ATI Fundamentals Practice Exam A

A nurse is caring for a client who has pneumonia: Exhibit 1: Vitals Signs 0800: Heart Rate 109/min Respirations 26/min BP 125/65 mm Hg Temp 39.2 degrees C (102.6 degrees F) Oxygen Sat 95 % 1200: Heart Rate 94/min Respirations 18/min BP 115/65 mm Hg Temp 37.8 degrees C (100 degrees F) Oxygen Sat 96% Exhibit 2: Medication Administration Record 0.45% sodium chloride IV at 125 mL/hr Vancomycin 1 g intermittent IV bolus every 12 hr Acetaminophen 650 mg PO every 6 hr PRN temperature greater than 38.3° C (101° F) Codeine 20 mg PO every 4 hr PRN cough Exhibit 3: Nurses' Notes 0800: Oriented to person, place, and time. Appears fatigued. Diaphoretic, febrile. Reports not sleeping well last night due to "coughing a lot." Moves all extremities well. Tachycardia. All pulses palpable. Reports chest discomfort with coughing. Respirations 26/min, shallow. Auscultation reveals diminished breath sounds and bilateral crackles. Pulse oximetry 95% on O2 2 L via nasal cannula. Hypoactive bowel sounds present in all four quadrants. States tolerating diet with no nausea or vomiting but has no appetite. Client states voiding using the bedside commode with no difficulty. Output of 500 mL clear, yellow urine flushed. IV infusing to right arm, no noted redness or irritation at site. Acetaminophen administered for temperature. 1200: States feeling better following administration of acetaminophen. Vancomycin infusion started. Client voices no discomfort at this time. 1300: Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified.​ The nurse should identify that the client might be experiencing ____________ as evidenced by the client's _______________. 1.) a. urinary tract infection b. seizures c.extravasation 2.) a. urine appearance b. IV catheter site c. temperature

The nurse should identify that the client might be experiencing extravasation as evidenced by the client's IV catheter site.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? a. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. b. Determine the reasons why the client is refusing to use the incentive spirometer c. Document the client's refusal to use the incentive spirometer d. Administer pain medication

b. Determine the reasons why the client is refusing to use the incentive spirometer All other answers are correct, but they do not take priority

A nurse is caring for a client who has pharyngeal diphtheria. 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 caring for a client who asks about the purpose of advanced directives. Which of the following statements should the nurse make? a. "They allow the court to overrule an adult client's refusal of medical treatment." b. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." c. "They permit a client to withhold medical information from health care personnel." d. "They allow health care personnel in the emergency department to stabilize a client's condition."

b. "They indicate the form of treatment a client is willing to accept in the vent of a serious illness." Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

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 inform the client that this condition is a contraindication for which of the following therapies? a. Biofeedback b. Aloe c. Feverfew d. Acupuncture

d. Acupuncture 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. Biofeedback helps with stroke recovery, smoking cessation, and headaches. Aloe can help improve disorders and can have wound healing effects. Feverfew helps promote wound healing, but is contraindicated in anticoagulant therapy.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's 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. During the admission process 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 responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? a. check the client for injuries b. move hazardous objects away from the client c. notify the provider d. ask the client how she felt prior to the fall

a. check the client for injuries The first action the nurse should take would be to assess the client for injuries. All other answers are correct, but do not have priority.

A nurse is caring for a client who is receiving a unit of packed RBCs: Exhibit 1: Nurses' Notes 0800: Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815: Client reports itching and anxiety. Client's face is flushed and has hives. Exhibit 2: Vital Signs 0800: BP 112/64 mm Hg Heart rate 80/min Respirations 18/min Temperature 37.1° C (98.8° F) Oxygen saturation 97% on room air 0815: BP 106/54 mm Hg Heart rate 100/min Respirations 22/min Temperature 37° C (98.6° F) Oxygen saturation 95% on room air The client has manifestations of ______________ as evidenced by the client's ______________

The client has manifestations of allergic reaction as evidenced by itching

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? a. Administer the medication with the needle at a 45-degree angle b. Administer the medication into the client's non-dominant arm c. Pull the client's skin laterally or downward prior to administration d. Massage the injection site after administration

a. Administer the medication with the needle at a 45-degree angle The nurse should insert the needle at a 45-degree to 90-degree angle for subcutaneous injections. The nurse should administer enoxaparin into the abdomen, at least 5 cm (2 in) from the umbilicus. The Z-track technique involves displacing the skin laterally or downward prior to the administration of an IM injection. The nurse should not massage the injection site following the injection of an anticoagulant due to the risk of bruising.

