ATI Test Flashcards
A nurse is teaching a client and his family how to care for the clients tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
Use tracheostomy covers when outdoors.
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
The client’s caregiver washes out the feeding bag with warm water once every 24 hours.
A nurse is talking with an older adult client who is contemplating retirement. The client states, “I keep thinking about how much I enjoy my job. I am not sure I want to retire.” Which of the following responses should the nurse make?
Let’s talk about how the change in your job status will affect you.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client’s pain?
Is your pain sharp or dull
A nurse is caring for a client who is expressing anger about his diagnoses of colorectal cancer. Which of the following actions should the nurse take?
Reassure the client that this is an expected response to grief
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 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
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
Apply intermittent suction when withdrawing the catheter
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
Administer the medication with the need at a 45 degree angle
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?
Advocacy ensures clients’ safety, health, and rights.
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?
Press gently on the tragus of the client’s ear
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?
Use a bed exit alarm system
A nurse is initiating a protective environment for a client who has 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.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching
I will hire someone to trim the tree that hands low over the stairs of my front porch
A nurse is planning strategies to manage time effectively for client care. which of the following strategies should the nurse implement?
Use the planning step of the nursing process to prioritize client care delivery
A nurse is planning to insert a peripheral IV catheter or an older adult client. Which of the following actions should the nurse plan to take
Place the client’s arm in a dependent position
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel?
- Assist the client with a partial bed bath
- Measure the client’s BP after the nurse administers and antihypertensive medication
- Use a communication board to ask what the client wants for lunch
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indicate of a skin malignancy?
A mole with an asymmetrical appearance
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
Abdominal cramping
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?
SBAR
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client’s care, when should the nurse initiate discharge planning?
During the admission process
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nruse make?
We would give you oxygen through a tube in your nose
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.
Steps to take for a pt who died
Step one: Obtain the death pronouncement from the provider
Step two: Remove tubes and indwelling lines prior to cleansing the client’s body
Step three: Ask family members if they wish to see the body
Step four: Place a name tag on the body before transfer
Client teaching for self-administration of heparin
Administer the medication into the abdomen
Purpose of advance directives
They indicate the form of treatment a client is willing to accept in the event of serious illness
Which assessment should a nurse use to identify a client’s safety from falls
-Pupil clarity, visual fields, and visual acuity
A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
Calf swelling
A nurse is administering 1 L of sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
Decrease in heart rate
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
Check the client for injuries
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 has a terminal illness 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 hours
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
Place a client who has tuberculosis in a room with negative-pressure airflow
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.
What type of precaution is used for a client who has pharyngeal diphtheria
Droplet precautions
A nurse is caring for a client who is postop 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 every 15 minutes and report back in 1 hour. What is the nurses next step
Notify the nursing manager.
What fluid and electrolyte status should a nurse report to the provider?
Potassium 5.4 mEq/L
When changing a clients dressing, if they say it hurts what should you do?
Administer pain medication 45 min before changing the client’s dressing
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
Compare prescriptions with medications the client received while at the facility.
A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?
A client who has asthma
A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?
Droplet
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 is caring for a client who reports pain. When documenting the quality of the client’s pain on an initial pain assessment, the nurse should record which of the following client statements?
The pain is like a dull ache in my stomach
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?
I can take echinacea to improve my immune system
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
Compare prescriptions with medications the client received while at the facility
A nurse is reviewing a client’s medication prescription that reads, “digoxin 0.25 by mouth every day” Which of the following components of the prescription would the nurse verify with the provider?
Medication Dose
A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?
A client who has asthma
A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?
Droplet
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 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. Which of the following actions should the nurse take?
Withhold the blood transfusion
A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?
Current medications
A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?
Erythema on pressure points
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?
Practice sessions
A nurse is caring for a client who reports pain. When documenting the quality of the client’s pain on an initial pain assessment, the nurse should record which of the following client statements?
The pain is like a dull ache in my stomach
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
Initiate an enteral feeding through a gastrostomy tube
A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?
