ATI questions - Exam

A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take? A. Initiate NPO status for the adolescent B. Place the adolescent in a supine position C. Place a moist, warm pack on the adolescent's lower back D. Apply a eutectic mixture of local anesthetics (EMLA) to the adolescent's puncture site

: B. Place the adolescent in a supine position The nurse should place the adolescent in a supine position for 30 minutes to 1 hour following a lumbar puncture to decrease the risk of a post-dural puncture headache. Incorrect Answers: A. The nurse should encourage the adolescent to consume fluids following a lumbar puncture to promote replacement of cerebrospinal fluid. C. The nurse should assist the provider in applying an adhesive bandage to the puncture site following the procedure. The nurse should avoid the application of heat because it promotes blood flow to the site, which increases the client's risk for bleeding. D. The nurse should apply EMLA cream to the puncture site at least 1 hour prior to the lumbar puncture to decrease the adolescent's pain during the procedure.

A nurse is preparing a client for a lumbar puncture. The client has signed the consent form but tells the nurse that she does not remember what the doctor will do during the procedure. Which of the following actions should the nurse take? A. Page the provider stat to come and explain the procedure to the client. B. Remind the client that the doctor will insert a needle to get a sample of fluid from her spine. C. Explain how the assistant will position the client for the procedure. D. Tell the client that someone will explain the procedure when it is time to begin. Correct

B. Remind the client that the doctor will insert a needle to get a sample of fluid from her spine.

A nurse is caring for a client who is postoperative following a lumbar disk excision. Which of the following interventions should the nurse include in the client's plan of care? A. Keep the client's legs flat with the knees extended Encourage the client to sit up in a chair for as long as possible C. Logroll the client in bed for care procedures D. Expect urinary retention for the first postoperative day

C. Logroll the client in bed for care procedures The client should receive instructions about logrolling preoperatively. The nurse may need to engage other staff members in assisting with logrolling to maintain proper alignment of the client's spine at all times postoperatively. Incorrect Answers: A. The client's knees should be in a position of slight flexion to help relax the back muscles. B. Except while defecating, the client should avoid sitting in the immediate postoperative period. D. Urinary retention is an indication of neurological deterioration following a laminectomy. The nurse should report this finding to the surgeon immediately.

A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make? A. "I will give you an antibiotic before your procedure." B. "I will place you on your side during the procedure." C. "You might have a headache following the procedure." D. "I will place a pressure dressing over the area following the procedure.

D. "I will place a pressure dressing over the area following the procedure." Applying a pressure dressing over the area following the procedure helps prevent bleeding from the site. Incorrect Answers: A. The child should not receive an antibiotic prior to a bone marrow biopsy because the use of an antibiotic might skew the test results. B. The child should be in the prone position because the provider will obtain the specimen from the iliac crest. C. Bone marrow aspiration will not affect the brain or its fluids. Lumbar punctures are likely to cause headaches.

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting edema in lower extremities D. Lower back discomfort

D. Lower back discomfort An abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back pain and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain. Incorrect Answers: A. The nurse should assess for mid or lower abdominal pain to the left of the midline because of the enlarged artery mass. B. The nurse should auscultate for a bruit heard over the location of the mass. C. Pitting edema is a manifestation of heart failure. This is not an assessment expected with an abdominal aortic aneurysm.

A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? A. Side-lying B. Semi-recumbent C. Flexed sitting D. Supine

D. Supine The client should be placed in the supine position, with the legs in a frog position. Incorrect Answers: A. The side-lying position may be used during a lumbar puncture. B. A semi-recumbent position is used when performing a gavage feeding. The client's head and chest should be elevated. C. The flexed sitting position may be used during a lu

A nurse is caring for several clients who require diagnostic testing and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse direct the AP to perform first? A. Change the transparent dressing on a client who has a stage 2 pressure ulcer B. Bring a pitcher of fresh water to a client who has just had a lumbar puncture C. Transport a client to the radiology department for a routine chest X-ray D. Take an arterial blood gas specimen to the laboratory

Take an arterial blood gas specimen to the laboratory Arterial blood gas specimens are placed on ice and must be transported to the laboratory immediately to prevent degradation of the sample. Since this task needs to be done within a specified timeframe, it is the first task the AP should perform.

A client is scheduled for a lumbar puncture to rule out bacterial meningitis. She tells the nurse that she is fearful of becoming paralyzed from the needle placement in her spinal column. Which of the following responses should the nurse offer? A. "Let's not focus on the negative. Let's focus on getting better." B. "Why are you feeling so anxious about this procedure?" C. "The needle is inserted below the third lumbar vertebrae, which is well below the point at which the spinal cord ends." D. "Your doctor is very skilled at this procedure. Everything will be all right."

"The needle is inserted below the third lumbar vertebrae, which is well below the point at which the spinal cord ends." This therapeutic response provides information that specifically addresses the client's concerns and helps decrease anxiety and fears.