A nurse is caring for a client who has a new diagnosis of seizure disorder: Exhibit 1: Nurses' Notes 0800: Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. 0900: On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. Exhibit 2: Medication Administration Record Carbamazepine ER 200 mg PO twice per day Lorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min The nurse should first address the client's ___________, followed by the client's _____________ 1.) a. blood pressure b. physical safety c. privacy 2.) a. PRN medication b. positioning c. incontinence

The nurse should first address the client's physical safety, followed by the client's positioning.

A nurse in an emergency department is caring for a client: Exhibit 1: Physical Examination 1200: Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids. Exhibit 2: Vital Signs 1200: Temperature 38.4° C (101.1° F),Pulse rate 126/min, Respirations 28/min, BP 92/54 mm Hg, Oxygen saturation 93% Exhibit 3: Nurses' Notes 1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "I'm going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to client's family, no answer, message left. 1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated them on situation. Exhibit 4: Medication Administration Record Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hrPromethazine 25 mg IV bolus every 4 to 6 hr PRN nausea and vomiting. Diphenoxylate 5 mg PO four times daily. Acetaminophen 625 mg PO every 6 hr PRN temperature greater than 38.6° C (101.5° F) The nurse should first ____________, followed by _______________. 1.) a. review medications that might cause confusion b. obtain a prescription from the provider for restraints c. assess where the restraint will be placed 2.) a. padding bony prominences under the restraint b. monitoring the client in restraints every 2 hr c. using other methods to keep the client safe

The nurse should first review medications that might cause confusion, followed by using other methods to keep the client safe. Using the nursing process, the first step the nurse should take is to assess for the cause of the client's confusion. After assessing for the cause of the client's confusion, the nurse should attempt to use alternatives to the use of restraints, such as covering the client's IV lines or asking a family member to stay with the client. The use of restraints should be avoided if possible.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? a. Advocacy ensures clients' safety, health, and rights b. Advocacy ensures that nurses are able to explain their own actions c. Advocacy ensures that nurses follow through on their promises d. Advocacy ensures fairness in client care delivery and use of resources

a. Advocacy ensures clients' safety, health, and rights Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care. Accountability, not advocacy, is the responsibility of nurses to explain their own actions to clients and their employers. Fidelity, not advocacy, is an agreement by nurses to follow through with promises made to clients. Justice, not advocacy, is fairness in client care delivery, including the distribution of resources and care.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 2 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? a. Ask another nurse to observe the medication wastage b. Notify the pharmacy when wasting the medication c. Lock the remaining medication in the controlled substances cabinet. d. Dispose the vial with the remaining medication in the sharps container.

a. Ask another nurse to observe medication wastage A second nurse must witness the disposal of any portion of a dose of a controlled substance. Pharmacies do not require notification. The nurse should not lock the remaining medication in a controlled substance cabinet because this is a violation of the Controlled Substances Act. The nurse should not dispose of any remaining medication of a controlled substance in the sharps container because this is a violation of the Controlled Substances Act.

A nurse is caring for a client who has COPD: Exhibit 1: Nurses' Notes 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Exhibit 2: Vital Signs 1000: Temp 38.6 degrees C (101.5 degrees F) BP 114/56 mm Hg Heart Rate 99/min Respirations 32/min Oxygen Sat 85% on room air Exhibit 3: Diagnostic Results 1200: Chest x-ray shows lung hyperinflation and left upper lobe pneumonia. Select the 3 findings that require follow-up a. Breath sounds b. Blood pressure c. Oxygen saturation d. Temperature e. Heart Rate

a. Breath sounds c. Oxygen saturation d. Temperature

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? a. Examine personal values about the issue b. Tell the parents that this is a necessary procedure c. Inform the parents that the staff does not require their consent d. Contact a spiritual support person to explain the importance of the procedure

a. Examine personal values about the issue Nurses should examine their own personal values about the issue in question in order to provide care that is without bias.