Evacuate the client
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?
I can take echinacea to improve my immune system
A nurse enters a client’s room and finds her on the floor. The client’s roomate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
Client found lying on floor
A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?
Have the client stand with their arms at their sides and their feet together
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
When descending stairs, I will first shift my weight to my right leg
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
Flush the tube with 15 mL of sterile water
A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?
A client who smokes on pack of cigarettes each day
A nurse is planning care 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 client’s plate
A nurse is planning an education program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?
You should receive a pneumococcal vaccine when you are 65 years old
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
A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?
Auscultate lung sounds
A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client’s risk of developing plantar flexion contractures?
Apply an ankle-foot orthotic device to the clients feet
A nurse is planning care for a client who has tuberculosis. The nurse should use which of the followign pieces of personal protective equipment when providing care for the client?
N95 respirator
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?
Wrap monitoring cords with stockinette and tape them in place
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess
Distended neck veins
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?
Have the client use a trapeze bar when changing position
A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take?
Instruct the family to refrain from pushing the button for the client while she is asleep
A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?
An x-ray shows the end of the tube above the pylorus
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?
The caregiver insists on remaining in the room
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 client for orthostatic hypotension
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client’s plan of care?
Wrap blankets around all four sides of the bed
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?
- Check the cord routinely for frays or tearing
- Consider purchasing a generator for power backup
- Observe for signs of hypoxia
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?
Tell the client to keep the head of the bed elevated at least 30 degrees
A nurse is calculating a client’s fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client’s intake and output record as 120mL of fluid?
8 oz of ice chips
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
Cleanse the wound from the center outward
A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. Which of the following information should the nurse include in the teaching?
Have family members wear a gown and gloves when visiting.
A nurse is caring for a client who requires a 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching.
I flushed what I urinated at 7 a.m. and have saved all urine since
A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate
Ambulating a client who is postoperative
Three tenths
0.3
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?
The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively
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 caring for a client who is receiving fluid through a peripheral Iv catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration
Skin blanching
Basic Principles of Ethics
- Advocacy: Support and defend clients’ health, wellness, safety, wishes, and personal rights, including privacy.
- Responsibility: Willingness to respect obligations and follow through on promises.
- Accountability: Ability to answer for one’s own actions
- Confidentiality: Protection of privacy without diminishing access to high-quality care.
Ethical Principles For Client Care
- Autonomy: The right to make one’s own personal decisions, even when those decisions might not be in that person’s own best interest
- Beneficence: Action that promotes good for others, without any self-interest
- Fidelity: fulfillment of promises
- Justice: fairness in care delivery and use of resources
- Nonmaleficence: A commitment to do no harm
- Veracity: A commitment to tell the truth
Unintentional Torts
- Negligence: A nurse fails to implement safety measures for a client at risk for falls.
- Malpractice: A nurse administers a large dose of medication due to a calculation error.
Quasi-intentional torts
- Breach of confidentiality: A nurse releases a client’s medical diagnoses to a member of the press.
- Defamation of character: A nurse tells a coworker that they believe the client has been unfaithful to their partner
Intentional torts
- Assault: A nurse threatens to place an NG tube in a client who is refusing to eat.
- Battery: A nurse restrains a client and administers an injection against their wishes.
- False Imprisonment: A nurse uses restraints on a competent client to prevent their leaving the health care facility.
Informed Consent
- Provider: Obtains informed consent
- Client: Gives informed consent
- Nurse: Witnesses informed consent
Nurses Role in Advance Directives
- Provide written information about advance directives
- Document the client’s advance directives status
- Ensure that the advance directives reflect the client’ts current decisions
- Inform all members of the health care team of the client’s advance directives.
