ATI RN Fundamentals Questions And Answers Graded A+.

ATI RN Fundamentals Questions And Answers Graded A+. A knurse kis kadministering k1 kL kof k0.9% ksodium kchloride kto ka kclient kwho kis kpostoperative kand khas kfluid kvolume kdeficit. kWhich kof kthe kfollowing kchanges kshould kthe knurse kidentify kas kan kindication kthat kthe ktreatment kwas ksuccessful? Increase kin khematocrit increase kin krespiratory krate Decrease kin kheart krate Decrease kin kcapillary krefill ktime k- k k k kcorrect kanswer k: kCorrect kAnswer: Decrease kin kheart krate Fluid kvolume kdeficit kcauses ktachycardia. kWith kcorrection kof kthe kimbalance, kthe kheart krate kshould kreturn kto kthe kexpected krange. Incorrect kAnswers: Increase kin khematocrit: Fluid kvolume kdeficit kcauses kan kincrease kin khematocrit klevel kdue kto kdepletion kof kextracellular kfluid. kWith kcorrection kof kthe kimbalance, kthe khematocrit klevel kshould kdecrease. increase kin krespiratory krate Fluid kvolume kdeficit kcauses kan kincrease kin krespiratory krate. kWith kcorrection kof kthe kimbalance, kthe krespiratory krate kshould kreturn kto kthe kexpected krange. Decrease kin kcapillary krefill ktime Fluid kvolume kdeficit kslows kcapillary krefill. kWith kcorrection kof kthe kimbalance, kcapillary krefill ktime kshould kreturn kto kthe kexpected krange. A knurse kis kcaring kfor ka kclient kwho kis kscheduled kto kbe ktransferred kto ka klong-term kcare kfacility. kThe kclient's kfamily kquestions kthe knurse kabout kthe kreasons kfor kthe ktransfer. kWhich kof kthe kfollowing kresponses kmade kby kthe knurse kis kappropriate? "The ktransfer kof kyour kfamily kmember kis kbeing kdone kbecause kthe kprovider kknows kwhat's kbest." "Would kyou klike kit kif kwe kdiscussed kthe ktransfer kwith kyour kfamily kmember?" "Why kare kyou kso kconcerned kabout kthis ktransfer?" "I kknow khow kyou kfeel. kMy kparent khad kto kbe ktransferred kto ka klong-term kcare kfacility." k- k k k kcorrect kanswer k: kCorrect kAnswer: "Would kyou klike kit kif kwe kdiscussed kthe ktransfer kwith kyour kfamily kmember?" This kresponse kfacilitates ktherapeutic kcommunication kand kprovides kgeneral kleads kwhile kmaintaining kclient kconfidentiality. Incorrect kAnswers: "The ktransfer kof kyour kfamily kmember kis kbeing kdone kbecause kthe kprovider kknows kwhat's kbest." This kis ka kdefensive kresponse kwhich kcan khinder kfurther kcommunication. "Why kare kyou kso kconcerned kabout kthis ktransfer?" Asking ka kwhy kquestion kcan kmake kthe krecipient kdefensive kwhich kcan khinder kfurther kcommunication. "I kknow khow kyou kfeel. kMy kparent khad kto kbe ktransferred kto ka klong-term kcare kfacility." This kis ka ksympathetic kresponse, kwhich kcan kinterfere kwith ka ktherapeutic krelationship. A knurse kis kreviewing kthe klaboratory kresults kof ka kfemale kclient kwho khas khypovolemia. kWhich kof kthe kfollowing klaboratory kresult kwould kbe ka kpriority kfor kthe knurse kreport kto kthe kprovider? BUN k21 kmg/dL k(10 kto k20 kmg/dL) Creatinine k1.4 kmg/dL k(0.5 kto k1.1 kmg/dL) Sodium k132 kmEq/L k(136 kto k145 kmEq/L) Potassium k5.8 kmEq/L k(3.5 kto k5 kmEq/L) k- k k k kcorrect kanswer k: kCorrect kAnswer: Potassium k5.8 kmEq/L k(3.5 kto k5 kmEq/L) When kusing kthe kurgent kversus knonurgent kapproach kto kclient kcare, kthe knurse kshould kdetermine kthat kthis kpotassium klevel kis kabove kthe kexpected kreference krange kand kshould