ATI exam 1 prep

A nurse in a long-term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which the nurse should perform the following steps 1. Place a name tag on the body 2. Obtain the pronouncement of death from the provider 3. Remove the tubes and indwelling lines 4. Wash the clients body 5. Ask the clients family member if they would like to view the body

2,3,4,5,1

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 in form the client that this condition is a contraindication for which of the following therapies? 1. Biofeedback 2. Aloe 3. Feverfew 4. Acupuncture

4. Accupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients care, when should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. After consulting with the client's family

A. Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A. Remove the outer cannula cautiously for routine cleaning. B. Use tracheostomy covers when outdoors.

Answer: B Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles. A. The outer cannula stabilizes the airway; therefore, the client should never remove it for cleaning.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? A. We would consult the person appointed by your healthcare proxy to make decisions. B. We would give you oxygen through a a tube in your nose.

Answer: B is not considered a resuscitative measure

A nurse is caring for a client who has pharyngeal diptheria. Which of the following types of transmission precautions should the nurse initiate? A. Contact B. Droplet C. Airborne D. Protective

B. Droplet

A nurse is initiating a protective environment for a client who had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A. Make sure the client's room has at least six air exchanges per hour. B . Make sure the client wears a mask when outside her room if there is construction in the area. C. Place the client in a private room with negative-pressure airflow. D. Wear an N95 respirator when giving the client direct care.

B. Make sure the client wears a mask when outside her room if there is construction in the area. (to protect from pathogens in the environment)

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? A. Insert the catheter at a 45° angle. B. Place the client's arm in a dependent position. C. Shave excess hair from the insertion site. D. Initiate IV therapy in the veins of the hand.

B. Place client's arm in a dependent position.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. Verify the clients name on their ID bracelet with medication administration record. C. Compare the client's home medication with the provider's prescriptions.

C. Compare the client's home medication with the provider's prescriptions.

A nurse is administering 1 L of 0.9% Sodium Chloride to client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that treatment is successful? A. Increase in hematocrit B. Increase in RR C. Decrease HR D. Decrease cap refill time

C. Decrease HR Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A. combine client care tasks when caring for multiple clients B. wait until the end of the shift to document client care C. use the planning step of the nursing process to prioritize client care delivery D. allow for interruption in tasks to discuss client care issues with colleagues

C. Use the planning step of the nursing process to prioritize client care delivery.

A nurse is caring fro a client who is postoperative and has signs of hemorrhagic shock. when the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. from a legal perspective, which of the following actions should the nurse take next? A. document provider's statement in the medical record B. complete and incident report C consult the facility's risk manager D. notify the nurse manager

D. Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. Bun 15 mg/dL (10-20) B. Creatinine 0.8 mg/dL (0.5-1.1) C. Sodium 143 mEq/L (135-145) D. Potassium 5.4 mEq/L (3.5-5)

D. Potassium

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? Lacrimal apparatus Pupil clarity Appearance of bulbar conjunctivae Visual fields Visual acuity

Pupil clarity Visual fields Visual acuity

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of beath and has noisy respirations from secretion in the airway. Which of the following actions should the nurse take? A. Turn client every 2 hours. C. Hold oral care.

A. turn every 2 hours The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.

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? B. Instill 15 mL of irrigation fluid into the catheter with each flush. C. Subtract the amount of irrigant used from client's urine output. D. Perform irrigation using a 20 mL syringe

Answer: C B. Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid. D. The nurse should use a 30- to 50-mL syringe to perform open irrigation.

A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid

Answer: D A. Alginate- treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. B. Gauze- Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. C. Transparent-Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. D. Hydrocolloid- promote healing in stage 2 pressure injuries by creating a moist wound bed.

Day 1:Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2:IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.

Stop the IV infusion is correct. The client has manifestations of IV infiltration. The nurse should stop the IV infusion and remove the IV catheter to reduce the risk for tissue damage. Elevate the client's left arm is correct. The nurse should elevate the client's left hand to decrease swelling and reduce the risk for tissue damage. Apply heat to the client's left hand is correct. The nurse should apply heat to the client's left hand to reduce swelling and promote comfort. Place a pressure dressing over the IV site is incorrect. The nurse should not apply pressure to the IV site, because this can cause tissue damage. Start a new IV in the client's left hand is incorrect. The nurse should start a new IV in a different extremity to reduce the risk of tissue damage.

Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed. SATA A. Wear an N95 mask when caring for the client is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. B. Place a container for soiled linens inside the client's room C. Place the client in a negative airflow room D. Remove mask after exiting the client's room. E. Wear a sterile, water-resistant gown

Wear an N95 mask when caring for the client is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection. Place the client in a negative airflow room is correct. The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system. Remove mask after exiting the client's room is correct. The nurse should remove their mask after leaving the room of a client who is in airborne precautions for tuberculosis to prevent exposure to the infection. Wear a sterile, water-resistant gown if within 3 feet of the client is incorrect. The nurse should identify that the client has tuberculosis, which requires airborne precautions. Sterile gowns are not indicated when caring for a client who is in airborne precautions. Water-resistant gowns are only indicated if there is a likelihood of contact with the client's body fluids.