Exudate Types
1st- serous- clear and gold- normal drainage every time you cut the body
2nd- serous sangranious- pink tinged- can be normal
3rd- sangranious- bloody drainage
4th- purulent or puss- yellow/green
Disinfectant
A chemical used on surfaces to kill pathogenic organisms, but not necessarily spore forms or viruses
Antiseptic
A chemical that is applied to living tissues to reduce the number or microorganisms present
Standard precautions
- apply to blood, blood products, all body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes
-Alcohol-based waterless antiseptic recommended if hands are not visibly soiled.
-Soap and water for C. diff.
-
Airborne precautions
- Airborne respiratory particle: < 5 microns
- Infection: measles, chickenpox, disseminated varicella zoster, pulmonary or laryngeal tuberculosis
-Protection:
Private room
Negative-pressure airflow of at least 6 to 12 exchanges per hour via high-efficiency particulate air (HEPA) filtration;
=[mask or respiratory protection device, N95 respirator (depending on condition), gown, gloves, dedicated equipment
Droplet precautions
- Respiratory droplets come from coughs, sneezes, or talking. They can travel only a few feet through the air
- For disease that are transmitted by large droplets (> 5 microns) W/in 3 feet of the patient.
- Infection: Diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants and young children, pertussis, mums, Mycoplasma pneumonia, meningococcal pneumonia or sepsis, pneumonic plague
- Protection: private room or cohort patients; mask or respirator required (depending on condition) Masks, gown and gloves, Dedicated equipment
Contact Precautions
- This can be direct skin-to-skin contact or indirect contact such as when an infection carrying person touches a surface and then someone else touches that same surface.
- Blood and bodily fluids can transmit disease if they contact a susceptible host’s broken skin or mucous membranes.
- infection: colonization or infection with multi drug-resistant organisms such as VRE and NRSA, Clostridium difficile, shigella, and other enteric pathogens; major wound infections; herpes simplex; scabies; varicella zoster (disseminated); respiratory syncytial virus in infants, young children, or immunocompromised
- Protection: private room or cohort patients, gloves, gowns (patients may leave their rooms for procedures or therapy if infectious material is contained or covered, placed in a clean gown, and if hands are clean)
Examples of tasks nurses may delegate to PN’s
- Monitoring findings (as input to the RN’s ongoing assessment)
- Reinforcing client teaching from a standard care plan
- Performing tracheostomy care
- Suctioning
- Checking NG tube patency
- Administering enteral feedings
- Inserting a urinary catheter
- Administering medication, excluding IV medication
Examples of tasks nurses may delegate to AP’s
ADL’s
Bathing, grooming, dressing, toileting, ambulating, feeding, positioning.
Bed making, specimen collection, I&O, Vital signs
Sterile Field
- The outer wrappings and 1 inch edges of packaging that contains sterile items are not sterile
- Any object below the waist or above the chest is contaminated.
Herpes Zoster
A common viral infection that erupts years after exposure to chickenpox and invades a specific nerve tract
seizure precautions
-Make sure oxygen, an oral airway, suction equipment, padding for side rails are at the bedside.
Restrain prescriptions
- 4 hrs for an adult
- 2 hrs for 9-17 year old
- 1 hour for younger than 9
Nursing responsibilities for clients in restrains
- Assess skin integrity and give skin care every 2 hours
- Pad bony prominences
- Make sure restraints are loose enough to fit two fingers between.
- Never leave the client alone without restraints
Fire Safety
RACE Rescue Alarm Contain Extinguish
Semi-Fowler’s
- Client supine with HOB elevated 30 degrees
- Prevents regurgitation of enteral feedings and aspiration
- Promotes lung expansion
High-Fowler’s
- Client supine with HOB elevated 45-60 degrees
- Promotes lung expansion, Prevents aspiration
Supine
Client on their back
Prone
Client on their abdomen
Aloe
Wound healing
Chamomile
Anti-inflammatory, calming
Echninacea
Enhances immunity
Garlic
Inhibits platelet aggregation
Ginger
Antiemetic
Ginko biloba
Improves memory
Ginseng
Increases physical endurance
Valerian
Promotes sleep, reduces immunity
