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ATI Adult Physical Assessment: While performing a head-to-toe assessment, you perform the Romberg test. You do this to test the patient's Balance While performing a cardiovascular assessment, you m... ight encounter a variety of pulsations and sounds. Which of the following findings is considered normal? A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line As part of your general patient survey, you find that your patient has a body mass index (BMI) of 23. From this finding, you can conclude that your patient has a body mass index within normal limits When performing a complete, head-to-toe physical examination, which physical-assessment technique should you perform first? inspection While performing an abdominal assessment, you place your fingertips over the patient's painful area and gradually increase pressure, then quickly release it. The patient reports increased pain on release of pressure, so you document that your patient has positive rebound tenderness When assessing peripheral vascular status of the lower extremities, you place your fingertips on the top of your patient's foot between the extensor tendons of the great toe and those of the toes next to it. Which pulse are you palpating? Dorsalis pedis When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory phase of each respiratory cycle. These sounds are best identified as crackles Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate? RLQ, Right lower quadrant What is your primary goal in performing a comprehensive physical assessment? to develop a plan of care When using and maintaining your stethoscope, it is important to insert the earpieces at an angle toward your nose While examining your patient's head and face, you determine that cranial nerve I is intact when the patient follows your instructions and successfully identifies a minty scent You are performing a physical examination of the spine for an older adult. Which of the following findings is common with aging? Kyphosis ATI Infection: A primary care provider is considering the various pharmacologic options for a patient who has a gynecologic infection and a history of alcohol use disorder. Which of the following medications can cause a reaction similar to disulfiram (Antabuse) if the patient drinks alcohol while taking it? (Select all that apply.) -Cefotetan -Metronidazole (Flagyl) A health care professional is caring for a patient who is taking warfarin (Coumadin) and is about to begin taking trimethoprim/sulfamethoxazole (Bactrim) to treat a urinary tract infection. The health care professional should question the drug regimen because taking these two drugs concurrently can increase the patient's risk for which of the following? Bleeding A primary care provider should prescribe a lower dose of aztreonam (Azactam) for a patient who has a respiratory tract infection and also has which of the following? Renal impairment Which of the following drugs should a provider prescribe for a patient who has streptococcal pharyngitis and is allergic to penicillin? Erythromycin A health care professional is caring for a patient who is about to begin taking ketoconazole to treat a fungal infection. The health care professional should tell the patient to report which of the following adverse effects of the drug? Gynecomastia A health care professional is caring for a patient who is taking ciprofloxacin (Cipro) to treat a urinary tract infection and has rheumatoid arthritis, for which he takes prednisolone (Prelone). Recognizing the adverse effects of ciprofloxacin, the health care professional should tell the patient to report which of the following? Tendon pain A health care professional is caring for a patient who is about to begin taking metronidazole (Flagyl) to treat an anaerobic intra-abdominal bacterial infection. The health care professional should recognize that cautious use of the drug is indicated if the patient also has which of the following? Seizure disorder A health care professional is caring for a patient who is about to begin taking chloroquine (Aralen) to prevent malaria. When talking with the patient about taking the drug, the health care professional should include which of the following instructions? (Select all that apply.) -Wear sunglasses outdoors. -Avoid driving. -Take the drug with food. A health care professional is caring for a patient who is about to begin taking nitrofurantoin (Macrodantin) to treat a urinary tract infection. The health care professional should tell the patient to report which of the following adverse effects of the drug? Cough A primary care provider is prescribing drug therapy for a patient whose sputum culture results indicate methicillin-resistant Staphylococcus aureus (MRSA). Which of the following drugs should be administered? Vancomycin (Vancocin) A health care professional is caring for a patient who is about to begin using nystatin (Mycostatin) to treat oral Candida albicans that resulted from tetracycline therapy. Which of the following instructions should the health care professional include about using the antifungal preparation? Swish the suspension in the mouth before swallowing it. A health care professional is caring for a patient who is about to begin taking isoniazid (INH) to treat tuberculosis. The health care professional should tell the patient to report which of the following adverse effects of the drug? (Select all that apply.) -Jaundice -Numbness of the hands -Dizziness A health care professional is preparing to administer amphotericin B IV to a patient who has a systemic fungal infection. Which of the following drugs should the health care professional administer prior to the infusion to prevent or minimize adverse reactions during amphotericin B