ATI review Flashcards
Hand off report
ISBAR
Introduction
Situation
Background
Assessments
Recommendation
a nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. which of the following findings should the nurse ID as manifestations of fluid volume deficit SATA
- decreased skin turgor
- concentrated urine
- bradycardia
- low grade fever
- tachypnea
decreased skin turgor
concentrated urine
tachypnea
A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the critical thinking attitudes did the nurse demonstrate?
Confidence
Perseverance
Integrity
Discipline
- *Discipline**
- Develops a systematic approach to thinking
Integrity-Practice truthfully and ethically
A Nurse on a med surg unit has received change of shift report and will care for 4 clients. Which one of the following client’s needs may the nurse assign to AP?
A. Feeding a client admitted 24hrs ago with aspir. pneumonia
B. Reinforcing Teaching w/ a client who is learning to walk w/ a cane
C. Reapplying a condom cath for a client who has urinary incontinence
D. Applying sterile dressing to a pressure ulcer
C
Teaching needs professional knowledge
Nurse is delegating ambulation of a client who had knee arthoplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (select all that apply)
A. The roommate is up independently
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30min ago
E. Client is allergic to codeine
F. Client ate 50% of his breakfast this morning
B,C,D
An RN is making assignments for client care to an LPN at the beginning of a shift. Which of the following assignments should the LPN question?
A. Asisst the client who is 24hrs post op w/ incentive spirometry
B. Collecting a clean catch urine specimen for a client who was admitted on previous shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump
D
patient-controlled analgesia pump
Nurse is preparing an in service program about delegation, Which of the following elements should she identify when presenting the 5 rights of delegation? (select all that apply)
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right Time
E. Right circumstances
B,C,E
Right person doesn’t mean patient, means CNA
Nurse can delegate?
Bathing
Grooming
Dressing
Toileting
Ambulating
Feeding
Specimen collection
I&O
Vital sings
A charge nurse is assigning client care for four clients. Which one the following tasks should the nurse assign to a PN?
A, Creating plan of care for a client who is recovering following a stroke
B, Assessing a pressure injury on a client who is on bed rest
C, Providing nasopharyngeal suctioning for a client who has pneumonia
D, Teaching a client who has asthma to use a metered-dose inhaler
C
A nurse is preparing an in-service program about delegation.
Which of the following are components of the five rights of delegation?
a) Right place
b) Right supervision and evaluation
c) Right direction and communication
d) Right documentation
e) Right circumstances
B,C, E
Right place means right route
A nurse is caring for a client who decides not to have surgery despite significant blockage of the coronary arteries.
a) Fidelity
b) Autonomy
c) Justice
d) Nonmaleficence
b
A nurse offer pain meds to a client who is postoperative prior to ambulation.
a) Fidelity
b) Autonomy
c) Justice
d) Beneficence
d
All clients waiting for a kidney transplant have to meet the same qualification.
a) Fidelity
b) Autonomy
c) Justice
d) Nonmaleficence
C
A nurse questions a medication prescription as too extreme in light of the client’s advanced age and understand status.
a) Fidelity
b) Autonomy
c) Justice
d) Nonmaleficence
d
A nurse fails to implement safety measures for a client at risk for falls
Negligence?
Malpractice?
Negligence
A nurse administers a large dose of meds due to calculation error. The client has a cardiac arrest and dies.
Negligence?
Malpractice?
Malpractice
(Professional negligence)
A nurse threatens to place an NG tube in a client who is refusing to eat.
Assault?
Battery?
False imprisonment?
Assault
verbal abuse
A nurse restrains a client and administers an injection against their wishes.
Assult?
Battery?
False imprisonment?
Battery
Physical abuse
A nurse uses restraints on a competent client to prevent their leaving the health care facility.
Assult?
Battery?
False imprisonment?
False imprisonment
Informed consent
Nursing responsibility
Witnesses informed consent
Ensure that provide give enough info.
Ensure the clients understand.
Have the client sing the document
Advance directive
Nurse responsibility
Provide written information about advance directives.
Ensure that the advice directives reflect current client’s decision.
Therapeutic communication
Eye contact!
Eye level!
Presenting reality is an effective communication.
“Your daily routine will be different when you get back home”
Encourage pt to talk!
Use interpreter
Must be medical profession interpreter
No family, nurse
Look at the client not interpreter
A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
A. pad the client’s wrist before applying the restraints
B. evaluate the client’s circulation q8h after application
C. remove the restraints q4h to evaluate the client’s status
D. secure the restraint ties to the bed’s side rails
A
B>the nurse should evaluate the client’s circulation, ROM, VS, and overall status every 15 min after initial application of restraints
a nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the client?
A. use a bed exit alarm system
B. raise four side rails while the client is in bed
C. apply one soft wrist restraint
D. dim the lights in the client’s room
A
RACE fire mnemonic
R- rescue patient
A- activate alarm
C- close window contain
E- extinguish
A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (Select all that apply.)