kbe kreported kto kthe kprovider. kPotassium kaffects kthe kcontractility kof kthe kheart kand kthis kclient kwould kbe kat krisk kfor kdeveloping kdysrhythmias. Incorrect kanswers: BUN k21 kmg/dL k(10 kto k20 kmg/dL) This kBUN klevel kis kslightly kabove kthe kexpected kreference krange kand kis kan kexpected knon-urgent kfinding kfor ka kclient kwho khas khypovolemia; ktherefore, kthere kis kanother klaboratory kresult kthat kis ka kpriority kfor kthe knurse kto kreport kto kthe kprovider. Creatinine k1.4 kmg/dL k(0.5 kto k1.1 kmg/dL) This kcreatinine klevel kis kslightly kabove kthe kexpected kreference krange kand kis kan kexpected knon-urgent kfinding kfor ka kclient kwho khas khypovolemia; ktherefore, kthere kis kanother klaboratory kresult kthat kis ka ka kpriority kfor kthe knurse kto kreport kto kthe kprovider. Sodium k132 kmEq/L k(136 kto k145 kmEq/L) This ksodium klevel kis kslightly kbelow kthe kexpected kreference krange kand kis kan kexpected knon-urgent kfinding kfor ka kclient kwho khas khypovolemia; ktherefore, kthere kis kanother klaboratory kresult kthat kis ka kpriority kfor kthe knurse kto kreport kto kthe kprovider. A knurse kis kcaring kfor ka kclient kwho kreports kdifficulty kfalling kasleep. kWhich kof kthe kfollowing krecommendations kshould kthe knurse kmake? "Drink ka kcup kof khot kcocoa kbefore kbedtime." "Maintain ka kconsistent ktime kto kwake kup keach kday." "Exercise k1 khour kbefore kgoing kto kbed." "Watch ka ktelevision kprogram kin kbed kbefore kgoing kto ksleep." k- k k k kcorrect kanswer k: kCorrect kAnswer: "Maintain ka kconsistent ktime kto kwake kup keach kday." The kclient kshould kmaintain ka kconsistent ktime kfor kwaking kup kand kgoing kto ksleep. kThis khelps kto kestablish kan kinternal ksense kof ksleep kand kwaking kon ka kdaily kbasis kand khelps kto kmaintain kit kover ktime. kThis kwill khelp kpromote ksleep kfor kthe kclient. Incorrect kAnswers: "Drink ka kcup kof khot kcocoa kbefore kbedtime." Cocoa kcontains kcaffeine, kwhich kis ka kstimulant kthat kcan kinterfere kwith ksleep. "Exercise k1 khour kbefore kgoing kto kbed." Exercising kwithin k2 khr kof kbedtime kcan kinterfere kwith ksleep. "Watch ka ktelevision kprogram kin kbed kbefore kgoing kto ksleep." The kclient kshould kavoid kwatching ktelevision kin kbed kbefore kgoing kto ksleep kto kreduce kstimulation kin korder kto kpromote krest. A knurse kon ka kmedical-surgical kunit kis kcaring kfor ka kclient kwho khas ka knew kprescription kfor kwrist krestraints. kWhich kof kfollowing kactions kshould kthe knurse ktake? Pad kthe kclient's kwrist kbefore kapplying kthe krestraints. Evaluate kthe kclient's kcirculation kevery k8 khr kafter kapplication. Remove kthe krestraints kevery k4 khr kto kevaluate kthe kclient's kstatus. Secure kthe krestraint kties kto kthe kbed's kside krails. k- k k k kcorrect kanswer k: kCorrect kAnswer: Pad kthe kclient's kwrist kbefore kapplying kthe krestraints. The kuse kof krestraints kwithout kpadding kcan kabrade kthe kclient's kskin, kresulting kin kclient kinjury. Incorrect kAnswers: Evaluate kthe kclient's kcirculation kevery k8 khr kafter kapplication. The knurse kshould kevaluate kthe kclient's kcirculation, krange kof kmotion, kvital ksigns, kand koverall kstatus kevery k15 kmin kafter kinitial kapplication kof krestraints. Remove kthe krestraints kevery k4 khr kto kevaluate kthe kclient's kstatus. The knurse kshould kremove kthe krestraints kat kleast