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Foundations- Exam 2 (ATI questions)
Terms in this set (23)
A nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hours while reporting pain at a 2 on scale of 0 to 10 after receiving medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply)
a) Extremes in age
b) Impaired circulation
c) Impaired/suppressed immune system
e) Poor wound care
b) The client who has type I diabetes mellitus is at risk for impaired circulation.
c) The client who has type I diabetes mellitus is at risk for impaired immune system function.
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (select all that apply)
a) Increase in incisional pain
b) Fever and chills
c) Increase in serosanguinous drainage
d) decrease in thirst
a) The nurse should expect the client to have pain and tenderness at the wound site of an incisional infection.
b) The nurse should expect the client to have fever and chills with an incisional infection
c) The nurse should expect the client to have reddened or inflamed wound edges with an incisional infection.
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention (select all that apply)
a) Stage III ulcer
b) Sutured surgical incision
c) Casted bone fracture
d) Laceration sealed with adhesive
e) Open burn area
a) Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges.
e) Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges.
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take?
a) Cover the area with saline-soaked sterile dressings.
b) Apply an abdominal binder snugly around the abdomen.
c) Use sterile gauze to apply gentle pressure to the exposed tissues.
d) Position the client supine with his hips and knees bent.
e) Offer the client a warm beverage, such as herbal tea
a) The nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene.
d) This position minimizes pressure on the abdominal area.
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply)
a) Keep the head of the bed elevated at 30 degrees.
b) Massage the client's bony prominences frequently.
c) Apply cornstarch liberally to the skin after bathing.
d) Have the client sit on a gel cushion when in a chair.
e) Reposition the client at least every 3 hours while in bed.
a) The nurse should slightly elevate the client head of bed reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heals.
d) The nurse should have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas.
A nurse in a provider's office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (select all that apply)
a) "does your lack of sleep interfere with your ability to function during the day?"
b) "Do you feel confused in late afternoon?"
c) "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?"
d) "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?"
e) Tell me about any personal stress you are experiencing."
a) Daytime sleepiness, which can interfere with functioning, is common during the day when people cannot sleep at night.
c) Caffeinated drinks act as a stimulant and can interfere with sleep.
d) Periods of apnea warrant a prompt referral for diagnostic sleep studies.
e) Emotional stress is the most common cause of short-term sleep problems.
A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? Select all that apply
a) Practice muscle relaxation techniques.
b) exercise each morning
c) Take an afternoon nap
d) Alter the sleep environment for comfort
e) Limit fluid intake at least 2 hours before bedtime
a) relaxation techniques, especially muscle relaxation, can help promote sleep and rest.
b) Following an exercise routine regularly, at least 2 hours prior to bedtime, can help promote sleep and rest.
d) For example, rather than trying to sleep with a restless pet at the food of the bed, move the pet to another sleep area.
e) Limiting fluids for a few hours before bedtime helps minimize getting up to urinate.
A nurse is caring for an older adult client who has been following the facility's routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take FIRST? Select all that apply
a) Rub the client's back for 15 minutes before bedtime
b) Offer the client warm milk and crackers at 2100.
c) Allow the client to take a bath in the evening.
d) Ask the provider for a sleeping medication.
c) When providing nursing care, the nurse should first use the least restrictive intervention. Of these options, allowing the client to follow her usual bedtime routine represents the least change, so it is the first intervention to try.
A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? select all that apply
a) REM sleep provides cognitive restoration
b) REM sleep lasts about 90 minutes
c) It is difficult to awaken a person in REM sleep.
d) Sleepwalking occurs during REM sleep.
e) Vivid dreams are common during REM sleep.
a) Cognitive and brain tissue restoration occur during REM sleep
c) In this stage, awakening is difficult. Awakening is relatively easy in stages 1 and 2 of non-REM sleep.
e) Dreaming does occur in other stages, but less vivid and possibly less colorful.
A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
a) "I'll add plenty of carbohydrates to my meals."
b) "I'll take a short nap whenever I feel a little sleepy."
c) "I'll make sure I stay warm when I am at my desk at work"
d) "It's okay to drink alcohol as long as I limit it to one drink per day."
b) Client's who have narcolepsy should take short naps to reduce feelings of drowsiness.
A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine?
a) Presence of associated manifestations
b) Location of the pain
c) Pain quality
d) Aggravating and alleviating factors
a) the nurse should attempt to identify manifestations that occur along with the client's pain, such as nausea, fatigue, or anxiety.