A. Request assistance when repositioning a client.
B. Avoid twisting the spine or bending at the waist.
C. Keep the knees slightly lower than the hips when sitting for long periods of time.
D. Use smooth movements when lifting and moving clients.
E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles.
A,B,D
A nurse educator is teaching a module on proper body mechanics during employee orientation. Which
of the following statements by a newly hired nurse indicates the need for further teaching?
A. “My line of gravity should fall outside my base of support.”
B. “The lower my center of gravity, the more stability I have.”
C. “To broaden my base of support, I should spread my feet apart.”
D. “When I lift an object, I should hold it as close to my body as possible.”
A
Contact percussion
PPE
C.diff
Hyper zoster
Helps
gown and mask
Droplet percussion
PPE
Mask
A nurse is caring for a patient who has multiple sclerosis and has a chronic nonhealing wound. The nurse should recognize that which of the following types of medication is known to delay wound healing?
A. Tricyclic antidepressants
B. Corticosteroids
C. Beta blockers
D. Anticholinergics
B. Corticosteroids
Corticosteroids suppress the immune system and therefore can delay wound healing.
A nurse assessing a pressure ulcer over a patient’s right heel area observes a deep crater with no eschar or slough and no exposed muscle or bone. The nurse should document that this patient has a pressure ulcer that is
A. unstageable
B. a suspected deep tissue injury
C. stage IV
D. stage III
D. stage III
A patient who has Full-thickness wound continues to experienc considerable pain during dessing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressing should the nurse select to help minimize the pain of dressing changes?
A. Wet-to-dry
B. Antimicrobial
C. Gauze
D. Hydrogel
D. Hydrogel
In general, keeping some moisture within a wound reduces pain. Hydrogel dressings work by maintaining a moist wound environment, so they are a good choice for helping to reduce the pain associated with dressing changes.
A nurse is documenting data about a healing wound on a patient’s lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document this exudate as
A. serosanguineous
B. sanguineous
C. serous
D. purulent
A. serosanguineous
A nurse is preparing to insert a peripheral IV catheter into the clients arm.
Which of the nurse take to help dilate the vein?
a) Stroke the skin near the vein in an upward position
b) Dangle the client’s arm over the edge of the bed
c) Apply a cool compress to the vein for 10 min
d) Instruct the client to flex their arm with the hand open
B
A nurse is caring for a client who requires a peripheral IV insertion.
When choosing the site, which of the following sites should the nurse select?
a) Select a vein in the client’s dominant arm
b) Chose the most proximal vein in the extermity
c) Choose a vein that is soft on palpation
C
Recognizing phlebitis
S/S
Intervention
Edema
Throbbing
Burring
Pain
Erythema
Promptly discontinue
Elevate the extremity
Apply warm compresses
Increase temp
A nurse on the IV team is conducting an in-service education program about the complications of IV therapy.
Which one is infiltration? SATA
a) The temp around the IV site is cooler
b) The rate of the infusion increase
c) The skin at the IV site is red
d) The IV dressing is damp 湿った
e) The tissue around the venipuncture site is swollen
A,D,E
Due to IV solution entering subcutaneous
A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride.
Which of indicate fluid overload?
a) I feel lightheaded
b) I feel as though my heart is racing
c) I feel a little short of breath
d) The nurse told me that my BP was 150/90
e) I think my ankles are less swollen
B,C,D
Eye drop administer
1) conjunctival sac 1-2 cm
2) apply gentle pressure
If more than one medication, wait at least 5 mints
clotrimazole suppository
self-Insert
Supine and knees bent
Gently insert
Press the applicator’s plunger as far as it goes
Rectal suppository
self-Insert
Left lateral pr Sims
For adults, push it in one inch
For children, in a half inch
same position at least 5 mints
clotrimazole suppository
Insert by nurse
Supine and knees bent
Insert about 5 to 7.6cm
After insert, remain the position at least 5 minis
Pressure injury dressing
Stage 1
Self-adhesive
Transparent film
Pressure injury dressing
Stage 2
Hydrocolloid
Pressure injury dressing
Stage 3
Alginates
Pressure injury dressing
Stage 4
Alginates+gauze
Droplet
Example
Influenza
Rubella
Meningococcal pneumonia
Streptococcal pharyngitis
What is the quality of the pain
Sharp
Dull
What is the expecting urine specific gravity?
1.005-1.030
Purulent exudate
an inflammatory exudate with a high concentration of leukocytes
Can the nurse from another unit can see the document or document for the pt?
NO!
Nurse has to be the unit nurse=direct care the pt
Is necessary to include Client flow sheet with transfer report?
No
NO
They should have continuous urine flow
THerfore, nouse should irrigate the cathter to resolove blockage
Bladder scan shows 535ml
( volume greater than 200 mL is considered abnormal)
Which transmission is pharyngeal diphtheria?
Droplet
Nurse should wear mask if providing care when within 1m/3feet
Regular range amount
BUN
Creatinine
Sodium
K+
BUN 10-20
Creatinine 0.5-1.1
Na+ 136-145
K+ 3.5-5