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement: Exhibit 1: Nurses' Notes 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. The nurse is assessing the client. Which of the following actions should the nurse take? (Select all that apply) a. Stop the IV infusion rate b. Elevate the client's left arm c. Apply heat to the client's left hand d. Place a pressure dressing over the site e. Start a new IV in the client's left hand

a. Stop the IV infusion rate b. Elevate the client's left arm c. Apply heat to the client's left hand

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? a. Use a bed exit alarm b. Raise four side rails while the client is in bed c. Apply one soft wrist restraint d. Dim the lights in the client's room

a. Use a bed exit alarm The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. Raising four side rails while the client is in bed is a form of restraint and increases the risk of falls and injury. Applying one soft wrist restraint is a physical restraint that requires a prescription. Dimming the lights in the room of a dementia patient can reduce visibility and increases the risk for injury

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? a. Use the complete name of the medication magnesium sulfate b. Delete the space between the numerical dose and the unit of measure c. Write the letter U when noting the dosage of insulin d. Use the abbreviation SC when indicating an injection

a. Use the complete name of the medication magnesium sulfate The Institute for Safe Medication Practices (ISMP) designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate. The ISMP recommends including a space between the dose and unit of measure, such as in 10 mg, to avoid confusion when documenting medication dosages. The ISMP designates "units" as the correct term for use in medication documentation. The ISMP designates "subcut" or "subcutaneously" as the correct terms for use in medication documentation.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? a. pad the client's wrists before applying the restraints b. evaluate the client's circulation every 8 hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraints to the bed's side rails

a. pad the client's wrists before applying the restraints The use of restraints without padding can abrade the client's skin, resulting in client injury. The nurse should evaluate the client's circulation, range of motion, vital signs, and overall health status every 15 min after the initial application of restraints. The nurse should remove the restraints at least every 2 hr to reposition the client and assess the needs for hygiene and toileting. The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? a. "I can place an extension cord across my living room to plug in my television." b. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." c. "I will place my alarm clock on my bedroom dresser across the room." d. "I will replace the old throw rug with a new one."

b. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." Clearing stairs of any object that could cause the client to trip or require them to bend over while walking decrease the risk of falls. Extension cords should be securely fastened to the floor and should be run along the edge of the wall. Frequently used items such as an alarm clock, glasses, tissues, etc should be placed within reach, such as on a client's nightstand. Using throw rugs increases the client's risk for falls because they create a tripping and slipping hazard.

A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? a. "We would consult the person appointed by your healthcare proxy." b. "We would give you oxygen through a tube in your nose." c. "You would be unable to change your previous wishes about your care." d. "We would insert a breathing tube while we evaluate your condition."

b. "We would give you oxygen through a tube in your nose." Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. The staff must honor the client's wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the client's healthcare proxy. Clients determine advanced directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will.

A nurse in a provider's clinic is caring for a client who has diarrhea: Exhibit 1: Vital Signs Temp 36.2 degrees C (97.2 degrees F) Pulse Rate 116/min Respiratory Rate 24/min BP 102/68 mm Hg Oxygen Sat 95% Weight 52.2 kg (115 lb) Exhibit 2: Nurses' Notes 1000: Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. Weight at previous visit was 56.2 kg (124 lb). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100: Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching provided for managing diarrhea. Exhibit 3: Physical Examination 1015: Oriented to person, place, and time; lethargic, reports headache Tachycardia, hypotension, thready pulse, dry mucous membranes, tenting present. Respirations slightly labored, chest clear. Bowel sounds x 4 quadrants hyperactive. Reports urine is dark, minimal amount. The Nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. a. Increase intake of high-calcium foods b. Eat probiotic foods, such as yogurt c. Avoid alcohol while experiencing diarrhea d. Eat raw vegetables e. Eat three large meals a day f. Avoid caffeine while experiencing diarrhea g. Drink hot liquids several times a day h. Drink carbonated beverages to replace lost fluids i. Follow a low-fiber diet

b. Eat probiotic foods such as yogurt c. Avoid alcohol while experiencing diarrhea f. Avoid caffeine while experiencing diarrhea i. Follow a low-fiber diet

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? a. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain b. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm c. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum d. Palpate the client's abdomen before auscultating bowel sounds.

b. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm The nurse should use a blood pressure cuff that surrounds 80% of the client's arm to ensure an accurate reading. The nurse should use an age-appropriate pain-rating scale, such as the visual analog or numerical scale when assessing the pain level of an adult. The FLACC pain-rating scale is used for clients aged 2 months to 7 years old. The nurse should place the stethoscope at the point of maximal impulse, which is at the fifth intercostal space at the midclavicular line left of the sternum. When assessing an adult client's abdomen, the nurse should auscultate bowel sounds before performing palpation in order to not change the character of the sounds.

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 degree 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 the client's arm in a dependent position The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. The nurse should insert the catheter at a 10 to 30 degree angle. However, for an older adult, 10 to 15 degree angle is more acceptable. The nurse should clip excess hair from the IV insertion site and avoid shaving the area because it can cause breaks and cuts in the skin. The nurse should avoid using the fragile veins in an older adults hand because the loss of subcutaneous tissue can allow the veins to roll.

