ATI Fundamentals 2

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, “Help! My baby is choking on his food.” Which of the following findings indicates the toddler has an airway obstruction?Inability of the toddle to cry or speak.

bc no sounds passing through vocal cords
use heimliech maneuver

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?Collect the specimen upon arising in the morning.

in the morning it’s easier to cough up secretions
deepest specimens are usually collected in morning
try to collect before breakfast
prior to coughing into container: rinse mouth and deep breathe

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?Start chest compressions.

give priority to the factor or situation posing the greatest safety risk.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?Hold breath for 5 seconds after goal volume is reached.

decreases collapse of alveoli, which helps prevent risk of atelectasis and pneumonia

nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?Pinch the NG tube while removing the tube.

decreases risk of aspiration of any GI contents

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching.Cleanse the skin around the stoma with warm water.

using soap can leave a residue and cause poor adherence of pouch

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?Wipes the labia minor in an anteroposterior direction.
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
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Elevate the client’s head of bed 45 degrees before the feeding.

Rationale: the nurse should do this to prevent aspiration

nurse is collecting a urine specimen for a culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?Clamp the tubing below the collection port.

Rationale: The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.

A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?Check to determine if the catheter tubing is kinked.

first apply least invasive framework

A nurse is caring for a client who has a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device.Collapse the device of air after emptying.

Rationale: The nurse should collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device.

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection.
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the side hip between the iliac crest and anterior iliac spine

ventrogluteal injection

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?Purulent exudate.
A nurse is changing the dressings for a client recovering form an appendectomy following a ruptured appendix. The client’s surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?A halo of erythema on the surrounding skin.

Rationale: The nurse should report to the provider when the client has a ring of erythema on the surrounding skin, which might indicate underlying infection. This and any other manifestion of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider.

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?“I am going to listen to your abdomen.”

a common reason why client’s experience nausea and vomiting after a surgery is bc of delayed gastric emptying time or decreased peristalsis
determine presence of bowel sounds before liquids can be administered

nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?taut the skin around the IV catheter site that is cool to the touch.

stop infusion, elevate extremity, and apply warm moist compress

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client’s weight?Weigh the client on arising.

on rising, after voiding, and before breakfast
accurate weight – same garments, same scale,

nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first?Use the pain scale to determine the client’s pain level.
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?Place the stool specimen collection container in a biohazard bag.
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching.Granulation tissue fills the wound during healing,
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?Pull suction catheter back 1 cm if the client starts coughing.

will remove catheter from mucosal wall

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?Turn the stockings inside out up to the heel before applying.

Rationale: The nurse should turn the stocking inside out up to the client’s heel to make the application of the stocking easier and cause less constrictive wrinkles.

nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client’s diet?Vitamin C and Zinc.

both help fight wound infection

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?Explain the procedure to the client.
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?Determine whether the client is able to breathe.

before you can notify what is going on with the patient, you have to collect vital data from the patient

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?Offer the client tart or sour foods first.

Rationale: , The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take?remove the sleeve of the gown from the arm without the IV line.

do line arm last bc that will allow least amount of disruption to the line

A nurse is preforming eye irrigation for a client who has exposed to smoke and ash. Which of the following actions should the nurse take?Exert pressure on the bony prominences when holding the eyelids open.

Rationale: The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?Insert the tip of the tubing 8 cm.

will prevent dislodging of the tubing during the procedure and injury to rectal mucosa

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?Check the client’s perineum.
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?Lower abdomen.

Rationale: The nurse should secure with tape the client’s indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and tissue injury.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?Renew the prescription for the use of restraints within 24 hours.

after provider has evaluated condition

nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask.
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?Hold the linens away from the body and clothing.
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?face the client when speaking.
A nurse is replacing the surgical dressings on a client who has abdominal surgery. Which of the following actions should the nurse take?Don clean gloves to remove the old dressing.

Rationale: The nurse should use standard precautions by applying clean gloves whenever there is a possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean, not sterile, gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation.Montgomery straps.

Rationale: The nurse should apply the least restrictive priority-setting framework.

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse to decrease the risk of a fall?Use a gait belt during ambulation.

The nurse should use a gait belt to keep the client’s center of gravity midline and decrease the risk of a fall.

A nurse is collecting a urine specimen for a culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?Clamp the tubing below the collection port.

Rationale: The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?Drop the eye medication in the outer third of the lower conjunctival sac.
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?
What do you think caused the onset of your pan”

Rationale: The nurse is using an opne-ended question that allows the client to respond with a wide range of information by using more than one or two words.