Fundamentals-ATI Assessmemtn everything you need to know PDF

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FUNDAMENTALS a nurse is completing a nutritional assessment on a client and measures BMI, which of the following readings correlates with a BMI of an overweight client? 25 (25-29.9) a nurse is verifying ng tube placement by the pH of aspirated gastric fluid. which of the following pH values provides a good indication of correct tube placement? 2 (pH between 0-4) a nurse is caring for a client with a closed head injury. when pressure is applied to the client's nail beds, the clients eyes open and adduction of the arms with flexion of the elbows and wrists is noted. the client also moans with stimulation, what is the GCS? 7 eye opening 1-4 verbal 1-5 motor 1-6 a nurse should teach which of the following clients requiring crutches about how to use a three point gait? a client who has a R femur fracture with no weight bearing on the affected leg (bears all weight on one foot, then both shoulders on crutches, and uninvolved leg, the affected leg does not touch the ground) a nurse is providing teaching about the Mediterranean diet to a client newly who has a new diagnosis of hypertension. what statement indicates need for further teaching? i will limit my intake of red meat to 2x weekly a nurse is providing dietary education to a client with cholecystitis who has been prescribed a low-fat diet. which of the following meal selections by the client indicates understanding of education? roast turkey, rice pilaf, green beans a client with cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform Kegals (reduce pelvic prolapse and stress urinary incontinence) a nurse is caring for an older adult client with delirium. which intervention will most likely reduce the client's risk for falls? hourly rounding by the nurse a nurse is caring for a client who has been prescribed furosemide. which of the following foods should the nurse encourage this to include in his diet? oranges (along with dried fruits, tomatoes, avocados, dried peas, meats, broccoli, bananas are good for a potassium wasting diuretic)

a menopausal client is having difficulty getting to sleep and asks what actions she should incorporate in her daily routine to promote sleep. the nurse would encourage, which of the below measures to promote sleep? limit alcohol and nicotine prior to bedtime (at least 4 hours) a nurse is caring for several clients prescribed heat/cold therapies. which of the following clients are at risk of injury from these therapies? SATA use caution with clients who are very young, older adult, fair skinned, impaired cognition, and comorbidities --> higher risk for fragile skin a nurse is caring for a client with HF who has evidence of dyspnea, bibasalar crackles and frothy sputum. what dietary recommendations should be provided to this client in management of their HF? Reduce sodium intake (stop smoking, monitor fluid intake to 2L/d, increase protein, consume small frequent meals that are soft and easy to chew) a nurse is caring for a client receiving opiates for PM, initially after PM plan was started the client was sedated and sleeping most of the time. after three days the client is no longer sedated and sleeping regularly. what action should the nurse take? no action is needed at this time (opiates initially cause sedation but it subsides with maintenance pain control) a nurse is caring for a client who is admitted for observation and has full range of motion. which is the best manner to encourage the client to void? client bathroom(promotes independence and ADLs) a nurse is caring for a client with encephalopathy secondary to liver failure, the client has been prescribed a high calorie, low protein diet. which of the following meals are appropriate? chicken breast, mashed potatoes, spinach a client with hearing loss has been fitted for a hearing aid. which of the following teaching points are important for the nurse to discuss with the client? use mild soap and water to clean the ear mold what is the name of a legal document that instructs hcp's and family members about what, if any life-sustaining treatment and individual wants if at some time the individual is unable to make decisions? living will a nurse is caring for a client with celiac disease, which food should be removed? Tortillas (contain gluten)

a nurse is assisting a client with his meal that is at risk for aspiration d/t stroke, what interventions should the nurse take to prevent aspiration? position upright upper back and head are supported tuck chin when swallowing a nurse is assessing four clients for fluid balance, the nurse should identify what as dehydration? a client that has a temperature of 39C or 102F a nurse is preparing to administer TPN, what indicates a need to obtain a new bag? the TPN solution has an oily appearance and a layer of fat on top of the solution ("cracking") which can cause a low pulse ox reading? nadequate peripheral circulation