administration? (Select all that apply.) -Acetaminophen (Tylenol) -Diphenhydramine When administering erythromycin to a patient who has pneumococcal pneumonia, the health care professional should monitor for which of the following adverse effects of the drug? Cardiac dysrhythmias A patient who is taking tetracycline orally to treat a chlamydia infection contacts the health care professional to report severe blood-tinged diarrhea. Recognizing the adverse effects of tetracycline, the health care professional should suspect which of the following? Pseudomembranous enterocolitis While administering IV cefotetan to a patient to treat bacterial meningitis, the health care professional finds the IV insertion site warm and reddened. Which of the following actions should the health care professional take? Stop the cefotetan infusion. A patient who is taking amoxicillin (Amoxil) to treat a respiratory infection contacts the health care professional to report a rash and wheezing. Which of the following instructions should the health care professional provide? Call emergency services immediately. A health care professional is caring for a patient who is about to begin taking cephalexin (Keflex) to treat bacterial meningitis. The health care professional should explain to the patient the need to monitor which of the following laboratory tests? Creatinine A patient who is taking imipenem (Primaxin) to treat a bacterial infection contacts the health care professional to report an inability to eat because of mouth pain. Recognizing the adverse effects of imipenem, the health care professional should suspect which of the following? Suprainfection A health care professional is caring for a patient who is about to receive gentamicin to treat a systemic infection. The health care professional should question the use of the drug for a patient who is also taking which of the following drugs? Furosemide (Lasix) A health care professional is caring for a patient who takes an oral contraceptive and is about to begin rifampin (Rifadin) therapy to treat tuberculosis. The health care professional should include which of the following instructions? Use additional contraception. A patient who is taking ciprofloxacin (Cipro) to treat a respiratory tract infection contacts the health care professional to report dyspepsia. The health care professional should recommend which of the following instructions? Take an antacid at least 2 hr after taking the drug. A health care professional is caring for a patient who is about to begin taking acyclovir (Zovirax) to treat a herpes simplex infection. The health care professional should monitor which of the following laboratory values for the patient? BUN A health care professional is caring for a patient who is about to begin gentamicin therapy to treat an infection. The health care professional should monitor the patient for which of the following? Urine output A health care professional is caring for a patient who is about to begin receiving acyclovir (Zovirax) IV to treat a viral infection. The health care professional should recognize that cautious use of the drug is essential if the patient also has which of the following? Dehydration A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? Describing the location of the food on the plate by using a clock pattern allows the client to have greater independence during meals. A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? Allow extra time for the client to respond to question. Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to ask questions and absorb the information. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. The nurse should wear gloves when assisting with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever her hands might come in contact with a client's body fluids, such as saliva, and the mucous membranes in the mouth. the nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. The nurse should also wash her hands with soap and water when her hands have visible soiling. A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. 1. The nurse should first inject air into the vial of NPH without touching the needle to the solution. 2. inject air into the vial of regular insulin, and then withdraw the correct amount of the regular insulin. 3. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? Rapid heart rate Tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? Auscultate lung sounds. The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath. A nurse is assessing a client's readiness to learn about insulin 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." The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? Contact precautions Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client. A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? Intiate enteral feeding through gastronomy t is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface. A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in her own words. A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? Use progressive relaxation techniques at bedtime. Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action is for the nurse to determine why the client is refusing the treatment. A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? flush w 15 mL The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication. A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? "What could I have done to deserve this illness?" The client's terminal illness might prompt him to review his life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to him. A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? Press gently on the tragus of the client's ear. A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? have client stand w arms and legs together -Romberg's test helps identify alterations in balance. The nurse should have the client stand with her arms at her sides and her feet together to observe her for swaying and a loss of balance. A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? Have family members wear a gown and gloves when visiting. Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregivers must also wear gowns and gloves. A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role- performance stress? Role overload 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. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? Potassium 5.4 mEq/L The value is above the expected reference range and the nurse should report this finding. This client is at risk for dysrhythmia A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? A client who has an IV infusion pump receives an additional 250 mL of IV fluid. The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further similar incidents. A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? A nurse asks a nurse from another unit to assist with her documentation. Only health care professionals directly caring for a client may access medical information; therefore, this is a violation of HIPAA guidelines. A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? Have the client take sips of water to promote insertion of the NG tube into the esophagus. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube's passage into the trachea. A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 8 mL 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. The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output. A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.) Pupil clarity Visual fields visual acuity A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula backward into the esophagus. A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? 0.3 mg A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? - The first action the nurse should take is to assess the client to determine if he can bear weight and assist with his transfer. -Next, the nurse should position the chair on the side of the bed closest to the client's stronger side for easy access. -Next, the nurse should have the client sit and dangle his feet at the bedside to allow him to adjust to sitting up and prevent dizziness when transferring. -Finally, the nurse should use the stand-and-pivot technique to move the client to the chair. A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? "Are you able to help with your hygiene care?" 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? Stand close to the cabinet when lifting it. 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 has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? egg Evidence-based practice indicates the nurse should remove fried eggs from the client's tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? "Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? Acupuncture The nurse should inform the client that the use of acupuncture is contraindicated for a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection. what type of precaution is the flu? droplet A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? "I'll check the wires and cables on my TV to make sure they are in good working order." Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure the medication is mixed. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? assess client for injuries -The first action the nurse should take when using the nursing process is to assess the client for injuries. A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from further breakdown. A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown Have the client use a trapeze bar when changing position. By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development. A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? Remove the stockings at least once per shift. The nurse should remove the stocking once per shift to check the client's circulation and skin integrity. A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them. A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa. A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? "They indicate the form of treatment a client is willing to accept in the event of a serious illness." Advance directives include a living will, which permits the client to direct treatment in the event of a terminal illness A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? "You should have a fecal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually. A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? Semi-Fowler's Positioning the client in semi-Fowler's or high-Fowler's position allows for maximum expansion of the lungs. A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? Place the client's arm in a dependent position. The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? Assist the client to an upright position. When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed to the semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organ A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? The dose The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer. A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility. A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? "I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlled substance. