ATI STUDY

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port

Correct Answer: D. Clamp the tubing below the collection port The nurse should clamp the tubing below the collection port to allow fresh, uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.

A nurse is assessing four adult clients. WHich of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.

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?

Examine personal values about the issue.

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?

Have the client take sips of water to promote insertion of the NG tube into the esophagus.

A nurse is caring for a client who had a spinal cord injury and has paraplegia.

- Passive range-of-motion exercises to lower extremities performed once each day - Plantar flexion contractures noted bilaterally - Left heel with 1.3cm x 1.3 cm area of nonblanchable erythema, skin intact is correct.

A nurse is caring for a client who is postoperative following abdominal surgery.

- Urinary output - Reported pain level - Vital signs

A nurse in a provider's clinic is caring for a client who has diarrhea. 4 instructions that the nurse should include in the teaching.

-Eat probiotics. - Avoid alcohol - Avoid caffeine - Follow low-fiber diet

Advocacy

clients' safety, health and rights

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet

A nurse is initiating a protective environment for a client who had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area.

Placing the bell of the stethoscope on the client's neck, the nurse hears the following sound.

Narrowed arterial lumen. Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.

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 ever 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager.

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.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Rapid Heart rate Tachycardia indicates fluid volume deficit which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

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

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?

The client holds the cane on the stronger side of her body.

Home safety assessment for a client who is receiving supplemental oxygen

The client identifies the location of a fire extinguisher

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 hour.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors.

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?

We would give you oxygen through a tube in your nose

Nurse is reviewing the client's medical record. (Client has tested positive for Pneumonia). Which of the following actions should the nurse take?

- Place the client on a droplet isolation precaution - Apply oxygen at 2 L/min via nasal cannula - Request a prescription for an antipyretic medication - Remain 1 m from the client

Findings that indicate the client is malnourished.

1. Cachectic with flaccid muscle tone. 2. Skin dry and scaly with bruises on extremities 3. Pulse rate 118/min 4. Abdomen distended 5. BMI 17

A nurse is caring for a client who has pancreatitis. 3 Tasks the nurse should delegate to an assistive personnel (AP)

1. Document the client's vital signs 2. Measure the client's intake and output 3. Transfer the client from wheelchair to bed

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? A. Antigravity B. Antagonistic C. Synergistic D. Skeletal

Correct Answer: B. Antagonistic The nurse should teach the client that the antagonistic muscle group is responsible for movement of the knee joint by contracting while other muscles relax.

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: 29 To solve using ratio and proportion and "desired over have" methods: Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the volume the nurse should infuse? 700 mL Step 3: What is the total infusion time? 24 hr Step 4: Should the nurse convert the units of measurement? Yes (hours are not equal to minutes) 1 hr/ 60 min = 24 hr/ X min X = 1,440 min Step 5: Set up the equation and solve for X. Volume (mL)/Time (min) x Drop factor (gtt/mL) = X 700 mL/1440 min x 60 gtt/mL = X gtt/min 29.1666 = X Step 6: Round if necessary. 29.1666 = 29 Step 7: Determine whether the amount to administer makes sense. If the prescription is for 0.9% sodium chloride 700 mL IV infused over 24 hr, the nurse should set the manual IV infusion to deliver 0.9% sodium chloride IV at 29 gtt/min. To solve using dimensional analysis: Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the quantity of the drop factor that is available? 60 gtt/min Step 3: What is the total infusion time? 24 hr Step 4: What is the volume the nurse should infuse? 700 mL Step 5: Should the nurse convert the units of measurement? Yes (hours are not equal to minutes) 1 hr/60 min = 24 hr/X min Step 6: Set up the equation and solve for X. X = Quantity/1 mL x Conversion (hr)/Conversion (min) x Volume (mL)/Time (hr) X gtt/min = 60 gtt/1 mL x 1 hr/60 min x 70 mL/24 hr X = 29.1666 Step 7: Round if necessary. 29.1666 = 29 Step 8: Determine whether the amount to administer makes sense.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? A. Administer 0.9% sodium chloride until TPN is available from the pharmacy B. Check the client's capillary blood glucose level every 4 hr C. Obtain the client's weight each week D. Change the IV tubing every 3 days

Correct Answer: B. Check the client's capillary blood glucose level every 4 hr The nurse should check the client's capillary blood glucose level every 4 hours or according to facility policy due to the client's risk of hyperglycemia while receiving TPN. The dextrose concentration in TPN increases the risk of this complication.

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. "With your palm facing down, move your wrist sideways toward your thumb." B. "Move your palm toward the inner part of your forearm." C. "With your palm facing down, move your wrist sideways toward your little finger." D. "Bring the back of your hand as far back toward the wrist as you can."

Correct Answer: A. "With your palm facing down, move your wrist sideways toward your thumb." This motion describes adducting the wrist. The client should be able to move her wrist 30º to 50º with this motion.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

Correct Answer: C. Pinch the NG tube while removing the tube The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.

A nurse in a long-term facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

1. Obtain death pronouncement from the provider. 2. Remove tubes and indwelling lines 3. Clean the body 4. Ask the family members if they would like to view the body. 5. Name tag

120 mL of fluid

8 oz of ice chips

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

A nurse in a provider's clinic is caring for a client who has heart failure.

- I am limiting my sodium intake to 2gram daily - I am eating fewer potato chips and more fruit for snacks - I know to call my doctor if I gain 3 pounds or more in 2 days

A nurse is caring for a client who has TB. Which of the following actions should the nurse take?

- Place the client in a room with negative-pressure airflow - Wear gloves when assisting the client with oral care. - Use antimicrobial sanitizer for hand hygiene.

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?

- Pupil clarity - Visual fields -Visual acuity

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?

Acupuncture

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?

C. Assess the client for orthostatic hypotension The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in the Trendelenburg position B. Perform percussions directly over the client's bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain

Correct Answer: A. Place the client in the Trendelenburg position The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's left lower lobe.

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for tracheostomy care B. Obtaining cotton balls for tracheostomy care C. Obtaining sterile gloves for tracheostomy care D. Obtaining a sterile brush for tracheostomy care

Correct Answer: B. Obtaining cotton balls for tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assistance. B. Begin chest compressions. C. Confirm unresponsiveness. D. Give rescue breaths.

Correct Answer: C. Confirm unresponsiveness. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client to obtain the knowledge needed to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use a staple remover and remove each suture individually." B. "Bandage scissors are used to cut the sutures." C. "Tweezers are necessary only for removing retention sutures." D. "I will clip each suture close to the skin and pull it through from the other side."

Correct Answer: D. "I will clip each suture close to the skin and pull it through from the other side." Clipping close to the skin and pulling the suture from the other side does not disrupt the wound-healing process.

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only the blood pressure readings needed for 15-min intervals. C. Obtain manual and automatic readings and compare them. D. Disconnect the machine and measure the blood pressure manually every 15 min.

Correct Answer: D. Disconnect the machine and measure the blood pressure manually every 15 min. If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply.) A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." D. "Keep your elbows away from your body." E. "Adjust the monitor screen so that you have to tilt your head slightly to look at it."

Correct Answers: A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." Using lumbar support in a straight-back chair helps maintain good posture and prevent back pain. Keeping the knees at the level of the hip or higher helps reduce the risk of lordosis, which is an exaggeration of the curve of the lumbar spine. Using a keyboard that maintains ergonomic positioning of the wrists can help prevent carpal tunnel syndrome.

A nurse on a medsurg 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.

Pyschomotor approach to learning

Practice sessions