Fundamentals ATI- Final
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"
What is the creatinine range?
0.5-1.2 mg/dL
What is the expected range for BUN?
10-20 mg/dl
1oz is equal to how many mL
30mL
enoxaparin should be administered at a ______ degree angle into the ________
45; abdomen
A patient eats 8oz of ice chips, how many oz should be documented for fluid intake?
4oz
When should patients receive their pneumococcal vaccine?
65 years old
Oxygen via nasal cannula should be at a rate of no more than...
6L/min
It is important to ensure a blood pressure cuff surrounds _____% of a patients arm
80
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. What action should the nurse take?
Examine personal values about the issue
During what test does the nurse have the patient stand with their arms at their sides and their feet together?
Romberg test
_______ is a communication tool used during change-of-shift report
SBAR
T/F Measuring the clients intake and output can be delegated to unlicensed personnel
True
Wearing gloves when assisting with oral care, using antimicrobial hand sanitizer for hand hygiene, and placing the client in a room with negative pressure airflow are all appropriate measures to take...
When a client has TB
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 legal document designed to indicate a person's wishes regarding care in case of a terminal illness or during the dying process
advance directives
_________ ensures client's safety, health, and rights
advocacy
A nurse is planning 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 feeding?
arrange food in a consistent pattern on the clients plate
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1mL of the medication from a 2mL vial. What should the nurse do with the remaining medication?
ask another nurse to observe the wasting
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 the patient for orthostatic hypotension
How can a nurse prevent plantar flexion contractures?
by using a device to maintain dorsiflexion
Question-answer sessions promote _________ learning
cognitive
VRE is a ________ precaution
contact
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?
contact precautions
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?
determine the reasons why the client is refusing to use the incentive spirometer
What should a client do for a 24-hr urine collection?
discard the first voiding and save all subsequent voiding
Rubella, meningococcal pneumonia, and streptococcal pharyngitis are all ________ precaution
droplet
T/F Collecting data about a patient's pain level can be delegated to unlicensed personnel
false
T/F Massage the site following the injection of insulin
false
T/F When doing trach care, carefully remove the outer cannula
false (the outer cannula should never be removed)
distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, increase in BP, and a bounding pulse are all indications of what?
fluid volume excess
What should a nurse do before administering medication through an enteral feeding tube?
flush the tube with 15 to 30mL of sterile water
What can be used in stage 4 pressure injuries by causing debridement and allowing granulation of the wound bed?
gauze
What size should the suction catheter be for a patient who has a new tracheostomy that needs to be suctioned?
half the size of the lumen
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
hydrocolloid
A client who smokes a pack a day is at risk for ________tension
hyper
Skin blanching at the IV site indicates what?
infiltration
What would you rate your pain on a scale of 0-10 is an example of assessing pain _________
intensity
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
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?
make sure two fingers can fit under the sleeves
comparing the client's home medications with the provider's prescriptions is an example of what?
medication reconciliation
A nurse is caring for a client who is postoperative and 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 report back in 1 hour. What should the nurse do next?
notify the nursing manager
Warmth at the IV site indicates _________
phlebitis
"The pain is like a dull ache in my stomach" is describing the _________ of pain
quality
Is your pain sharp or dull is an example of assessing pain ________
quality
What does the RACE mnemonic stand for?
rescue, activate the alarm, confine the fire, extinguish
A patient has a cast and crutches for a break in his left leg. What leg should he first shift his weight to when going down the stairs?
right leg
pupil clarity, visual fields, and visual acuity should all be assessed when assessing a patient for what?
risk for falls
A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?
role overload
"I'm having mild pain" describes the _________ of pain
severity
A mole with asymmetrical appearance is a potential indication of what?
skin cancer
A client has been diagnosed with terminal liver cancer and states, "What could I have done to deserve this illness?", what may they be experiencing?
spiritual distress
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
stand closer to the cabinet when lifting it
________cardia indicates fluid volume deficit, which is an expected finding for someone who has had vomiting and diarrhea for three days
tachy
Fluid volume deficit causes _______cardia
tachycardia
What action should the nurse take first when caring for a client who has a NG tube and is receiving intermittent feedings through an open system?
tell the client to keep the head of the bed elevated at least 30 degrees
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?
the client identifies the location of a fire extinguisher
Who is responsible for witnessing the client sign a consent form for a procedure?
the nurse
What side should clients cane be on?
their stronger side
Echinacea is an herbal supplement used for what?
to promote immunity and reduce the risk of infection
_________ dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing
transparent
T/F A nurse can delegate unlicensed personnel to ambulate a client who is post-op
true
T/F Essential oils can be contraindicated in patients with asthma
true
T/F Family members visiting a patient with C-Diff must wear a gown and gloves
true
T/F Initiating an enteral feeding through a gastrostomy tube is in the RNs scope of practice
true
T/F It is beneficial for patients with diarrhea to eat probiotics, such as yogurt
true
T/F Patients should be placed in a negative airflow room when they have tuberculosis
true
A nurse is caring for a client who has terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. What action should the nurse take?
turn the client every 2 hrs.
An experienced nurse is precepting a a new grad and notices she documented mag sulfate given PO at 1400, what should the experienced nurse tell the new grad to do different?
use the complete name, magnesium sulfate
What should patients remember when going outside with tracheostomies?
use tracheostomy cover
Patients who receive an allogenic stem cell transplant have to take what precautions when going out of their room?
wear a mask
What type of activity is recommended for a patient who is at risk for osteoporosis?
weight-bearing (walking)
At what pain intensity should a client be instructed to push their PCA pump?
when they feel they need it
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. What should the nurse do?
withhold the blood transfusion
A nurse is responding to a call light and finds a client lying on the bathroom floor. What action should the nurse take first?
check the client for injuries
A nurse is admitting a client who is having exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
during the admission process
T/F Patient's family can push the PCA pump button for them when they are sleeping
false
T/F When inserting an NG tube, remove immediately if the patient starts choking or gagging
false
T/F Surgical masks can be worn when caring for patients with TB
false (N95)
process of creating an accurate list of all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing the list to the physician's admission, transfer, or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital
medication reconciliation
What is the ethical principle of veracity?
obligation to tell the truth and not to lie or deceive others
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
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. What method can the nurse use as a psychomotor approach to learning?
practice sessions
A patient asks a nurse if they have cancer and the nurse responds affirmatively, what principle is the nurse demonstrating?
the ethical principle of veracity
How can a nurse caring for a patient keep them safe and minimize risk of injury?
use a bed exit alarm