A nurse is reviewing evidence-based practice principles about the administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? a. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter b. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min c. Make sure the reservoir bag of a partial rebreathing mask remains deflated d. Use petroleum jelly to lubricate the client's nares, face, and lips

b. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2). The nurse should regulate the oxygen flow rate with the middle of the ball on the flow meter. The reservoir bag should inflate by 1/2 to 1/2 upon inspiration. If it remains deflated, it indicates the client is breathing in too much of the carbon dioxide they exhaled. Evidence-based practices support the use of a water-soluble lubricant to protect the client's skin from the drying affects of oxygen.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. The client uses a wool blanket on their bed b. The client identifies the location of a fire extinguisher c. The client stores an extra oxygen tank under their bed d. The client has a weekly inspection checklist for oxygen equipment

b. The client identifies the location of a fire extinguisher The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them. The client should use a cotton blanket instead of a wool blanket to avoid generating static electricity that could ignite the oxygen. The client should store extra oxygen tanks in an upright position to maintain safety. The client or caregiver should inspect oxygen equipment daily

A nurse is initiating a protective environment for a client who has 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 client care

b. make sure the client wears a mask when outside her room if there is construction in the area An allogeneic stem cell transplant compromises a client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. A protective environment requires at least 12 air exchanges per hour. The nurse should place the client in a private room with positive-pressure airflow. The nurse should wear an N95 respirator when caring for clients who require airborne precautions, not a protective environment.

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? (Select all that apply). a. lacrimal apparatus b. pupil clarity c. appearance of bulbar conjunctiva d. visual fields e. visual acuity

b. pupil clarity d. visual fields e. visual acuity Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. Visual fields is correct. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. Visual acuity is correct. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? a. "You would have so much more time to spend with your family." b "You should consider getting a part-time job or doing volunteer work." c. "Let's talk about how the change in your job status will affect you." d. "Why wouldn't you want to retire and relax?"

c. "Let's talk about how the change in your job status will affect you."

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of skin malignancy? a. A lesion with uniform pigmentation b. New appearance of petechia c. A mole with an asymmetric appearance d. The presence of a papule

c. A mole with an asymmetric appearance An uneven or asymmetrical shape is a potential indication of skin malignancy. This is manifested when part of a lesion or mole looks different from the other part. Variations in pigmentation are a possible indication of skin malignancy. A lesion with uniform pigmentation is not an expected indication of skin malignancy. Petechiae are capillaries that have burst under the skin and appear as small spots on the skin. Although they can be indications for other conditions, petechiae are not an expected indication of skin malignancy. Papules are solid elevations that are palpable in the skin and are less than 1 cm (0.39 in) in size. They are not an expected indication of skin malignancy.

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? a. Insert the needle at a 15-degree angle b. Aspirate for blood prior to administration c. Administer the medication into the abdomen d. Massage the site following the injection

c. Administer the medication into the abdomen The nurse should instruct the client to administer the medication into the abdomen 5 cm (2 in) from the umbilicus. The nurse should instruct the client to insert the needle at a 45 to 90-degree angle. The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. The nurse should instruct the client no to massage the area because this can cause tissue damage and bruising.

A nurse is administering 1 L of 0.9% sodium chloride to a patient who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a. Increase in hematocrit b. Increase in respiratory rate c. Decrease in heart rate d. Decrease in capillary refill time

c. Decrease in heart rate. When in fluid volume deficit, the patient will have an increased hematocrit, increased respiratory rate. increased heart rate, and decreased capillary refill

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? a. Assist the client into a prone position b. Place a sleeve over the top of each leg with the opening at the knee c. Make sure two fingers can fit under the sleeve d. Set the ankle pressure at 65 mm Hg

c. Make sure two fingers can fit under the sleeve The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate. The nurse should place the client in a dorsal recumbent or semi-fowler's position to facilitate the application of the sleeves. The nurse should place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg so that it is secure. The nurse should set the ankle pressure between 35 and 55 mm Hg to achieve a therapeutic affect while also preventing damage to the client's skin and circulatory impairment.