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) Wear gloves when assisting the client with oral care. Place the client in a room with negative-pressure airflow. Use antimicrobial sanitizer for hand hygiene. Blood Transfusions A type of protein the immune system produces to neutralize a threat of some kind, such as an incompatible substance in the blood, is called an antibody. -An antibody is a protein the immune system produces to neutralize a threat. Antibodies are also called agglutinins. You started a transfusion of packed red blood cells about 1 hour ago. Your patient has suddenly developed shaking chills, muscle stiffness, and a temperature of 101.4° F (38.6° C). He appears flushed and reports a headache and "nervousness." Your patient has most likely developed which type of transfusion reaction? Febrile nonhemolytic -This is the most common type of transfusion reaction. The characteristic fever usually develops within 2 hours after the transfusion is started. Other classic symptoms include chills, headache, flushing, anxiety, and muscle pain. This type of reaction is usually a result of sensitization to the plasma, platelets, or white blood cells. Although this type of reaction is not life-threatening, it can be frightening and uncomfortable for the patient. A patient about to receive a unit of packed red blood cells states, "This is my third unit of blood today. I don't want to get some disease from all this blood." Which of the following would be your best response? "Donated blood is carefully screened for infectious diseases." -This is your best response because it offers the patient some factual information to help allay his concerns. You might continue to explain that the approach to blood safety in the U.S. includes stringent donor selection practices and the use of screening tests for HIV/AIDS, hepatitis B and C, syphilis, and other infectious diseases. Infected blood and blood products are safely discarded and are not used for transfusions. You are caring for a patient with severe trauma whose blood type is A. A blood transfusion is ordered stat. You know that the patient can safely receive blood from blood group O because type O blood contains no A antigens. -Type O blood contains no antigens at all, which is why people with type O blood are considered universal donors - because their blood can be transfused to people with any ABO-related type without putting them at risk for an ABO incompatibility. It is the specific antigens in the transfused blood that trigger hemolytic reactions. Since type O has no antigens, it is safe for this patient and for any other patient. A patient is about to receive a unit of packed red blood cells. The unit of blood has arrived and you are about to initiate the transfusion. Which of the following procedures will help you protect the patient against the possibility of a blood-group incompatibility? Comparing the ID numbers on the blood unit with those on the order form and the wristband -After comparing the patient's identification from the hospital wristband, the facility identification number, and a second patient identifier - typically the patient's date of birth - with the blood order sheet, you must check the barcode wristband, comparing the unique identification number with the number on the order form and on the unit of blood. This helps ensure that all documentation of the type of blood the patient is about to receive is the correct type for that patient. Most facilities mandate that you have a second qualified staff person check the patient's identifiers as well. Which component of blood transports waste products to the kidneys and liver? Plasma -Plasma is the liquid portion of the blood in which the various types of blood cells are suspended. Plasma is responsible for transporting waste products from cellular metabolism to the kidney and the liver for eventual excretion. A patient who could benefit from a blood-product transfusion has stated on admission that she is a Jehovah's Witness. It is most likely that this patient will agree to autologous transfusion. -Some Jehovah's Witnesses will agree to certain types of autologous transfusion - the process of collecting, storing, and re-infusing the patient's own blood. A platelet transfusion is indicated for a patient who has thrombocytopenia. -Thrombocytopenia is a low platelet count. When platelet counts drop below 20,000/mm3, a transfusion of platelets is generally indicated. Prior to administering a blood transfusion, it is essential to explain to the patient that he must immediately report any subjective symptoms like chills, nausea, or itching. -Although you can identify objective signs of a transfusion reaction (changes in vital signs, flushing, cyanosis, coughing, and to some extent, dyspnea), you might not be able to tell if the patient is experiencing subjective symptoms (chills, nausea, chest pain, headache, backache, muscle pain). Subjective signs are important clues, and you must be aware of them. A patient who is anticipating total hip replacement is considering autologous transfusion. When teaching this patient about autologous transfusion, it is important to emphasize that it eliminates the risk of alloimmunization. -Alloimmunization is an immune response to another person's antigens. Because the patient is her own donor, there is no risk of exposure to another person's antigens. When administering a transfusion of packed red blood cells, it is important to make sure the entire unit is transfused within 4 hours. -Infusion times that exceed 4 hours increase the risk for bacterial proliferation. Ideally, a unit of packed red blood cells is infused within 2 hours. Patients at risk for fluid-volume excess will require slower rates, but the entire transfusion must not exceed 4 hours. Which is an essential nursing action prior to starting a blood transfusion? Ensure informed consent has been obtained. - It is the responsibility of the prescribing healthcare provider to answer the patient's questions about need, risks, and benefits, but a nurse can witness the patient's signature indicating informed consent. This must be