question

what supplies should not be used during trach care

answer

cotton balls

question

what is the purpose of the nurse being a witness to consent

answer

to make sure the signature on the consent form belongs to the client

question

BP readings for patient with hypertension should be done...

answer

under the same conditions (same place and position)

question

steps of abdominal assessment

answer

inspection auscultation percussion palpation

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most important aspect of hand hygiene

answer

friction

question

primary prevention includes

answer

elimination of the exposure

question

what should you do if the reliability of monitoring equipment is questioned

answer

use manual monitoring (esp for BP) and remove malfunctioning equipment

question

physical exam on a toddler

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do the most distressing part of the exam last

question

body mechanics for making an occupied bed

answer

put bed in high horizontal position

question

where should the nurse place a stethoscope to listen to the aortic valve

answer

2nd intercostal space to the right of the sternum

question

patient concerned about getting an infection from a blood transfusion

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patient can donate autologous blood prior to surgery

question

colorectal cancer screening

answer

fecal occult blood test every year screening for patients at average risk starts at age 50

question

what do you do if patient with nasal cannula has difficulty breathing

answer

assist to upright position

question

what do you do prior to liquid medication administration

answer

shake the liquid to make sure its properly mixed

question

how to improve self-feeding for a patient with vision loss

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arrange food in clock pattern

question

exercises for patient at risk of osteoporosis

answer

weight bearing exercises such as walking briskly

question

position for incentive spirometer use

answer

semi-fowler's

question

procedure for 24 hour urine collection

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discard first void and save all voids after

question

contradictions for herpes zoster and other skin infections

answer

acupuncture can increase risk of infection

question

steps in assisting client from bed to chair

answer

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

question

mixing insulin

answer

air in NPH air in regular withdrawal regular withdrawal NPH

question

aid for position changes for patient with LE weakness

answer

trapeze bar

question

infiltration of IV

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skin blanching, edema, coolness

question

phlebitis of IV

answer

red line, warmth

question

cane use

answer

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

question

food not on mechanical soft diet

answer

fried eggs (eggs can be poached or scrambled)

question

advanced directives

answer

indicate form of treatment client is willing to accept in the case of a serious illness

question

indication client on bed rest has developed thrombophlebitis

answer

swelling, redness, tenderness and swelling of calf

question

describe quality of pain

answer

how the pain feels to the patient, such as dull ache

question

ear medication administration

answer

ear up and out, press gently on the tragus

question

check patient with visual impairments for these things to prevent fall

answer

pupil clarity, visual fields, visual acuity

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if client is angry about a diagnosis

answer

reassure client this is a normal phase of grief

question

what do you do when inserting a peripheral IV

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put the arm in a dependent position

question

patient with latex allergy

answer

wrap monitoring cords in sockinette and tape them

question

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

answer

major wound infection that requires contact precautions

question

antiembolic stocking interventions

answer

remove antiembolic stockings at least once per shift to assess circulation and skin integrity

question

bed position for enteral feedings

answer

HOB at 30°

question

priority intervention for older adult receiving IV fluids

answer

monitor lung sounds which can indicate FVE

question

abnormal sounds in the carotid arteries

answer

bruits which means narrowing of the arterial lumen

question

what finding is a major concern in patient who has V/D for the past 3 days

answer

tachycardia because it can indicate FVD

question

irrigating an indwelling catheter

answer

subtract the amount of irrigant used from the client's urine output

question

procedure within RN scope of practice

answer

initiate enteral feedings

question

tracheostomy suctioning

answer

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

question

romberg's test

answer

helps identify alterations in balance and has the patient stand with arms at side and feet together

question

contact precaution diseases

answer

MRSA VRE RSV C. diff Scabies Ebola

question

droplet precaution diseases

answer

Meningitis Flu Rubella Pertussis (whopping cough) Mumps Ebola

question

airborne precaution diseases

answer

TB Varicella (chicken pox) Measles

question

vector precaution diseases

answer

Lyme's Disease Malaria

question

protective environment used for who

answer

immune system compromises

question

weighing patient with FVE

answer

same time every day - in the morning on arising same clothes same scale balanced daily

question

foods to offer patient with dysphagia

answer

tart or sour foods because they increase saliva production which helps with chewing and swallowing

question

when can you remove an NG tube

answer

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

question

what type of patient do you assess for oxygen toxicity while on oxygen therapy

answer

patient on 100% oxygen via partial rebreather mask

question

when can oxygen toxicity occur

answer

oxygen concentrations above 50% for longer than 24-48 hrs

question

when are tube feedings prescribed

answer

when patient is unable to eat by mouth

question

before starting patient on any diet (giving any food or liquid), what must the nurse do

answer

listen to bowel sounds because must have bowel sounds before they can eat or drink anything

question

where should the nurse tape a catheter on a male to prevent pressure on the urethra at the penoscrotal junction

answer

lower abdomen or inner aspect of thigh

question

what nursing action prevents injury to client's eye when giving eye drops

answer

hold the tip above the eye, never let it touch the eye

question

irrigating ostomy

answer

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

question

communicating with hearing impaired patient

answer

face the client and speak slowly

question

type of enema given before digital removal of fecal mass

answer

oil retention enema

question

what observation should be reported when changing wound dressing

answer

a halo of erythema on the surrounding skin which may indicate an underlying infection

question

replacing surgical dressing

answer

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

question

concerns for wounds healing by secondary intention

answer

increased susceptibility for infection because wound edges are left open

question

teaching for client who will be changing dressing at home

answer

proper hand hygiene and medical (clean) asepetic technique

question

how often should a post-op patient use an incentive spirometer after surgery

answer

4-5 times every hour

question

when will a sputum specimen for culture and sensitivity be collected

answer

in the morning, on arising (before breakfast)

question

first action when coming across patient in need of CPR

answer

chest compressions (before attaching AED)

question

to promote healing and fight wound infection, the nurse will plan to increase the client's intake of what

answer

vitamin c and zinc in a multivitamin and mineral supplement of both (also possible vitamin e)

question

highest priority for performing eye irrigation

answer

wear gloves

question

what should the nurse use around the incision area for a dressing that will be changed frequently

answer

montgomery straps

question

priority before administering opioids

answer

measure vital signs

question

what action will ensure proper operation of a closed wound suction device

answer

collapsing the device whenever it is 1/2 to 2/3 full of air

question

nursing action if NG tube is not draining

answer

irrigate tube, but if unsuccessful and tube is likely obstructed you must notify the surgeon

question

first action nurse should take before inserting NG tube

answer

explain the procedure

question

what is the first thing for a nurse to do when patient complains of pain, irritation, etc.

answer

assessment

question

signs of IV infilatration

answer

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

question

what should the nurse do when obtaining a urine specimen for culture and sensitivity from an indwelling catheter

answer

cleanse the entry port prior to withdrawing urine

question

urine specimen collection for culture and sensitivity testing

answer

surgical asepsis clean gloves can be used instead of sterile gloves

question

urine specimen collection is unsterile if

answer

urine is collected from the urometer port or from the drainage bag

question

urine specimen via dipstick to test specific gravity will have results that will indicate the amount of what

answer

solutes in urine

question

example of an open-ended statement used to elicit further information from the client

answer

"tell me how you are feeling right now"

ATI: Practice Test A 2016, Fundamentals I and II – Flashcards

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