ATI Fund. B w/ rationales

a nurse enters a clients room and finds her on the floor. the clients 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?

"Pt. found lying on floor" Rationale: nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed without including opinions or judgements about motives or cause.

Other liquid medication info:

1. Do not transfer to a medication cup if the liquid is prepackaged because it increases the risk of altering the remeasured dose 2. Place pt. in high-fowlers to reduce risk of aspiration 3. do not transfer prepackaged medication to measuring device to reduce risk of altering the remeasured dose

Colorectal precautionary tests

1. Double contrast barium enema- 5 years 2. Colonoscopy- 10 years 3. Sigmoidoscopy- 5 years

Action's to take for NG tube intermittent feedings

1. Head to bed elevated--> priority 2. rinse the feeding bag with water between feedings--> should rinse to reduce risk for bacterial growth. 3. Make sure the enteral formula is at room temp--> needs to be to prevent cramping and discomfort from cold formula. 4. wipe the top of the formula can with alcohol--> remove or disinfect any dirt or organisms that can cause contamination.

All require physicians and surgeons

1. Insert an implanted port 2. close a laceration with sutures 3. place an endotracheal tube

Other precautions and protocols for suctioning secretions from new tracheostomy

1. Pre-oxygenate pt. with 100% oxygen before suctioning to prevent hypoxemia 2. Lubricate the end of the suction catheter with sterile water or sodium chloride irrigation solution to decrease trauma to the mucosa 3. Adjust the suction pressure to 120mmHg and no higher than 150 mmHg to prevent hypoxemia and trauma to mucosa

Principle of autonomy

1. pt. who has a prescription for nasogastric tube refuses it, nurse complies with the pt. wishes; pt. has a right to refuse treatment 2. DNR order requires a request on pt. or pt. power of attorney for health care decisions; enforcing DNR order supports this ethical principle of pt. end of life wishes

IV site indicators:

1. purulent exudate: infection 2. warmth: phlebitis 3. bleeding: anticoagulation

a nurse is calculating a clients fluid intake over the past 8 hours. which of the following items should the nurse plan to document on the clients intake and output record as 120 ml of fluid?

8 oz. of ice chips Rationale: half of the volume of ice chips when calculating intake to account for the air in-between the chips - understand that 4 oz. of liquid water is equal to 120mL of fluid

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 pt. Rationale: only healthcare workers directly caring for pt. should have access to pt. medical information

a nurse is caring for a group of clients on a medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity?

A pt. who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively Rationale: ethical principle of veracity, the nurse must tell the truth at all times and never deceive others

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 pt. who is postoperative Rationale: ambulating pt, is within range of function for an AP; so a nurse can delegate this task since it does not require special skills, assessment, or teaching.

a nurse has just inserted an NG tube for a client. which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus Rationale: an abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement

a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures?

Apply ankle-foot orthotic device to the pt. feet Rationale: use a device to maintain dorsiflexion, like this one or a foot board placed perpendicular to the mattress.

a nurse is caring for a client who has an indwelling urinary catheter. which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine Rationale: pt. who has an indwelling catheter should have continuous urine Flow without an accumulation of urine in bladder; nurse should irrigate the catheter to resolve any existing blockage

a nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. which of the following pieces of information is the priority for the nurse to provide?

Breath Sounds Rationale: use ABC approach to prioritize current status pt.

a nurse is caring for a client who has a prescription for wound irrigation. which of the following actions should the nurse take?a. wear sterile gloves when removing the old dressing

Cleanse the wound from the center outward Rationale: nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface

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 pt. received while at facility Rationale: create a current, accurate list of every medication the pt. should be taking -identify any duplications -any contradictions -addressing and correcting discrepancies -assess and document

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 Rationale: to ensure pt. safety and continuity of care

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 Rationale: indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in lungs, dyspnea, bounding pulse, and increase in BP

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. Rationale: ensure that the medication is mixed together

a nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use?

Have the pt. stand with arms at their sides and feet together Rationale: A Romberg test helps identify alterations in balance. The nurse should have the pt. stand like this to observe for swaying and loss of balance.