done prior to obtaining or administering the blood. Central Venous Access Devices: A patient who has sustained trauma from a motor-vehicle crash is transported to an emergency department. The provider determines the need for immediate central venous access for fluid and blood replacement and prophylactic antibiotic therapy. The appropriate central venous access device for this patient is: a nontunneled percutaneous central catheter A nurse is preparing to obtain a blood sample from a patient who has a triple-lumen central catheter in place for multiple therapies. Which of the following is an appropriate action for the nurse to take? Turn off the distal infusions for 1 to 5 minutes before obtaining the blood sample A nurse is caring for a patient who has a central venous catheter. When flushing the catheter, the nurse uses a 10-mL syringe to prevent which of the following complications associated with central vascular access devices? Catheter rupture A nurse is caring for a patient who has a central venous catheter and suddenly develops dyspnea, tachycardia, and dizziness. The nurse suspects air embolism and clamps the catheter immediately. The nurse should reposition the patient in which of the following positions? On his left side in Trendelenburg position (helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle) An older adult patient who adheres to a regular cardiovascular rehabilitation schedule that includes water aerobics and swimming requires long-term central venous access. Which of the following central venous access devices is the best choice for allowing him to continue his aquatic program? An implanted port A nurse is preparing to flush a patent's peripherally inserted central catheter (PICC). Because the patient's catheter has a valved tip, the nurse: Uses non-heparinized saline solution for the flush (there is no blood back-up) A nurse is caring for a patient who has a central venous access device in place. Which of the following routine measures should the nurse use specifically to prevent lumen occlusion? Clamping the extension tubing while removing a syringe from the injection cap A nurse caring for a patient who has gastric cancer is initiating an infusion of parenteral nutrition via the patient's implanted port. Which of the following is an appropriate action for the nurse to take? Cover the device and the needle with a sterile transparent dressing (needle must be first supported and anchored, then the port and the needle are covered with a transparent dressing) Surgical Asepsis: While waiting for a sterile procedure to begin, how do you position your hands and arms? With your hands clasped together in front of your body above waist level *Holding your hands and arms in this manner keeps them from coming into contact with nonsterile items. Inquire if the patient has a latex allergy Before beginning a sterile procedure at bedside or surgical suite you should check for what first? A nurse donning gloves knows that the proper technique for gloving the dominant hand prevents contact between the contaminated hand and the noncontaminated glove because The inner edge of the cuff will lie against the skin and thus will not be sterile *Direct contact with the skin makes the inner edge of the cuff nonsterile. When donning sterile gloves using the open-gloving method, it is important to remember to Grasp only the inside of the glove with your ungloved hand *The inside of the glove is considered nonsterile and will be placed against the skin of the hand, which is also considered nonsterile. When donning gloves using the open-gloving method, you would use a skin- to-skin and glove-to-glove technique. The goal surgical asepsis is to Create and maintain a micro-organism-free environment *Surgical asepsis consists of methods and practices directed toward keeping an area or object free of all micro-organisms. Prior to entering the surgical-scrub area, which of the following personal protective equipment (PPE) items do the team members don? (Select all that apply.) Protective eyewear Hair cover Mask Shoe covers *A gown used for a sterile procedure is considered sterile and is not donned until the surgical hand scrub has been completed and the hands have been dried. *Protective eyewear is worn to protect mucous membranes from splashes or sprays of blood and body fluids. *Hair is covered to keep hair and dander from contaminating the sterile field. *A mask is worn to protect mucous membranes from splashes or sprays of blood body fluids. *Shoe covers are worn to facilitate sanitation whenever splashes or spills are anticipated. A nurse preparing to flush and change the dressing on a patient's central venous catheter should understand that the primary purpose for performing this intervention using surgical asepsis is to Control the introduction of micro-organisms at the catheter site *The primary goal of surgical asepsis is to implement methods and practices directed toward keeping an area or object free of all micro-organisms. When opening a sterile pack, which of the following actions would compromise the sterility of the instruments and supplies inside the pack? Holding the sterile pack below waist or table level *The top of the table or sterile field is the only area that is considered sterile. Anything below waist or table level is considered nonsterile. During surgical handwashing, the hands are kept above the elbows to Encourage water and soap to flow away from the clean hands *The water and soap runs by gravity from the fingertips to the elbows, thus directing the contaminated substances away from the clean hands and preventing recontamination. Which area of the hands requires special attention before you begin a surgical hand scrub? The area under each fingernail *The area under the