A nurse is talking with partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? a. Role ambiguity b. Sick role c. Role overload d. Role conflict

c. Role overload Role overload refers to having more responsibilities within a role than one person can manage. Role ambiguity occurs when people are unclear about the expectations of their role in a given situation. Sick role refers to the expectations placed on the individual who has the alteration in health rather than the caregiver. Role conflict develops when a person must assume multiple roles that have opposing expectations

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? a. Place the client in a side-lying position b. Instill 15 mL of irrigation fluid into the catheter with each flush c. Subtract the amount of irrigant from the client's output d. Perform the irrigation using a 20 mL syringe

c. Subtract the amount of the irrigant from the client's output The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output. For catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter. Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid. The nurse should use a 30 to 50 mL syringe to perform open irrigation.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? a. The top of the cane is parallel to the client's waist b. When walking, the client moves the cane 46 cm (18 in) forward c. The client holds the cane on the stronger side of her body d. The client moves her stronger limb forward with the cane.

c. The client holds the cane on the stronger side of her body The client should hold the cane on the stronger side of her body to increase support and maintain alignment. The top of the cane should be parallel to the client's greater trochanter. To maintain balance, the client should advance the cane 15 to 30 cm (6 to 12 in) at a time. The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg.

A nurse is caring for a client who is postoperative following abdominal surgery: Exhibit 1: Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200: Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort. Exhibit 2: Medication Administration Record Morphine 4 mg IV bolus every 4 hr PRN pain Metoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting Exhibit 3: Vital Signs 1100: Temp 36.2 degrees C (97.2 degrees F) Heart Rate 76/min Respirations 18/min BP 122/68 mm Hg Oxygen Sat 98% on room air 1200: Temp 36.8 degrees C (98.2 degrees F) Heart Rate 116/min Respirations 20/min BP 112/68 mm Hg Oxygen Sat 93% on room air Which assessment findings below should the nurse report to the provider?(Select all that apply) a. Neurological assessment b. Incisional drainage c. Urinary output d. Reported pain level e. Gastrointestinal assessment f. Vital signs

c. Urinary output d. Reported pain level f. Vital signs Urinary output is correct. A client who has an indwelling urinary catheter should produce at least 30 to 50 mL/hr of urine. The client's output is less than the expected volume. The nurse should assess the catheter's placement and potential for blockage due to their reduced urine output. The reported pain level is correct. The client's pain has not been relieved with the administration of morphine. According to the client's report, their pain level is increasing. Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? a. "Is your pain constant or intermittent?" b. "What would you rate your pain on a scale of 0 to 10?" c. "Does the pain radiate?" d. "Is your pain sharp or dull?"

d. "Is your pain sharp or dull?" Asking the client whether their pain is sharp, dull, crushing, throbbing, aching, etc helps determine the quality of the pain. Asking the client whether the pain is constant or intermittent help determine the onset, duration, and pattern of the pain. Asking the client to rate their pain determines the intensity of the pain. Asking whether the pain radiates helps determine the pain's location.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? a. Protective environment b. Airborne precautions c. Droplet precautions d. Contact precautions

d. Contact precautions Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client. Clients who have a compromised immune system require a protective environment. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles. Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, streptococcal pharyngitis

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? a. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube b. Remove the NG tube if the client begins to gag or choke c. Apply suction to the BG tube prior to insertion d. Have the client take sips of water to promote insertion of the NG tube into the esophagus

d. Have the client take sips of water to promote insertion of the NG tube into the esophagus Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea. The client should be sitting in High-Fowler's position with the head of the bed elevated to 90 degrees to reduce the risk for aspiration. The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings will the nurse use? a. Alginate b. Gauze c. Transparent d. Hydrocolloid

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

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to monitor the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? a. Document the provider's statement in the medical record b. Complete an incident report c. Consult the facility's risk manager d. Notify the nursing 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 the client receives the necessary care. All other answers are correct, but they do not take priority at this time.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in the chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? a. Bend at the waist b. Keep his feet close together c. Use his back muscles for lifting d. Stand close to the cabinet when lifting it

d. Stand close to the cabinet when lifting it This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching. The nurse should bend the knees when lifting the cabinet. The nurse should spread the feet wide apart to create broad base of support. The nurse should use the arm and leg muscles.

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 b. creatinine 0.8mg/dl c. sodium 143 mEq/l d. potassium 5.4 mEq/l

d. potassium 5.4 mEq/l The value is above the expected reference range of 3.5 to 5 mEq/l, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias. BUN of 15 mg/dl is within the expected range of 10 to 20 mg/dl. Creatinine 0.8 mg/dl is within the expected range of 0.5 to 1.1 mg/dl for women and 0.6 to 1.3 mg/dl for men. A sodium of 143 mEq/l is within the expected range of 135 to 145 mEq/dl.