understand the providers plan for the appendectomy.
CORRECT: c. Ask the client if they understand the providers plan for the appendectomy. -REASON- to ensure informed consent, the nurse should ask the client if they understand the planned procedure. In most states, a married adolescent is considered emancipated, and has the legal authority to provide their own consent.
A nurse is reviewing the medical record for a client who is receiving continuous enteral feedings. Which of the following findings should the nurse report to the provider? a. Gastric residual of 50 mL b. Weight gain of 0.23 kg (0.5) lb in 24hrs c. Blood glucose of 105 mg/dL d. Gastric aspirate pH of 7
CORRECT: d. Gastric aspirate of pH of 7 REASON: the nurse should identify that a gastric ph of 7 is an indication thenasogastric tube is not in the stomach. Gastric pH is usually between 1-4 but can be up to 6, if the client receives a medication that alters the gastric pH. The client is at risk for aspiration and the nurse should report this finding to the provider.
The nurse at a community health center is teaching a group of clients about the use of aromatherapy. The nurse should include in the teaching that which essential oil is used to alleviate swollen joints?
Chamomile
General Consent to Tx
Does not address invasive and high-risk procedures
A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse include int he plan to decrease the clients risk for venous stasis?
Instruct the client to elevate her legs when sitting in a chair - to prevent pooling and clotting of the blood in the lower extremities
A charge nurse is delegating tasks for four clients. Which of the following tasks should the nurse delegate tot he assistive personnel (AP)?
Prepare the room for a client who requires seizure precautions Reason: An AP can set up a room with equipment a client requires for seizure precautions because the necessary equipment is the same for each client.
Primary prevention
focuses on decreasing the clients risk or exposure. ex immunizations, genetic screening
secondary prevention
focuses on early detection of a disease and interventions to provide prompt treatment of disease. ex: hypertension screening
Implied consent
______________ ___________is used for noninvasive procedures, such as obtaining vital signs, in which the client allows the action to take place
high gastric residual
can indicate delayed gastric emptying and increases the clients risk for aspiration
when caring for a client with fecal incontinence
clean the least contaminated area first and then the least so buttocks and then anus
venous stasis
condition of slow blood flow in the veins
Lavendar
essential oil that can be used for calming effect or as a sedative to alleviate insomnia
Sage
essential oil that can be used to minimize gastrointestinal distress, to alleviate discomfort in the mouth and throat, and as a supplement to help treat depression
Jasmine
essential oil that can be used to stimulate mood or alleviate menstrual cramps and lower back pain
Chamomile
essential oil that has anti-inflammatory properties that can be used to alleviate swollen joints and muscle aches
Breast exam
every 3yrs until age 39 and then annually as part of cancer detection.
cholesterol screening
every 5 years for young adults or more frequently if their results are above the expected ref range
Uritcaria
hives
safety data sheets (SDSs)
information about cleaning up chemical spills. Provides info about the process for cleaning up specific materials as well as first aid guidelines in the event of exposure
TB test
instruct young adult clients to have this every 2 years unless at high risk
NPH insulin
intermediate-acting insulin
LDL 170 mg/dL
is above the expected reference range and places the client at increased risk for heart disease; the nurse should report this result to the provider
incident report
is required for a circumstance that leads to injury or poses a risk of injury to a client. ex. when a provider prescribes a medication to a client who has a known allergy to that Rx, even if the Rx was not administered
a client who is allergic to bananas, chestnuts, strawberries, and kiwi fruit is at risk for developing a cross-sensitivity to _________________
latex
LDL ref range
less than 100mg/dL= Optimal 100-129mg/dL= near optimal/above optimal 130-159mg/dL= borderline high 160-189mg/dL= high
cranial nerve III
oculomotor nerve - check by checking pupils reaction to light and by using a penlight
PCA pump
patient controlled analgesic administered intravenously with a machine
dorsal recumbent position
position where the pt lies on the back with the lower extremities moderately flexed and rotated outward. ex vaginal exam
_______________ should be withheld and not given if the patients heart rate is less than 50/min.
propranolol
a client who has a history of smoking is at risk for _____________ _____________ with anesthesia
pulmonary complications
Regular insulin
rapid-acting insulin
telecommunication device
requires a computer and printer to transfer typed words over the telephone. both sender and receiver need the device
guaiac stool test
screens for colon cancer. Clients should not consume citrus fruits or juices for 3 days prior to this test because Vit C can produce a false negative result.
4 months
the age when an infant is expected to be able to sit up with support and should have no head lag when sitting
9 months
the age when an infant is expected to creep on their hands and knees
9 months
the age when an infant is expected to use the pincher grasp
12 months
the age when an infant is expected to use utensils to feed themselves
allergic transfusion reactions
urticaria, flushing of the face, and itching of skin
Gastric pH
usually between 1-4 but can be up to 6
baseline ECG
young adult clients should schedule this at age 35