fingernails, called the subungual area, harbors micro-organisms. You must clean it thoroughly during the first scrub of the day and whenever visibly soiled. You are about to open a sterile pack. Place the following steps in the proper sequence for opening the sterile pack. The flap furthest from your body The side flaps The flap closest to your body *You would open the flap furthest from you body first, followed by the side flaps, and finally, the flap closest to your body. Any other order would risk your gown coming into contact with the sterile wrap or your arm reaching over the sterile field, both of which would result in contamination. A nurse preparing a sterile field knows that the field has been contaminated when (Select all that apply.) A cotton ball dampened with sterile normal saline is placed on the field The nurse turns to address the patient's question concerning the procedure The procedure is postponed for 30 minutes to accommodate the patient *Principles of surgical asepsis state that a sterile field becomes contaminated by capillary action when it comes into contact with moisture. *A 1-inch (2.5 centimeter) border around a sterile field is considered contaminated. *The near side of the field is an appropriate location for introducing items onto the field without reaching over the field itself. *Principles of surgical asepsis state that a sterile field becomes contaminated when it is out of visual range. *Principles of surgical asepsis state that a sterile field becomes contaminated when it is exposed to air for prolonged periods. *The recommended pouring distance is between 4 and 6 inches. IV Therapy: Which of the following is an important nursing action when converting an IV infusion to a saline lock? Flush the IV catheter to confirm patency Rationale: It is essential to attach the pried saline lock adapter to the extension tubing and to flush the tubing with normal saline to confirm patency. B could cause embolism. A nurse is discontinuing an IV infusion. For which of the following reasons is it important to verify and document the integrity and condition of the IV catheter? A broken-off catheter tip indicates the risk for an embolus Rationale: The tip of the catheter can break off, thus creating an embolus. To limit the movement of the embolus, the nurse should apply a tourniquet high on the extremity where the IV line was located and notify the provider immediately. A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. Which of the following actions should the nurse preform next? Lower the catheter until it is almost flush with the skin Rationale: Lowering the angle and then advancing the catheter slightly facilitates full penetration of the wall of the vein, thus placing the catheter within the vein's lumen and making it easy to advance the catheter off the stylet. Securing catheter is one of final steps, advancing the catheter at this point may puncture the opposite wall, stylet should remain in place until catheter is positioned further within the vein. A nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the catheter, the nurse should leave the connection between the hub and the tubing uncovered Rationale: This makes it possible to replace the tubing without removing the dressing. A nurse finds a patient's IV insertion site red, warm, and slightly edematous. Which of the following actions should the nurse perform first? Discontinue the IV line Rationale: The patient has classic signs of phlebitis, an inflammation of the vein. The IV line must be discontinued immediately to reduce the risk of thrombophlebitis and embolism. A nurse is removing an IV catheter from a patient whose IV infusion has been discontinued. Which of the following actions is appropriate? Pull the catheter straight back form the insertion site Rationale: With the catheter stabilized and using a slow, steady movement, the nurse should withdraw the catheter straight back and away form the insertion site, making sure to keep the hub parallel to the skin. A patient in early stage renal failure is prescribed an infusion of 0.45% NaCl. This type of solution is appropriate because it dilutes extracellular fluid and rehydrates the cells Rationale: Infusing a hypotonic solution such as 0.454% sodium chloride moves fluid into the cells, thus enlarging and rehydrating them. A is hypertonic, C is isotonic, D is hypertonic A nurse has just initiated a peripheral IV infusion of 5% dextrose in water. How often should the nurse plan to replace the primary infusion tubing? Every 96 hours Rationale: Unless the infusion system has been compromised in some way, changing the administration set 72 hours after initiating the IV would be inappropriate. CDC recommends changing the IV tubing no more than every 92 hours unless the tubing has been contaminated, punctured, or obstructed. A nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. The nurse should teach the patient that which of the following findings is an indication of early infiltration? Coolness Rationale: Coolness is a classic sign of infiltration, along with swelling, pallor, and possibly tenderness. Infiltration is a leakage of IV solution out of the intravascular compartment into the surrounding tissue. A patient is to receive 1,000 mL of 5% dextrose in lactated Ringer's over 8 hours. Using tubing with a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at how many drops per minute? 