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 Rationale: taken to promote immunity and reduce the risk of infection

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 a 7 am and have saved all urine since" Rationale: for 24 hour collection, the pt. should discard first voiding and save all subsequent voiding after. -collect urine free of feces -keep on ice or fridge -no specific amount needed

a 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?a. Instruct the family to refrain from pushing the button for the client while she is asleep.

Instruct the family to refrain from pushing the button for the pt. while she is asleep Rationale: PCA pumps minimize the risk of overdose, toxic effects could still occur if the pt. receives more medication than necessary to control pain

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 Rationale: middle adulthood is generativity vs. self-absorption and stagnation. the focus of this task is on offering support and guidance to future generations; nurse should explore opportunities for mastering the developmental tasks of this stage with pt. ex: volunteering or mentoring young people

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 rationale: require psychomotor skills when learning

a nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

Pt. who has asthma Rationale: some essential oils can cause bronchospasms; the nurse should consult the dr. before using this therapy

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 Rationale: tachycardia indicates fluid volume deficit, which is an expected finding for a pt. who has vomiting and diarrhea for 3 days.

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 Rationale: nurse should select this one to prevent hypoxemia and trauma to the mucosa

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 Rationale: caregivers who insist on staying in the room indicate potential mistreatment of pt. receiving care. Nurse should evaluate pt. for additional signs of abuse

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 required intervention by the charge nurse?

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. Rationale: should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

Cranial nerve V; trigeminal nerve

Touch the face with a cotton ball Rationale: touch pt. corneas with a wisp of cotton to measure light touch and pain across face

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 Rationale: weight bearing exercises are essential for maintaining bone mass, prevents osteoporosis. Walking engages older adult pt. in this preventative therapeutic strategy

a nurse is caring for a client who requires an informed consent for a surgical procedure. which of the following actions is the nurses responsibility?

Witness the pt. signature on the consent form Rationale: only thing the nurse is responsible for; confirm that the pt. appears competent to give consent and that the pt. understands the procedure

physical abuse

affect sensitivity to touch and contradictions with therapeutic touch

Weber test

apply a vibrating tuning fork to pt. forehead Rationale: identify sound lateralization when assessing hearing

phenol solution

clean surfaces contaminated with bacteria and fungi; does not kill c DIFF spores

Neglect

form of abuse or mistreatment that is characterized by omission of necessary care.

Ginkgo biloba

improve memory reduce stress

urine specific gravity of 1.035

indicates urine is concentrated not an indication for irrigation

Contact

infections that spread via direct contact with another person or contact with environment, including vancomycin-resistant enterococci, MRSA and scabies

Evaluating inflammation

perform direct percussion over the area of the kidneys

Position a trochanter roll under pt. hips

place under butt and alongside hips to prevent external rotation of hips while the pt. is supine

Feverfew

promote wound healing decrease inflammation associated with arthritis

Protective environment

pt. who has compromised immune systems: allogenic hematopoietic stem cell transplant

Principle of fidelity

pt. who is about to undergo painful procedure receives pain meds 30 mins before the procedure that the nurse promised to administer; keeping promises

a community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension?

pt. who smokes one pack of cigs each day Rationale: other risks: -pt. 60 years or older -no regular exercise -heavy alcohol consumption

Ginger

relieve nausea vomiting aid in digestion

urine positive for ketones

sign of diabetes mellitus with poor glucose control

urine with unusual odor

sign of infection not an indication for irrigation

DESIRED OVER HAVE METHOD

step 1: units: mL/hr step 2: dose: desired=800 units/hr step 3: dose available: have= 25,000 units step 4: convert the units? no step 5: quantity of dose available: 250mL Step 6: equation and solve for X X= desired x quantity/ have X mL/hr= 800 units/hr x 250 mL/ 25,000 units X mL/hr= 8 mL/hr

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 Rationale: pt. is describing quality of pain, which is how pain feels in pt. own words

Pillow under pt. knee's

used to prevent pressure on the heels

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 shift my weight to my right leg Rationale: to descend stairs, the pt. should first shift body weight to his right, unaffected leg

a nurse is a surgical suite notes documentation on a clients medical record that he has a latex allergy. in preparation for the clients procedure, which of the following precautions should the nurse take?

wrap monitoring cords with stockinette and tape them in place Rationale: many cords contain latex; nurse should prevent any contact of these cords and devices with pt. skin by covering them with a barrier and securing them.

