AtI Practice A

quality of pain, assses usuing which words

ask if pain is sharp dull electric or shooting like.

Protective environment Precautions ( Allogenic Stem Cell)

-12 air exchanges per hour -Client wears a mask when outside her room if there is construction in area -Positive pressure room

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)

AP Can: -asist with bed bath -Measure BP after nurse administers an antihypertensive -use communication board to determine what pt wants for lunch.

The nurse should remove the restraints at least every

At least every 2 hours to reposition and asssess hygiene and toileting needs

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions.

pharyngeal diphtheria requires what kind of precaution?

Droplet

which type of dressing for a stage 2 pressure injury

Hydrocolloid Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

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 measure 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?

Notify the nursing manager. This is PRIORITY

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear. Pressing gently on the tragus of the ear will help the medication get into the inner ear.

What position for catheter irrigation?

Supine or dorsal recumbent

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

The client's caregiver washes out the feeding bag with warm water once every 24 hr. Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination.

Is it correct to flush tubing before and after administering medications?

Yes this helps prevent clogging

The client should lie on one side with the ear that received the instillation facing upward for how long

for 2 to 5 min

For an adult client, the nurse should move the auricle how

upward and backward or upward and outward to straighten the ear canal.

How many ml of irrigation fluid for an open irrigation technique

30-40mL

Administer pain meds how long before changing wound dressing

30-60 min

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?

Pad the client's wrist before applying the restraints. The use of restraints without padding can abrade the client's skin, resulting in client injury.

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?

-Place the client's arm in a dependent position. this helps the veins dialate due to gravity -10-30 degree angle for needle. 10-15 for older adult.

Assessing client that has been on bedrest for a month what is an indication that the client has developed thrombophlebitis?

-Swelling, -Redness, -and tenderness in a calf muscle are manifestations of thrombophlebitis a common complication of immobility.

A nurse is administering 1 L of 0.9% sodium chloride to a client 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?

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

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 reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.

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?

Subtract the amount of irrigant used from the client's urine output.

Fluid volume deficit causes

Tachycardia

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

Turn the client every 2 hr. To break up secretions and prevent noisy respirations

The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every how often

every 15 min after initial application of restraints