31 gtt/min IV Therapy Administration: A patient is to receive 1 g of Ceftriaxone (Rocephin) in 100 ml over 30 min. the tubing drip rate is 10 gtt/ml. the nurse should adjust the flow rate to what infusion rate? 33 gtt/min To determine the correct flow rate divide the volume to be infused by the time in minutes and multiply by the drop factor. So, 100 (volume to be infused) divided by 30 (time in min) x 10 (drops per mL) = 33 gtt/min. A nurse is caring for a patient with a peripherally inserted central catheter (PICC line). Which of the following is true about this type of intravenous route? A PICC line is a long catheter inserted through the veins of the antecubital fossa A patient was admitted to the hospital for same day surgery and has orders for continuous intravenous therapy. Before performing a venipuncture, the nurse should Inspect the IV solution for fluid color, clarity, and expiration date A nurse is caring for a patient receiving 0.9% sodium chloride at 75 ml/hr through a triple lumen central venous catheter. The pump is alarming that there is an occlusion. Which of the following is the first thing the nurse should do? Check the line at or above the hub for kinked tubing that is creating a resistance to flow A nurse is about to administer an iv medication directly into the vein. The nurse should understand that a disadvantage of parenterally administered medications is that they Are irreversible A nurse administers the first dose of a pt's prescribed antibiotic via IV piggyback. During the first 10 to 15 min of administration of the medication, the nurse gives priority to which of the following assessments? Patient for systemic allergic reaction A nurse is caring for a pt who is receiving D5W with 20 mEq of KCL at 75 ml/hr. the provider has prescribed 1 g Ceftriaxone (Rocephin) iv. When preparing to administer this medication by iv piggyback, which of the following data is the highest priority for the nurse to collect? The medication's compatibility with the primary IV solution A nurse is assessing a pt receiving iv normal saline at 125ml/hr. which of the following should the nurse recognize as a possible complication related to the iv therapy? Patient reports cough and shortness of breath Nutrition Feeding and Eating: Which of the following are appropriate choices for a patient prescribed to a full liquid diet? Plain yogurt Custard Pureed vegetables Gelatin To assess a stroke patient for complications secondary to inadequate swallowing, the nurse should do which of the following? Auscultate the patient's lungs. "Silent" aspirations are a common complication of swallowing impairment Which of the following dietary modifications should an adolescent engaging in sports implement? Drink water before and after sports activity. An adolescent should drink water before and after sport activities to prevent dehydration. A nurse is caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this patient undergo which of the following? Swallowing examination. Patients at high risk for aspiration include those with a decreased level of consciousness. Thispatient has some periods of decreases alertness, thus a swallowing examination is essential to determine his ability to ingest food safely by mouth. Which of the following strategies for enhancing the intake of healthful foods is appropriate for an adolescent? Making healthful food choices more convenient and available for adolescents This helps promote the adolescent to make healthier food choices Which is the primary purpose to ask a patient to keep a 3 to 7 day food diary? To assess the pattern of intake and compare with the daily reference intake. A time period of 3-7 days is an adequate amount of time for assessing dietary habits and patterns and thus the adequacy of the patients nutritional intake. A nurse is performing a nutritional assessment. When obtaining and interpreting anthropometric values, the nurse should recognize which of the following? The patient should be weighed on the same scale at the same time each day. Weighing a patient on the same scale at the same time of day provides the most consistent data for gauging trends in the patients weight, as shifts in fluid intake and output can alter weight significantly. The patient should also be weighed with he same amount of clothing and/or linen each time. A nurse should recognize that which of the following is correct regarding albumin level as a diagnostic marker for nutritional status? Albumin level is a poor short-term indicator of protein status. Albumin is not sensitive to acute changes in nutritional status. ITs long half (21 days) makes it better indicator of chronic illness states than of current protein status at a given point in time. When teaching the parents of a toddler about feeding and eating, the nurse should include which of the following safety measures? Do not offer the child raw vegetables. Raw vegtaables, aw well as hot dogs, grapes, nuts, popcorn, and candy, have been implicated in choking deaths and should be avoided at least until the child is 3 years old. A patient has finished a 16-oz container of orange juice. The intake and output sheet documents fluid in milliliters. Which of the following should the nurse document as intake? 480 mL 1 fluid oz= 30 mL 16 fluid oz= 480 mL A nurse is caring for a patient who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the patient with feeding? Elevate the head of the bed 45 to 90 degrees The patients head should be sufficiently elevated to prevent aspiration. Which of the following interventions should a nurse use at mealtimes for a patient who has visual deficits? Identify the food locations as though the plate were a clock. Telling the patient, the example, that the chicken is at 9 o'clock and the broccoli is at 12 o'clock helps orient her to the items on the plate and thus facilitates independence in eating. Enteral Feedings: An older adult in a long term care facility is receiving intermittent enteral feeding in his room. His affect is flat and the nurse suspects that he is feeling isolated. Which intervention is appropriate for this patient. Encourage him to go to the dining room at meal times to talk with other patients A nurse inserting a nasogastric tube asks the patient to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by closing off the glottis To determine how much of the length of the nasocenteric tube to insert, a nurse should measure the distance from the tip of the patients nose to the earlobe and from the earlobe to the xiphoid process plus 20 to 30 cm more To prevent a common complication of continuous enteral tube feedings, a nurse should limit the time the formula hangs to 4 hours A patient with a gastric ileum postop requires nutritional support for approx. 