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a nurse is admitting a client who has TB and a productive cough. what types of isolation precautions should the nurse initiate for the client? airborne(measles, chicken pox, herpes zoster, TB) TB requires negative pressure room, and staff need to wear N95 a nurse manager is providing staff education on the correct use of restraints. what should be included in this education? restraints are a last resort NV and NS status should be assessed every 2h use the least restrictive intervention possible and never let it interfere with treatment thorough and timely documentation need to be completed when restraints are applied a nurse is caring for a client receiving chemo that is experiencing neutropenia, what should the nurse include in pt education? avoid crowded events (can't fight infection) a nurse is caring for a client with a stage 2 pressure ulcer, define the characteristics of this ulcer? partial-thickness kin loss involving the epidermis and the dermis ulcer is visible and superficial, may appear as abrasion, blister, or shallow crater edema persists, ulcer may become infected with possible pain and scant drainage a nurse is preparing to administer 250mg of an antibiotic IM. available is 3g/5mL. how many mL would the nurse administer per dose? 0.4

a nurse is reviewing psychosocial stages of development for a school-age child, what would be an expected behavioral finding for this child?

develop sense of industry through advances in learning, strive to develop healthy self-respect by finding out in what areas they excel peer groups plays important role in social development a nurse is assessing a client who has Parkinsons disease, what manifestations should be expected? Bradykinesia a nurse is caring for a client receiving radiation treatments for cancer. the client states he is experiencing dryness, redness, and scaling at the treatment area. which of the following should the nurse instruct the client to do? liberally apply prescribed lotion to the area a nurse is assessing the pain level of a client who has dementia and difficulty communicating, which pain assessment technique should the nurse use? behavioral indicators (increased agitation, restlessness) a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should the nurse do first? recheck the clients BP(reassess prior to any intervention) a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify as a cath occlusion? bladder distention (inability to empty the bladder, impaired elimination) a nurse is discussing immunity with a client who has received an immunization, the nurse should identify that an immunization functions as part of which of the following types of immunity? acquired immunity (artificial/acquired immunity occurs when antigens from toxoids or immunizations are ADMINISTERED to a client, once in the body, the stimulate the production of antibodies) a nurse is reviewing the health history of an OA who has a hip fracture the nurse should identify what is a risk of developing pressure injuries? urinary incontinence (r/f skin breakdown--> pressure injury, poor nutrition, infection, poor tissue perfusion, friction and shear, immobility, alterations in sensory perception) a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red and there is warmth along the coarse of the vein, what should the nurse do? d/c the infusion (assessment suggest phlebitis, d/c, apply warm compress//if continued therapy required, start new IV) a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. which of the following terms should the nurse use to document this finding?

macule (nonpalpable smaller than 1cm, ex: freckle) a community health nurse is teaching a group of clients about first aid for different types of wounds. which of the following client statements indicates an understanding of the teaching? i should apply clean dressings over the top of blood saturated dressings and hold pressure (to prevent disruption of wound tissue) a nurse is sitting with the partner of a client who recently died. which of the following actions should the nurse take to facilitate mourning? encourage the partner to ask for help when needed a nurse is in an acute care facility is caring for a client who is postop following abdominal surgery. which of the following behaviors should the nurse identify as increasing the client's risk for constipation? urge suppression history of chronic stimulant laxative use inadequate fluid intake a nurse is caring for a client who expresses anxiety about an upcoming surgery, what should the nurse do? ask the client to describe feelings a nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. which of the following actions should the nurse take to prevent contamination during the dressing change? restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray (if liquid comes in contact with the sterile field at any point it is considered contaminated and unsterile) a nurse is caring for a pt who is scheduled for a cataract surgery, the client states "is see just fine and have decided to cancel my surgery". which of the following responses should the nurse make? share with me more about the thoughts that are concerning you a nurse is teaching a client about the use of a MDI, which instruction should the nurse include in the teaching? inhale the medication deeply for 3-5seconds (hold breath for 10s after inhalation, shake MDI vigorously, hold mouthpiece 2.5-5cm/1-2in in front of mouth) a nurse is teaching a group of AP about the expected integumentary changes in OA, which should the nurse include decrease in elasticity (increase in pigmentation, decrease in subq and moisture levels)

a nurse is monitoring a client who has been receiving intermittent enteral feedings, what should the nurse identify as an intolerance to the feeding? nausea(vomiting, dumping syndrome-change the rate or type of formula) a nurse enters a clients room and sees smoke coming from the trash can. which of the following actions should the nurse take first evacuate the room (RACE) a nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery, which of the following statements should the nurse make? the surgeon will answer your questions before surgery a nurse is reviewing info about advance directives with a newly admitted client. which of the following statements by the client indicates an understanding of the teaching? i have a living will that outlines my wishes when i am unable to make a decision a nurse is admitting a client who has meningococal meningitis, what should the nurse do first? initiate droplet precaution (put in private room and wear surgical mask within 3ft) a nurse finds a client on the floor of their room experiencing a seizure, which of the following actions is the nurse's priority place the client on their sided with their head forward (ABC) a nurse is providing discharge teaching to a client who has a prescription for home O2, which info should the nurse teach? wear cotton socks when the O2 is in use (other fabrics cause static) a nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. which of the following client information should the nurse identify as a contributing factor to the decrease in the medication's effectiveness? the client has a history of recurring bowel inflammation (GI issues decrease motility, decreasing med effectiveness, so oral meds should be avoided) a nurse is teaching a client about the correct use of a cane, what should the nurse include? ensure the cane has a rubber cap hold the can on the stronger side flex the elbow slightly when using the cane use a quad cane for increased support a nurse is teaching about safety risks for adolescents, what should be included? at this age, peer influence to participate in high-risk behaviors can lead to injury

a nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. the nurse should instruct the client to avoid which of the following foods?

orange slices (membranes of the oranges are hard to swallow, so are other hard foods and raw fruits/veggies) a nurse is reviewing the medical records of a group of OA clients. the nurse should identify that which of the following is a risk factor that places OA at an increased risk for developing infections? lowered immune system function(manifest as fever, redness, confusion, agitation, general fatigue) a nurse is caring for a client who has a prescription for a narcotic med, after admin the nurse is left with an unused portion, what should the nurse do? discard the med with another nurse as a witness (2 person for controlled substance) a nurse is performing a focused assessment for a client who has dysrhythmias, what indicates ineffective cardiac contractions? pulse deficit (comparing apical and radial pulses at the same time can help detect pulse deficit indicating ineffective cardiac contraction and presence of cardiac dysrhythmias) a nurse is preparing to transfer a client from a chair to the bed. the client can bear partial weight and has upper body strength. which of the following devices should the nurse use to transfer the pt? a stand-assist lift(for pt with upper body strength and able to bear partial bodyweight) a nurse is planning to administer several meds to a client through a ng tube, which actions should the nurse take? dissolve crushed tablet meds in sterile water(in 15-30mL sterile water) a nurse is teaching about measures to promote sleep with insomnia, what statement indicates understanding? i should reduce my fluid intake to 2 hours before bedtime(2-4 hours before sleeping to prevent interruptions, a carb snack h.s., exercise 3h prior to, avoid naps) a nurse is teaching about foot care to a client who has DM, what statement indicates understanding? i should wear my slippers whenever i am out of bed (barefoot poses risk of injury to feet, avoid lotion between toes, cut nails straight across, avoid soaking in warm water) a nurse is preparing to perform a routine abdominal assessment for a client, which action should the nurse take? perform palpation after auscultation a nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3d, what lab results indicates the client is experiencing FVD? increased hematocrit (increased USG and BUN)

a nurse is updating a plan of care after an evaluation of a client who has dysphagia, which interventions should the nurse include in the plan? have the client sit upright for 1 hr following meals (facilitates swallowing of undigested food and reduce risk of aspiration) a nurse is caring for a client who reports burning around the peripheral IV site, which finding should the nurse identify as a manifestation of infiltration? edema (leakage of the IV solution into the extravascular tissue) a charge nurse is making assignments for the upcoming shift, what assignments should the charge nurse assign to a LPN? a client who has dehydration and IBD(does not require complex med admin or assessment) a nurse is in an ED monitoring the hydration status of a client receiving oral rehydration, what should the intervene for? heart rate 120/min(initiate IV fluid replacement) a nurse is documenting client care, which of the following entries should the nurse identify as an example of implementation of client care? contacted the provider to report client findings a charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. the charge nurse should identify that the nurse is accountable for which of the following torts? Negligence a nurse is completing an admission assessment for a client who has hearing lsos, what action should the nurse take? use written communication to assist with communication a nurse is caring for a client who has dementia and frequently tries to get out of bed, which of the following actions should the nurse take? ( SATA) turn on the bed alarm maintain the bed in the lowest position encourage the family to stay with the pt

a nurse is preparing a client for transfer to another unit? which finding does the nurse include in the transfer report? response to pain medication review of ongoing discharge plan

recent physical changes a nurse in a providers office is assessing the motor skill development of a 15 month old toddler during a well-child visit, what gross motor skills should the nurse expect? walks without assistance using a wide stance a nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. which of the following actions should the nurse take first after obtaining the client's history and assessment? Identify the client's needs a nurse is planning a community education program about colorectal cancer. which of the following risk factors should the nurse identify as modifiable? smoking alcohol consumption high-fat diet a nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea, which of the findings should the nurse expect? flaring of the nostrils(increased RR, increased depth of R, expected pulse ox reading of...