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain?
a) Ask the client what precipitates the pain
b) Question the client about the location of the pain
c) Offer the client a pain scale to measure his pain
d) Use open-ended questions to identify the client's pain sensations.
c) The nurse should use a pain rating scale to help the client report the intensity of his pain. The nurse should use a numeric, verbal, or visual analog scale appropriate to the client's individual needs.
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?
a) A client who has a broken femur and reports hip pain
b) A client who has incisional pain 72 hour following pacemaker insertion.
c) A client who has food poisoning and reports abdominal cramping.
d) A client who has episodic back pain following a fall 2 years ago.
d) A client who reports pain that lasts more than 6 months and continues beyond the time of tissue healing is experiencing chronic pain. The nurse should identify this client's pain as chronic, and assist with planning interventions to relieve manifestations associated with the pain.
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (select all that apply)
a) Urinary incontinence
d) orthostatic hypotension
c) Opioid analgesia can cause respiratory depression, which causes respiratory rates to drop to dangerously low levels. The nurse should monitor the client's respiratory rate, and administer naloxone if indicated.
d) Opioid analgesia can cause orthostatic hypotension. The nurse should monitor the client for dizziness or lightheadedness when changing positions.
e) Opioid analgesia can cause nausea and vomiting. The nurse should monitor for and treat these complications as needed.
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?
a) "I'll want to use the device until it is absolutely necessary"
b) "I'll be careful about pushing the button too much so I don't get an overdose."
c) "I should tell the nurse if the pain doesn't stop while I am using this device"
d) "I will ask my adult child to push the dose button when I am sleeping"
c) PCA allows the client to self-administer pain medication on an as-needed basis. If the client is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the client's pain management plan and possible dosage change.
A nurse is caring for a client who is 1 day postoperative following a total knee arthoplasty. The client states his pain level is a 10 on a scale of 0 to 10. After reviewing the client's medication record, which of the following medications should the nurse adminstered?
a) Meperidine 75 mg IM
b) Fentanyl 50 mcg/hr transdermal patch
c) Morphine 2 mg IV
d) Oxycodone 10 mg PO
c) The nurse should administer IV morphine because the onset is rapid, and absorption of the medication int the blood is immediate, which provides the optimal response for a client who is reporting pain at a level of 10.
A nurse is teaching a client about taking multiple oral medications at home to include time-release capsules, liquid medications, enteric-coated pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
a) I can open the capsule with the beads in it and sprinkle them on my oatmeal
b) If I am having difficulty swallowing, I will add the liquid medication to a batch of pudding.
c) I can crush the pills with the coating on them.
d) I will eat two crackers with the pain pills.
d) The client should take irritating medications, such as analgesics, with small amounts of food. It can help prevent nausea and vomiting.
A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include?
a) Flush the tube before and after each medication.
b) Mix your medications with your enteral feeding
c) Push tablets through the tube slowly
d) Mix all the crushed medications prior to dissolving them in water.
a) The client should flush the tubing before and after each medication with 15 to 30mL water to prevent clogging of the tube.
A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take?
a) Use a 22-gauge needle.
b) Select a site on the client's abdomen.
c) Spread the skin with the thumb and index finger.
d) Observe for bleb formation to confirm proper placement.
b) For a subcutaneous injection, the nurse should select a site that has an adequate fat-pad size (abdomen, upper hips, lateral upper arms, thighs)
A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands proper technique?
a) I will straighten my ear canal by pulling my ear down and back.
b) I will gently apply pressure with my finger to the front part of my ear after putting in the drops.
c) I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.
d) After the drops are in, I will place a cotton ball all the way into my ear canal.
b) The client should gently apply pressure with the finger to the tragus of the ear after administering the drops to help the drops go into the ear canal.
A nurse prepares an injection of morphine to administer to a client who reports pain. Prior to administering the medication, the nurse assists another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take?
a) Offer to assist the client who needs the bedpan
b) Administer the injection the other nurse prepared
c) Prepare another syringe and administer the injection
d) Tell the client who needs the bedpan she will have to wait for her nurse
The second nurse should offer to assist the client who needs the bedpan. This will allow the nurse who prepared the injection to administer it.
A nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable administration times for this medication? select all that apply
A & D
The nurse should administer medications within 30 minutes of the time it is due. 0905 & 0840 are within 30 minutes of the time the medication is due.
A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention?
a) taking all medications out of the unit-dose wrappers before entering the clients room
b) checking with the provider when a single dose requires administration of multiplication tablets
c) Administering a medication, then looking up the usual dosage range
d) Relying on another nurse to clarify a medication prescriptions
If a single dose requires multiple tablets, it is possible that an error has occurred in the prescription or transcription of the medication.
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