ATI Comprehensive Flashcards
An immobilized client requires passive range of motion (ROM) for each joint. Which technique is correct when performing these exercises?
Continue to flex the joint until full resistance is felt.
Exercise the joint to the point of pain.
Hyperextend healthy joints to increase flexibility.
Support the client’s joints that are distal to the joint exercised.
Incorrect: It is safe to flex the joint until slight resistance is felt, but not beyond. Exercising a joint until full resistance is felt could damage the affected joint.
Incorrect: Exercising a joint to the point of pain increases the risk for trauma to the joint. The nurse should note the point at which the client experiences pain and stop the exercise before this point is reached.
Incorrect: Hyperextending the joint may increase the risk of injury to the joint and is therefore contraindicated.
Correct: Support of distal joints during passive ROM reduces the risk of injury and damage to affected joints. Passive ROM exercises should be performed slowly and carefully to ensure support of the client’s joints.
The nurse is assessing a client with diabetes mellitus who is at risk for developing hypoglycemia. Which symptom occurs with hypoglycemia?
Deep, rapid respirations
Diaphoresis
Excessive thirst
Frequent urination
Incorrect: Deep, rapid respirations are a symptom of hyperglycemia, not hypoglycemia. Kussmaul’s respirations are the body’s attempt to “blow off” the extra acid produced with diabetic ketoacidosis.
Correct: Diaphoresis is a symptom of hypoglycemia. The sympathetic nervous system is activated when there is a decrease in the amount of glucose available to the cells. Activation of the sympathetic nervous system produces profuse sweating.
Incorrect: Excessive thirst is related to hyperglycemia, not hypoglycemia. When the blood contains higher amounts of glucose, the body attempts to dilute the blood with intracellular and extracellular fluid. As a result, the tissues lose water, causing thirst.
Incorrect: Frequent urination is related to hyperglycemia, not hypoglycemia. When the blood contains higher amounts of glucose, the body attempts to dilute the blood with intracellular and extracellular fluid. This extra fluid increases urine output.
The nurse is preparing a client for a fecal occult blood test. Which statement provides the most accurate information about this test?
Dietary preparation is not necessary for this test.
One positive test indicates gastrointestinal bleeding.
The client can continue to take vitamins and aspirin during the test period.
This test detects small amounts of blood in the feces.
Incorrect: Dietary preparation is generally required for this test. The client needs to avoid red meat, poultry, and raw vegetables before and during the test to prevent a false positive reaction.
Incorrect: One positive test is not diagnostic for blood in the stool. Three tests must be positive in order to confirm the presence of blood in the stool.
Incorrect: The client should avoid vitamin C and aspirin during the test period because these preparations may result in a false positive result.
Correct: The fecal occult blood test is a useful diagnostic tool for detecting blood in feces that may be due to colon cancer.
What is the purpose of the Apgar score after birth?
To estimate gestational age
To determine if the baby needs to be transferred to the intensive care unit (ICU).
To determine if the newborn needs resuscitation.
To predict if the baby will have long-term problems.
Incorrect: Apgar scores do not correlate with the gestational age, and are not used for this purpose.
Incorrect: Although babies that score low on the Apgar may be transferred to the ICU, this is not the purpose of the Apgar.
Correct: The one-minute and five-minute Apgar is a ten-point scoring tool used to assess the need for resuscitation systematically in the newborn. This score reflects the baby’s physical condition at birth.
Incorrect: Apgar scores are not used to evaluate the baby for long-term health needs or health problems.
The nurse is administering eye drops to a client. To prevent injury, the nurse should:
Ask the client to “look down” before instilling the eye drops.
Drop the eye drops directly onto the client’s cornea.
Rest his hand on the client’s forehead.
Shine a bright light into the client’s eye.
Incorrect: The nurse should ask the client to “look up” before instilling the eye drops. This action reduces stimulation of the corneal reflex and injury to the eye, should the client jerk away.
Incorrect: Eye drops should never be dropped directly onto the cornea as this action may injure the cornea. The nurse should deposit the medication onto the lower conjunctiva.
Correct: As a safety precaution, the nurse administering eye drops should rest his hand on the client’s forehead. In case the client moves, the nurse’s hand will move at the same time, lowering the risk that the dropper will hit the client’s eye.
Incorrect: When administering eye drops, it is essential to have an adequate amount of light. However, the nurse should not shine a bright light directly into the client’s eye.