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.)

1. inject 10 units of air into the bottle of NPH insulin 2. inject 5 units of air into the bottle of regular insulin 3. withdraw the correct dose of regular insulin from bottle 4. withdraw correct dose of NPH insulin from bottle

prep for transferring info:

1. rock the pt. up to standing position to generate momentum and reduce nurse workload of lifting 2. pivot on the foot farthest from chair to give pt. room to move; nurse can also use other knee to give pt. weak leg support 3. use gait belt to maintain pt. stability

Other wound irrigation info

1. use 35 mL syringe for safe amount of pressure and for it to be effective 2. warm irrigation solution to body temperature 3. wear clean gloves to remove old dressing

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feedings?

Arrange food in consistent pattern on the pt. plate Rationale: consistency in preparing plates and meals helps to facilitate self-feeding for pt. with vision loss. Staff can describe the location of the food on the plate by using clock pattern, allows for independence during meals.

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 for orthostatic hypotension Rationale: first action is to assess pt. risk for falls, fainting , assisting pt. to is and dangle feet of side of bed. assess dizziness and drop in BP before assissting

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 Rationale: erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown

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 Rationale: water can damage them

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 Rationale: within RN scope of practice for nurses to initiate these feedings through tubes.

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 Rationale: nurse should wear N95 respirator when providing care who requires droplet precautions as a result of TB to prevent transmission of bacteria

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 Rationale: blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as bruit.

a 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 Rationale: blanching, edema, and coolness at the IV site indicate infiltration

a nurse is caring for a client who has a terminal diagnosis and whose health is declining. the client request information about advanced directives. which of the following responses should the nurse make?

We can talk about advance directives, and I can also give you some brochures about them Rationale: nurse offers to provide the information the pt. needs in a direct and simple way

Airborne

infections that spread via droplet nuclei that are smaller than 5 microns: varicella, TB, and measles

PCA pumps info

1. monitor pt. every 1-2 hours during first 12 hours using it for risk for respiratory depression as a result of opioid admin. 2. teach to only activate when it is needed; do not wait until pain is unbearable 3. nurse cannot prescribe the rate and lock-out interval

a client who is non ambulatory notifies the nurse that his trash can is on fire. after the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the pt. Rationale: follow the RACE mnemonic. 1. rescue pt; move to safe area. 2. activate alarm system 3. contain fire; close all doors you can 4. extinguish the fire

a nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make?

Maintain a consistent time to wake up each day Rationale: pt. should maintain consistent time for waking up and going to sleep; this helps establish an internal sense of sleep and waking up on a daily basis and helps maintain it over time; promote sleep for pt.

Ulcerative colitis

contradiction for colonic detoxification

Permanent pacemaker

contradiction for magnet therapy

Exercises and osteoporosis

1. Riding a bicycle - no weight bearing advantages 2. Isometric exercises - no weight bearing 3. high impact aerobics -injure bones that have density loss

Essential Information to know for planning care for pt.

1. admitting diagnosis 2. Body temperature 3. diagnostic tests

Things to know for seizures

1. applying restraints increases risk for injury 2. turn pt. on side so that the tongue does not occlude the airway and so secretions can flow out of the side of mouth 3. inserting any objects into mouth of pt. can increase risk for injury to mucous membranes in mouth and damage teeth

a nurse is providing discharge teaching for 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)

1. check cord routinely for frays or tearing - o2 concentrators require electrical power; assess electrical function of device for safety reasons 2. consider purchasing a generator for power backup - loss of electricity prevents O2 from functioning and could deprive the pt. of necessary O2 3. observe for signs of hypoxia - anxiety, worsening fatigue, dizziness, rapid pulse, and RR, pallor, cyanosis

other enteral feeding info:

1. dissolve each med in 30 mL of warm, sterile water 2. draw up medications separately; do not mix 3. when encountering resistance during administration of meds, nurse should STOP and contact dr.

