ATI nur 352 questions

A nurse is assessing a clients radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? a.) assess the apical pulse for a full minute b.) assess the apical pulse with a doppler device c.) assess the pedal pulses for a full minute d.) assess the pedal pulses with a doppler device

A (for clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsations for 30 seconds and multiply by 2. For this client, the nurse should count for 60 seconds. This will help the nurse determine the regularity or irregularity of the heart. Unless the apical pulse site is difficult to evaluate with a stethoscope, there is no need to use a doppler ultrasound stethoscope. Checking the pulse at other peripheral sites is not necessary, nor is it necessary with a doppler ultrasound stethoscope, as these sites can have regular or irregular pulsations as well and will not help the nurse determine the regularity or irregularity of the heart.)

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use? a.) ask the client to perform a return demonstration of insulin injection b.) review the action of insulin therapy c.) explore the clients feelings about dietary modifications d.) have the client practice blood glucose monitoring using a glucometer

C (this teaching intervention allows the client to express acceptance of this change and focuses on affective learning. A and D focus on psychomotor learning. B focuses on cognitive learning)

A nurse is completing a client assessment for admission to the medical unit. Which of following abdominal assessment findings require further investigation by the nurse? a.) symmetrical convex sphere shape b.) concave umbilicus c.) bilateral bowel sounds in lower quadrants d.) ecchymosis

D (ecchymosis (a subcutaneous spot of bleeding with a larger than 1 diameter) is a finding outside of the expected reference range for an abdominal assessment and would require the nurse to further investigate for potential injury, bleeding disorder, or physical abuse.)

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? a.) restlessness b.) retractions c.) dependent edema d.) clubbing of the fingers

D (nurse should expect the client who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen and the ends of the fingers and toes can increase in size. Dependent edema is a manifestation of heart failure, not chronic respiratory insufficiency. Retractions are a manifestation of increased work with breathing or dyspnea, not chronic respiratory insufficiency. Restlessness is an early manifestation of inadequate oxygenation.)

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? a.) crackles b.) rhonchi c.) stridor d.) wheezes

d (wheezes are continuous, high-pitches squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope. A stridor is a continuous, shrill musical sound of constant pitch. Rhonchi are continuous rumbling, snoring, or rattling sounds resulting from fluid or mucous. Crackles are a series of short, interrupted, high-pitched sounds audible just before the end of inspiration. The sound is similar to that of rolling hair between the fingers just behind the ear.)

locate Deltoid site

locate the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three finger widths below the acromion process

locate Vastus Lateralis site

- located on the anterior lateral aspect of the thigh, and extends in an adult from a hand breadth above the knee to a hand breadth below the greater trochanter of the femur -- Use the middle third of the muscle for injection. -- The width of the muscle usually extends from the midline of the thigh to the midline of the outer side of the thigh

Subcutaneous

- outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs - Alternative subcutaneous sites include the scapular areas of the upper back and the upper ventral or dorsal gluteal areas. -- The injection site you choose needs to be free of skin lesions, bony prominences, and large underlying muscles or nerves. -Only administer small volumes (0.5 to 1.5 mL) of water-soluble medications -If you can grasp 2 inches (5 cm) of tissue, insert the needle at a 90-degree angle; if you can grasp 2.5 cm (1 inch) of tissue, insert the needle at a 45-degree angle

Intradermal

- typically are used for skin testing - ID sites need to be lightly pigmented, free of lesions, and relatively hairless - The angle of insertion for an ID injection is 5 to 15 degrees, and the bevel of the needle is pointed up. - inner forearm and upper back are ideal locations

CDC movement milestones: 4 months

1.) Holds head steady, unsupported 2.) Pushes down on legs when feet are on a hard surface 3.) May be able to roll over from tummy to back 4.) Can hold a toy and shake it and swing at dangling toys 5.) Brings hands to mouth 6.) When lying on stomach, pushes up to elbows

CDC movement milestones: 5 years

1.) Stands on one foot for 10 seconds or longer 2.) Hops; may be able to skip 3.) Can do a somersault 4.) Uses a fork and spoon and sometimes a table knife 5.) Can use the toilet on her own 6.) Swings and climbs

CDC movement milestones: 2 years

1.) Stands on tiptoe 2.) Kicks a ball 3.) Begins to run 4.)Climbs onto and down from furniture without help 5.) Walks up and down stairs holding on 6.) Throws ball overhand 7.) Makes or copies straight lines and circles

CDC movement milestones: 9 months

1.) Stands, holding on 2.) Can get into sitting position 3.) Sits without support 4.) Pulls to stand 5.) Crawls

Sites for IM

1.) Ventrogluteal -preferred and safest site for all adults, children, and infants, especially for medications that have larger volumes (greater than 2 ml) and are more viscous and irritating 2.) Vastus Lateralis -often used for infants, toddlers, and children receiving biologicals (e.g., immunoglobulins, vaccines, or toxoids) 3.) Deltoid -Use this site only for small medication volumes, when giving immunizations (e.g., hepatitis B, flu shots), or when other sites are inaccessible because of dressings or casts

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow 1. open outermost flap away from self 2. use inner surface of package as sterile field 3. perform hand hygeine 4. open innermost flap toward self 5. place package on work surface 6. open side flap pulling to the side

3, 5, 1, 6, 4, 2 (first the nurse should perform hand hygiene. hand hygiene reduces the number of micro-organisms on the skin and prevents the spread of micro-organisms to the sterile field. Next, the nurse should place the package on a flat, clean, dry work surface above waist level. Next the nurse should open the outermost flap away from herself. The nurse should open the outermost flap by first gripping the tip of the flap. The nurse should keep her arms outstretched and away from her body. The nurse should then open the side flap, pulling it to the side. The nurse should grasp the outer edge of the first side flap and allow the flap to lie flat on the table surface. The nurse should keep her arms to the side and not over the sterile surface. Repeat these steps for the second side flap. The nurse should not allow flaps to spring back onto the sterile items. Next, the nurse should open the innermost flap toward herself. The nurse should grasp the outside border of the last innermost flap. It should fall flat and not spring back onto the sterile items. Finally, the nurse should use the inner surface of package as a sterile field. The sterile package will contain sterile items.)

