Exam (elaborations)
B260 Infection_Skin_Elim_02_AcidBase ATI practice test (1).
B260 Infection_Skin_Elim_02_AcidBase ATI practice test (1).
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B260 Infection/Skin/Elim/02/AcidBase ATI practicetest
d
According to evidenced-based practice, this client has multiple risk factors for skin breakdown:
the aging process (decreased muscle mass, thin and fragile skin) and the limitation of
movement due to traction. Therefore, this client is at the greatest risk for skin breakdown. -
ANS-A nurse working on an orthopedic unit is caring for four clients. Which of the following
clients should the nurse identify as being at greatest risk for skin breakdown?
a. an adolescent who has a cervical fracture and is in a halo brace
b. a young adult who has a femur fracture and is in skeletal balanced suspension traction
c. a middle adult who has a fractured radius and an arm cast.
d. an older adult who has a hip fracture and is in buck's traction.
a
A client experiencing metabolic acidosis would have a decreased pH, a decreased HCO3 and a
decreased PaCO2. - ANS-A nurse is caring for a client who has the following arterial blood gas
results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is
experiencing which of the following acid base imbalances?
a. Metabolic acidosis
b. respiratory acidosis
c. Metabolic alkalosis
d. respiratory alkalosis
c
A sterile object remains sterile only if the nurse touches it with another sterile object. This
principle guides the nurse in placement of sterile objects and how she should handle them such
as using sterile forceps or wearing sterile gloves to handle objects on a sterile field. - ANS-A
nurse is planning to perform a sterile dressing change for a client. Which of the following actions
should the nurse plan to take?
, a. Hold gauze packages 7.6 cm (3 in) above the sterile field
b. place sterile supplies within the 2.54 cm (1 in) border of the sterile field
c. Use sterile forceps to move the sterile items on the sterile field
d. position the wrapped package on the bedside table so the outer flap opens towards her
d
A client who has measles requires airborne precautions as well as a negative pressure room. -
ANS-a charge nurse is reviewing guidelines for initiating airborne precautions. Which of the
following clients should the nurse identify as requiring airborne precautions?
a. a client who has scabies
b. a client who has pertussis
c. a client who has streptococcal pharyngitis
d. a client who has measles
b
This position makes it easier for the enema solution to flow by gravity into the sigmoid and
descending colon. The nurse should also have the client's right leg flexed to facilitate insertion. -
ANS-A nurse is preparing to administer a soapsuds enema to an adult client. Which of the
following actions should the nurse take?
a. put on sterile gloves
b. assist the client to the left sims' position
c. hang the enema container 60 cm (24 in) above the anus
d. insert the tubing about 15 cm (6 in) into the anus.
d
Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the
abdominal organs and allows for increased expansion of the lungs. The head and neck can be
extended, which promotes a patent airway. This is the first action the nurse should take and is
the least invasive. - ANS-A nurse is caring for a client who has returned to the unit following a
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