What interferes with sleep:

1. drinking caffeine before bed, it is a stimulant 2. exercising within 2 hours of bedtime 3. avoid watching TV to reduce stimulation in order to promote rest

Other hearing aid and hearing loss issues

1. fine tuning of volume on behind the ear device 2. physical activity can easily dislodge this type 3. whistling during insertion can mean aid does not fit properly or buildup of ear wax

Fluid volume deficit:

1. hypotension 2. dehydration 3. dry mucous membranes 4. sunken eyeballs 5. weak, thready pulse 6. increased hematocrit 7. urine specific gravity 8. slow cap. refill

Nurses tasks only (no AP)

1. inserting indwelling catheter -sterile technique 2.demonstrating use of IS to pt. - requires nursing knowledge and is outside AP range 3. confirming pt. pain has decreased after receiving analgesics - evaluating pain level requires advanced judgment

other crutches info:

1. place crutches 15 cm in front and to the side of each foot 2. before sitting, the pt. should hold both crutches by their hand bars in one hand 3. to avoid injury to underlying nerves, shoulder rests should be at least 2.5- cm below axillae

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.)

1. place the pt. in a room with negative air flow - airborne precautions 2. wear gloves when assisting with oral care. - must wear gloves when hands could come in contact with bodily fluids like saliva and mucous membranes. 3. Use antimicrobial sanitizer for Hand hygiene - routine hand hygiene and should also wash visibly soiled hands

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 Rationale: ABC method is priority auscultate for monitoring of fluid volume excess complication of IV therapy manifestations: fluid volume excess include moist crackles in lung fields, SOB

a nurse is admitting a client who has rubella. which of the following types of transmission-based precautions should the nurse initiate?

Droplet Rationale: required for pt. who have infections that spread via droplet nuclei and are larger than 5 microns in diameter: flu, rubella, pneumonia, and strep pharyngitis

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 Rationale: flush feeding tube with 15-30mL of sterile water before administering and between each medication. -flush with 30-60 mL of sterile water following the last medication

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 Rationale: nurses are responsible for ensuring family members wear a gown and gloves to prevent the transmission of c DIFF spores

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 pt. use a trapeze bar when changing positions Rationale: to assist with repositioning and transferring, the pt. avoids the friction and shearing that result from sliding up and down in bed. shearing is a risk factor for pressure-injury

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?

Medication Dose Rationale: the prescription dose is not complete. the number 0.25 should be followed by unit of measurement (mg or mL)

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?A) Rinse the feeding bag with water between feedings.B) Tell the client to keep the head of the bed elevated at least 30°.

Tell the pt. to keep the head of the bed elevated at least 30 degrees. Rationale: use ABC approach to prevent aspirations of the enteral formula; this is priority to keep the head of bed elevated to prevent reflux of the formula into the esophagus.

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? Rationale: might prompt pt.to review their life and question the meaning; manifestation of pt. distress is asking why this illness is happening to them

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 Rationale: principle of autonomy ensures that a pt. who is competent has the right to refuse treatment

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 clients plan of care?

Wrap blankets around all four sides of the bed Rationale: affix linens or blankets around the head, foot. and side rails f the bed to pad them and prevent injury

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 Rationale: colorectal cancer screening for pt. who are at average risk begins at age 50; one option for screening is fecal occult blood test annually.

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 vaccine when you are 65 years old Rationale: receive one of two vaccines when they are 65 years old -can be given to 19 year olds who have certain conditions: chronic heart, Lung, liver diseases, diabetes mellitus, alcohol disease, smokers

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.) RATIO AND PROPORTION METHOD:

step 1: unit of measurement: mL/hr step 2: what is the dose the nurse should give: desired= 800 units/hr step 3: dose available: have=25,000 units step 4: should nurse convert the units of measurement: no step 5: quantity of dose: 250 mL step 6: set up an equation and solve for X: have/quantity= desired/X 25,000 units/ 250mL= 800 units/hr/ XmL X mL/hr = 8mL/hr step 7: round if needed step 8: determine if the amount to administer makes sense; set infusion pump to administer 8 mL/hr