ATI: Practice Test A 2016, Fundamentals I and II – Flashcards
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most important aspect of hand hygiene
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friction
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primary prevention includes
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elimination of the exposure
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what should you do if the reliability of monitoring equipment is questioned
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use manual monitoring (esp for BP) and remove malfunctioning equipment
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physical exam on a toddler
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do the most distressing part of the exam last
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body mechanics for making an occupied bed
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put bed in high horizontal position
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where should the nurse place a stethoscope to listen to the aortic valve
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2nd intercostal space to the right of the sternum
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patient concerned about getting an infection from a blood transfusion
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patient can donate autologous blood prior to surgery
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colorectal cancer screening
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fecal occult blood test every year screening for patients at average risk starts at age 50
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what do you do if patient with nasal cannula has difficulty breathing
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assist to upright position
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what do you do prior to liquid medication administration
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shake the liquid to make sure its properly mixed
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how to improve self-feeding for a patient with vision loss
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arrange food in clock pattern
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exercises for patient at risk of osteoporosis
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weight bearing exercises such as walking briskly
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position for incentive spirometer use
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semi-fowler's
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procedure for 24 hour urine collection
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discard first void and save all voids after
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contradictions for herpes zoster and other skin infections
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acupuncture can increase risk of infection
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steps in assisting client from bed to chair
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1. ask if patient can bear weight 2. put chair on strong side of body 3. have client sit and dangle feet 4. use the stand-and-pivot technique to move the client to the chair
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mixing insulin
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air in NPH air in regular withdrawal regular withdrawal NPH
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aid for position changes for patient with LE weakness
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trapeze bar
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infiltration of IV
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skin blanching, edema, coolness
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phlebitis of IV
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red line, warmth
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cane use
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hold cane on stronger side of the body top of cane parallel to greater trochanter advance cane 6-12 inches at a time move weaker leg forward with the cane
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food not on mechanical soft diet
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fried eggs (eggs can be poached or scrambled)
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advanced directives
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indicate form of treatment client is willing to accept in the case of a serious illness
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indication client on bed rest has developed thrombophlebitis
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swelling, redness, tenderness and swelling of calf
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describe quality of pain
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how the pain feels to the patient, such as dull ache
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ear medication administration
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ear up and out, press gently on the tragus
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check patient with visual impairments for these things to prevent fall
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pupil clarity, visual fields, visual acuity
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if client is angry about a diagnosis
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reassure client this is a normal phase of grief
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what do you do when inserting a peripheral IV
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put the arm in a dependent position
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patient with latex allergy
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wrap monitoring cords in sockinette and tape them
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NG tube insertion
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bed at 90°, take sips of water, if patient gags or chokes do not remove tube just pull back slightly
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interventions for patient with purulent drainage
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major wound infection that requires contact precautions
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antiembolic stocking interventions
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remove antiembolic stockings at least once per shift to assess circulation and skin integrity
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bed position for enteral feedings
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HOB at 30°
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priority intervention for older adult receiving IV fluids
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monitor lung sounds which can indicate FVE
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abnormal sounds in the carotid arteries
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bruits which means narrowing of the arterial lumen
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what finding is a major concern in patient who has V/D for the past 3 days
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tachycardia because it can indicate FVD
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irrigating an indwelling catheter
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subtract the amount of irrigant used from the client's urine output
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procedure within RN scope of practice
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initiate enteral feedings
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tracheostomy suctioning
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catheter half the size of the lumen 100% O2 before suctioning lubricate end of catheter in sterile water or 0.9% NaCl adjust suctioning to 120 mm Hg and no more than 150 mm Hg
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romberg's test
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helps identify alterations in balance and has the patient stand with arms at side and feet together
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contact precaution diseases
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MRSA VRE RSV C. diff Scabies Ebola
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droplet precaution diseases
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Meningitis Flu Rubella Pertussis (whopping cough) Mumps Ebola
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airborne precaution diseases
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TB Varicella (chicken pox) Measles
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vector precaution diseases
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Lyme's Disease Malaria
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protective environment used for who
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immune system compromises
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weighing patient with FVE
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same time every day - in the morning on arising same clothes same scale balanced daily
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foods to offer patient with dysphagia
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tart or sour foods because they increase saliva production which helps with chewing and swallowing
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when can you remove an NG tube
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when there are bowel sounds and passing of flatus the client can have the tube removed and start on a clear liquid diet then progress to a regular diet
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what type of patient do you assess for oxygen toxicity while on oxygen therapy
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patient on 100% oxygen via partial rebreather mask
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when can oxygen toxicity occur
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oxygen concentrations above 50% for longer than 24-48 hrs
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when are tube feedings prescribed
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when patient is unable to eat by mouth
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before starting patient on any diet (giving any food or liquid), what must the nurse do
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listen to bowel sounds because must have bowel sounds before they can eat or drink anything
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where should the nurse tape a catheter on a male to prevent pressure on the urethra at the penoscrotal junction
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lower abdomen or inner aspect of thigh
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what nursing action prevents injury to client's eye when giving eye drops
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hold the tip above the eye, never let it touch the eye
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irrigating ostomy
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irrigating solution max of 20 inches above stoma use lukewarm tap water insert lubricated cone tip into ostomy stoma up to 1,000 mL can be used for irrigation
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communicating with hearing impaired patient
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face the client and speak slowly
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type of enema given before digital removal of fecal mass
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oil retention enema
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what observation should be reported when changing wound dressing
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a halo of erythema on the surrounding skin which may indicate an underlying infection
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replacing surgical dressing
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use clean gloves to remove old dressing loosen the dressing by pulling the tape towards the wound remove dressing layer by layer prepare the sterile field before removing old dressing
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concerns for wounds healing by secondary intention
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increased susceptibility for infection because wound edges are left open
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teaching for client who will be changing dressing at home
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proper hand hygiene and medical (clean) asepetic technique
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how often should a post-op patient use an incentive spirometer after surgery
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4-5 times every hour
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when will a sputum specimen for culture and sensitivity be collected
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in the morning, on arising (before breakfast)
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first action when coming across patient in need of CPR
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chest compressions (before attaching AED)
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to promote healing and fight wound infection, the nurse will plan to increase the client's intake of what
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vitamin c and zinc in a multivitamin and mineral supplement of both (also possible vitamin e)
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highest priority for performing eye irrigation
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wear gloves
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what should the nurse use around the incision area for a dressing that will be changed frequently
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montgomery straps
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priority before administering opioids
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measure vital signs
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what action will ensure proper operation of a closed wound suction device
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collapsing the device whenever it is 1/2 to 2/3 full of air
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nursing action if NG tube is not draining
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irrigate tube, but if unsuccessful and tube is likely obstructed you must notify the surgeon
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first action nurse should take before inserting NG tube
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explain the procedure
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what is the first thing for a nurse to do when patient complains of pain, irritation, etc.
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assessment
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signs of IV infilatration
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infusion slows or stops cool temp around injection swelling, hardness, pain around the needle site blood fails to return in the tubing when bottle is lowered
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what should the nurse do when obtaining a urine specimen for culture and sensitivity from an indwelling catheter
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cleanse the entry port prior to withdrawing urine
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urine specimen collection for culture and sensitivity testing
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surgical asepsis clean gloves can be used instead of sterile gloves
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urine specimen collection is unsterile if
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urine is collected from the urometer port or from the drainage bag
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urine specimen via dipstick to test specific gravity will have results that will indicate the amount of what
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solutes in urine
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example of an open-ended statement used to elicit further information from the client
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"tell me how you are feeling right now"
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