2 weeks. Which of the following types of feeding is appropriate for the patient? Nasointestinal tube Nasogastric tube feeding are an appropriate choice for a patient who is post op following laryngectomy The most reliable method for verifying initial placeent of a small-bore feeing tube is by obtaining an abdominal x-ray Which of the following formulas is approp to administer to a pt who has a dysfunctional gastrointestinal tract Elemental When teaching a pt who is about to receive an intermittent nasogastric feeding, what should the nurse instruct the pt to report immediately? persistent coughing To prevent aspiration during the administration of an enteral tube feeding, a nurse should place the pt in Fowler's position Nasogastric Tube: During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tube? Salem sump A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membrane? Provide frequent mouth care A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which of the following patients? A 40-year-old patient with a postoperative bowel obstruction A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? Inspect the oropharynx with a penlight and a tongue blade. A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded? Patient reports of nausea A nurse is caring for a patient who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying the initial placement? X-ray examination of the chest and abdomen When checking for nasogastric tube placement, the nurse should conduct which of the following procedures? Aspirate stomach contents and check the pH Ostomies: A nurse is obtaining health history from a young adult patient who has a colostomy. The patient reports frequent episodes of loose stools over the last month, but has no sings of infection or bowel obstruction. He reports that his concerns about leakage have limited his social activities. Which of the following should the nurse recommend? Consume foods that are low in fiber content. -Foods low in fiber help thicken the stool; examples include rice, noodles, white bread, cream cheese, lean meats, fish, and poultry. A nurse is providing preoperative teaching for a patient who has colon cancer. The surgeon informed the patient that his entire large intestine and rectum will be removed. The nurse should explain the type of ostomy he will have is: An ileostomy -After removing the entire large intestine and rectum, the surgeon will create an ileostomy to divert feces from the small intestine to the abdominal surface and into an ostomy pouch. A nurse is providing preoperative teaching for an older adult patient who has diverticulitis and is scheduled for a creation of a double-barrel colostomy in the sigmoid colon. Which of the following instructions should the nurse include in the teaching? Tape a dry gauze pad over the distal stoma to collect drainage. -The distal stoma (also called a mucous fistula) secretes mucus; it does not drain feces. A dry gauze dressing is usually suficient. A nurse is teaching a patient with a new ileostomy about incorporative preventive strategies at home. To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the patient to: Empty the pouch when it is no more than half full. -Waiting until the pouch is more than half full increases the risk of leakge. Ileostomy effluent is irritating to peristomal skin, so patients should replace the pouch when it is one-third to one-half full. While a nurse is teaching a patient how to replace her ostomy pouching system, the patient reports that removing the skin barrier is sometimes painful. Which of the following should the nurse suggest? Push the skin away from the barrier while removing it. -Pushing the skin away from the barrier helps prevent skin stripping, which can be painful and make the skin sensitive to the adgesive. If the patient is having difficulty with the initial release of the barrier, it may help if she starts in one corner and gently pulls it across the stoma while pushing the skin away from the barrier. A nurse is teaching a patient how to apply an extended-wear skin barrier. Which of the following strategies should the nurse instruct the patient to use for maximal adherence? Press gently around the barrier for 1 to 2 minutes. -The pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth ( from the fingers) to ensure adherence. A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following shoulder the nurse do first? Cleanse the stoma and the peristomal skin. -To facilitate the nurse's assessment of the stoma and the peristomal skin, the nurse must remove any effluent adhering to the area. A patient who has bladder cancer tells the nurse that, of the carioius urinary diversion options the surgeon presented, she prefers one that will allow her to have some control over urinary elimination. The nurse should explain the option that will allow that is: a Kock's pouch. -This is a continent ileal bladder conduit that does not require an external drainage collection device because the patient self-catheterizes every 2-4 hours to remove urine. This device will provide the control the patient desires. [Show More]

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