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation. 1. clean the wound using a circular motion 2. don clean gloves and remove the clients dressing 3. irrigate the wound until the solution becomes clear 4. place a waterproof pad under the clients leg 5. open a sterile dressing set and supplies

4, 2, 1, 5, 3 (the nurse should first place a waterproof pad on the bed under the clients leg to prevent soiling the bed linen. The nurse should hen apply clean gloves to remove and discard the old dressing. Next, the nurse should clean the puncture site using a circular motion, moving from the cleanest area in the center of the wound outward. After cleansing the wound, the nurse should prepare the equipment necessary for irrigation by opening a sterile dressing set and supplies. Finally, the nurse should irrigate the wound until the solution becomes clear to ensure that exudate is no longer present.)

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions? a.) atrial gallop b.) ventricular gallop c.) closure of the mitral valve d.) closure of pulmonic valve

B (an S3 represents a lenticular gallop caused by a rush of blood into a ventricle that is stiff or dilated. This can be a finding of heart failure and hypertension. Closure of the mitral valve is represented by the S1 heart sound. Closure of the pulmonic valve is represented by the S2 heart sound. An S4 heart sound represents atrial gallop)

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? a.) placing a sterile dressing 5 cm (2 in) from the border of the sterile field b.) holding a sterile item at just above waist level c.) opening a sterile package over the middle of the sterile field d.) opening the sterile tray by first unfolding the flap closest to his body

C (opening a sterile package over the middle of the sterile field requires reaching into a sterile field, which can result in contamination. The nurse should place the object on the field by approaching the field from an angle. The nurse should unfold the flap farthest from his body first, then the 2 side flaps, then the flap closest to his body. The nurse should hold objects above his waist to maintain their sterility. The nurse would contaminate the sterile dressing by placing it on the 2.5 cm (1 in) border around the edge of the sterile field.)

A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 DM. Which of the following actions should the nurse plan to take first? a.) establish short term, realistic goals for the client b.) give the client access to a video about diabetes c.) determine what the client knows about managing diabetes d.) evaluate the effectiveness of the clients admission teaching plan

C (the first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should find out what the client knows before proceeding with the plan.

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? a.) complete an incident report b.) request the risk manager obtain consent for HIV testing from the client c.) wash the site of injury with soap and water d.) consent to post-exposure treatment with antiretroviral medications

C (the greatest risk to the nurse is infection transmission, therefore the nurse should first wash the area with soap and water to reduce the risk of transmission. Although treatment with antiretroviral medications should be started within 1 to 2 hr after a needle stick injury and be continued for 28 days if the client's HIV status is positive, there is another action the nurse should take first. Although its important that the clients HIV status is determines, there is another action the nurse should take first. The nurse should complete an incident report; however, there is another action the nurse should take first.)

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires interventions by the charge nurse? a.) clamps the NG tube during auscultation b.) performs auscultation between meals c.) auscultates bowel sounds for 3-5 mins d.) palpate the abdomen prior to performing auscultation

D (the nurse should auscultate the abdomen prior to palpating it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify bowel sounds. The nurse should auscultate bowel sounds for 3-5 mins before determining that bowel sounds are absent. Bowel sounds are the result of gas and fluid moving through the intestines creating gurgling and clicking sounds at about every 5-20 seconds. They increase shortly after meals, and also increase when the client hasn't eaten for several hours. From about an hour after a meal up to 4 hours after a meal is the optimal time to listen to bowel sounds. The nurse should clamp the clients NG tube during auscultation to prevent mistaking the sound of suction for bowel sounds.)

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? a.) bradypnea b.) somnolence c.) pallor d.) tachycardia

D (the nurse should expect the client who has hypoxia to manifest tachycardia. The nurse should expect the client who has hypoxia to manifest cyanosis, a bluish discoloration of the skin and mucous membranes, in the late stages of hypoxia. The nurse should expect the client who has hypoxia to display restlessness and agitation, not somnolence (sleepiness, drowsiness). The nurse should expect to find rapid, shallow respirations and dyspnea, not bradypnea in the client who has hypoxia.)

A nurse is administering an IM injection to a client who has hep C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take? a.) recap the needle b.) place the cap on the bedside table and slide the needle into the cap c.) wrap the needle with gauze d.) dispose of the needle uncapped

D (the nurse should immediately place the uncapped needle in a puncture-resistant container to prevent a needle stick with the contaminated needle. Wrapping the needle with gauze is unnecessary and increases the risk for a needle stick. Recapping the needle after use using the slider recapping method increases the risk for a needle stick. Recapping the needle increases the risk for a needle stick.)

locate Ventrogluteal site

Place the palm of your hand over the greater trochanter of the patient's hip with the wrist perpendicular to the femur. Use the right hand for the left hip and the left hand for the right hip. Point the thumb toward the patient's groin and the index finger toward the anterior superior iliac spine; extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle; the injection site is the center of the triangle