The PN is preparing to administer an enteral feeding to a client. To prevent gastric cramping and discomfort due to the feeding, the nurse should:
Allow time for the formula to reach room temperature prior to administration.
Determine tube placement once every 24 hours.
Prepare to administer full-strength rather than diluted formula.
Elevate the head of the bed during and after feedings.
Correct: Cold formula can cause gastric discomfort. With enteral feedings, particularly via gastrostomy tube, the formula reaches the stomach quickly, with little or no opportunity to be warmed, as oral feedings would as they pass through the mouth and esophagus.
Incorrect: Tube placement is confirmed prior to beginning each feeding. This action does not prevent gastric discomfort. However, checking tube placement does help prevent the infusion of the formula into the lungs.
Incorrect: To prevent gastric discomfort, the concentration of the tube feeding formula needs to be advanced gradually. Full-strength formula may cause gastric discomfort, especially when the first few feedings are administered.
Incorrect: The head of the bed should be elevated at least 30° during the feeding and for at least 30 minutes after feeding. This is done to reduce the risk of aspiration, however, not to prevent cramping and discomfort.
A client develops wheals as a result of an allergic reaction to a medication. When documenting the reaction, the nurse correctly describes a wheal as:
A flat, nonpalpable, brown lesion with an irregular boarder.
A slightly elevated, palpable mass with a clearly defined border.
Fine, silvery-white, irregularly shaped flakes that adhere to the skin.
An itchy, elevated, reddened mass with an irregular border and shape.
Incorrect: This is a description of a macule, not a wheal. Freckles or flat moles are examples of macules.
Incorrect: This is a description of a papule, not a wheal. Warts or elevated nevi are examples of papules.
Incorrect: This is a description of scales, not wheals. Dandruff or dry skin are examples of scales.
Correct: This is the correct description of a wheal. Urticaria (or hives) is characterized by the development of wheals.
A pregnant client calls the telephone triage nurse and states, “I think I may be in preterm labor.” Which question should the nurse ask first?
“Have you discussed the signs of impending labor with your Certified Nurse Midwife (CNM)?”
“Have you experienced preterm labor before?”
“How often are your contractions?” “When is your estimated date of delivery (EDD)?
Incorrect: While assessing the client’s knowledge base concerning labor is important, it is not the first question the nurse should ask.
Correct: A history of preterm labor is the most important risk factor for subsequent preterm labor and delivery.
Incorrect: While this is an important question, it is not the first question the nurse should ask. The client may be experiencing Braxton-Hicks contractions, which are normal during pregnancy.
Incorrect: While the EDD is an important consideration in the assessment of preterm labor, it is not the first question the nurse should ask.
The nurse performs a physical assessment on a newborn baby. Which finding, if noted, is abnormal and needs to be reported?
Apnea lasting 5 to 15 seconds
Blue color in the fingers and toes
Gagging or choking
Respirations of 80 per minute
Incorrect: Apnea lasting 5-15 seconds is periodic apnea, and is normal for the newborn. No intervention is required as long as there is no change in the infant’s heart rate.
Incorrect: A blue color in the fingers and toes is called acrocyanosis, and it is a normal finding in the newborn in the first couple of days after birth.
Incorrect: Gagging or choking is common in the hours following birth because the infant was in a fluid-filled environment for the gestation. There should be a bulb syringe in the infant’s crib at all times to suction the mouth, pharynx, and nose, and clear the airway as needed.
Correct: Normal respirations range for the newborn is 30-60 respirations per minute. Rapid breathing is a sign of respiratory distress, which may indicate sepsis or other complications and should be reported immediately.
The nurse is caring for a client following insertion of a pacemaker. The client is placed on continuous ECG monitoring because it will:
Allow the primary care provider to adjust voltage settings.
Check placement of the pacer wires.
Detect a dramatic change in heart rate.
Determine dislodgement of pacer leads.
Incorrect: This is incorrect because pacemaker voltage settings are adjusted manually at the time of insertion.
Incorrect: A chest x-ray is used to check the placement of pacer wires after a pacemaker insertion.
Correct: The heart rate may change following pacemaker insertion because the pacemaker fails to maintain the pre-set heart rate. This problem can be detected immediately with continuous ECG monitoring.
Incorrect: Fluoroscopy is used to determine dislodgment of pacer leads after a pacemaker insertion. Dislodgement can be prevented with bedrest and minimal arm and shoulder activity.
