ATI Fundamentals Final Exam

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? - Compare the client's home medications with the providers prescriptions. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? - Administer the medication with the needle at a 45 degree angle. A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? - subtract the amount of irrigant used from the client's urine output. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? - Hydrocolloid. Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. Alginate dressing - used to treat stage 3 and 4 pressure injuries to absorb drainage which forms a soft gel when it comes into contact with drainage. Gauze - Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. Transparent dressing - promote healing in stage 1 pressure injuries by preventing further friction and shearing. a nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. which of the following actions should the nurse take? - Pad the client's wrist before applying restraints. a nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client. - Make sure the client wears a mask when outside her room if there is construction in the area. they need at least 12 air exchanges per hour, in a positive-pressure airflow room what is biofeedback? - a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? - This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching. a nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "everytime you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? - administer pain meds 45 min before changing the client's dressing. a nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? - I can concentrate best in the morning. a nurse is evaluating a client's use of a cane. which of the following actions should the nurse identify as an indication of correct use? - the client holds the cane on the stronger side of her body. The client should hold the cane on the stronger side of her body to increase support and maintain alignment. The client will also move her weaker leg forward with the cane which divides the client's body weight between the cane and the stronger leg. A nurse in a long term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. - 1. Obtain the pronouncement of death from the provider. 2. Remove tubes and indwelling lines. 3. Wash the client's body 4. Ask the client's family members if they would like to view the body. 5. Place a name tag on the body. A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "what would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? - We would give you oxygen through a tube in your nose. Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as the proper safety protocol? - The client uses NON-acetone nail polish remover. Equipment should be inspected daily!!! a nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly-licensed nurse. Which of the following actions should the nurse include? - Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min. Flow rate would be aligned with the middle of the silver ball inside the meter. Reservoir bag should inflate by one-third to one-half with the inspiration. If it remains deflated, it indicates that clients are breathing in too much of the CO2 they exhale. Lastly, EBP supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen. REVIEW LAB VALUES - BUN--10-20 mg/dL Creatinine Sodium: 136-145 mEq/L. Potassium 3.5-5 mEq/L A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea. - The client's caregiver washes the feeding tube bag with warm water once every 24 hours.