Med-Surge ATI Practice
A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage for this medication in the client's medical record?
0.3 mg
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a.Use a resuscitation bag with 80% oxygen prior to the procedure b.Select a suction catheter that is half the size of the lumen c.Place the end of the suction catheter in water-soluble lubricant d.Adjust the wall suction apparatus to a pressure of 170 mm Hg
b.Select a suction catheter that is half the size of the lumen
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? a.Critical pathway b.Situation,background,assessment, and recommendation (SBAR) c.Transfer report d.Medication administration record (MAR)
b.Situation,background,assessment, and recommendation (SBAR)
A nurse is giving discharge instruction to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? a. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." b."Ill use a woolen blanker if I get chilly while I'm using oxygen." c."I'll check the wires and cables on my TV to make sure they are in good working order." d."I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over."
c."I'll check the wires and cables on my TV to make sure they are in good working order."
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 wrist b.When walking, the client moves the one 46 cm (18 in) forward c.The client holds the cane on the stronger side of the body d.The client moves her stronger limb forward with the cane
c.The client holds the cane on the stronger side of the body
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? a.Place the client in high-fowler's position b.Increase the client's intake of carbohydrate c.Massage reddened areas with unscented lotion d.Have the client use a trapeze bar when changing position
d.Have the client use a trapeze bar when changing postition
A nurse is caring for a client who has a prescription fro 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.
1. Inject air into the vial of NPH without touching the needle to the solution 2.Inject air into the vial of regular insulin, then withdraw the correct amount of regular insulin 3.Insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin.
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plant 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 hands
b.Place the client's arm in a dependent position
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) a. Place the client in a room with negative-pressure airflow b. Wear gloves when assisting the client with oral care c. Limit each visitor to 2- hr increments d. Wear a surgical mask when providing client care e. Use antimicrobial sanitizer for hand hygiene
a. Place the client in a room with negative-pressure airflow b. Wear gloves when assisting the client with oral care e. Use antimicrobial sanitizer for hand hygiene
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? a.Gently shake the container of medication prior to administration b.Transfer the medication to a medicine cup c.Place the client in a semi-fowlers position prior to medication administration d.Verify the dosage by measuring the liquid before administering it
a.Gently shake the container of medication prior to administration
A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? a.A nurse who is caring for a client review's the medical chart with the nursing student b.A nurse asks a nurse from another unit to assist with her documentation c.A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care d. A nurse discusses a client's status with the physical therapist that is caring for the client at the client's bedside
b.A nurse asks a nurse from another unit to assist with her documentation
A nurse is caring for a client who has an NG tube and is receiving the intermittent feedings through an open system. Which of the following actions should the nurse take first? a. Rinse the feeding bad with the water between findings b.Tell the client to keep the head of the bed elevated to at least 30 degrees c.Make sure the enteral formula is at room temperature d.Wipe the top of the formula can with alcohol
b.Tell the client to keep the head of the bed elevated to at least 30 degrees
A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a.ensure sterilization of nondisposable items with ethylene oxide b.wrap monitoring cords with stockinette and tape them in place c.cleanse latex ports on IV tubing with chlorhexidine before injecting medication d.wear hypoallergenic latex gloves that contain powder
b.wrap monitoring cords with stockinette and tape them in place
A nurse is providing care to four clients. Which of the following situations requires the nurse to complete incident report? a.A nurse tied a client's restrain straps to the moveable part of the bed frame b.An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology c.A nurse administers a medication to a client 30 min before the dose is due d.A client who has an IV infusion pump receives an additional 250 ml of IV fluid
d.A client who has an IV infusion pump receives an additional 250 ml of IV fluid
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 the gag or choke c.Apply suction to the NG 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.