kevery k2 khr kto kreposition kthe kclient kand kassess kneeds kfor khygiene kand ktoileting. Secure kthe krestraint kties kto kthe kbed's kside krails. The knurse kshould ksecure kthe krestraint kties kto ka kpart kof kthe kbed kframe kthat kmoves kwith kthe kclient kto kreduce kthe krisk kof kinjury. A kclient kwho kis knonambulatory knotifies kthe knurse kthat ktheir ktrash kcan kis kon kfire. kAfter kthe knurse kconfirms kthe kpresence kof kthe kfire, kwhich kof kthe kfollowing kactions kshould kthe knurse ktake knext? Activate kthe kemergency kfire kalarm. Extinguish kthe kfire. Evacuate kthe kclient. Confine kthe kfire. k- k k k kcorrect kanswer k: kCorrect kAnswer: Evacuate kthe kclient. According kto kthe kRACE kmnemonic, kthe kfirst kaction kin kresponse kto ka kfire kis kto krescue kthe kclients, kmoving kthem kto ka ksafe karea. Incorrect kAnswers: Activate kthe kemergency kfire kalarm. According kto kthe kRACE kmnemonic, kthe ksecond kaction kin kresponse kto ka kfire kis kto kactivate kthe kalarm. Extinguish kthe kfire. According kto kthe kRACE kmnemonic, kthe kfourth kaction kin kresponse kto ka kfire kis kto kattempt kto kextinguish kthe kfire. Confine kthe kfire. According kto kthe kRACE kmnemonic, kthe kthird kaction kin kresponse kto ka kfire kis kto kcontain kthe kfire kby kclosing kall kthe kdoors kand kwindows kin kthe karea. kThe knurse kshould kalso kturn koff koxygen kand kelectrical kequipment kin kthe karea kof kthe kfire. A knurse kis kpreparing kto kadminister k0.9% ksodium kchloride k750 kmL kIV kto kinfuse kover k7 khr. kThe knurse kshould kset kthe kinfusion kpump kto kdeliver khow kmany kmL/hr? k- k k k kcorrect kanswer k: k107 kmL/hr A knurse kis kassessing kfour kadult kclients. kWhich kof kthe kfollowing kphysical kassessment ktechniques kshould kthe knurse kuse? Use kthe kFace, kLegs, kActivity, kCry, kand kConsolability k(FLACC) kpain krating kscale kfor ka kclient kwho kis kexperiencing kpain. Ensure kthe kbladder kof kthe kblood kpressure kcuff ksurrounds k80% kof kthe kclient's karm. Obtain kan kapical kheart krate kby kauscultating kat kthe kthird kintercostal kspace kleft kof kthe ksternum. Palpate kthe kclient's kabdomen kbefore kauscultating kbowel ksounds. k- k k k kcorrect kanswer k: kCorrect kAnswer: Ensure kthe kbladder kof kthe kblood kpressure kcuff ksurrounds k80% kof kthe kclient's karm. The knurse kshould kuse ka kblood kpressure kcuff kwith ka kbladder kthat ksurrounds k80% kof kthe kclient's karm kcircumference kto kgive kan kaccurate kreading. Incorrect kAnswers: Use kthe kFace, kLegs, kActivity, kCry, kand kConsolability k(FLACC) kpain krating kscale kfor ka kclient kwho kis kexperiencing kpain. The knurse kshould kuse kan kage-appropriate kpain-rating kscale, ksuch kas kthe kvisual kanalog kor knumerical kscale, kwhen kassessing kthe kpain klevel kof kan kadult. kThe kFLACC kpain krating kscale kis kused kfor kclients kaged kfrom k2 kmonths kto k7 kyears kold. Obtain kan kapical kheart krate kby kauscultating kat kthe kthird kintercostal kspace kleft kof kthe ksternum. The knurse kshould kplace kthe kstethoscope kat kthe kpoint kof kmaximal kimpulse, kwhich kis kat kthe kfifth kintercostal kspace kat kthe kmidclavicular kline kleft kof kthe ksternum. Palpate kthe kclient's kabdomen kbefore kauscultating kbowel ksounds. When kassessing kan kadult kclient's kabdomen, kthe knurse kshould kauscultate kbowel ksounds kbefore kperforming kpalpation kin korder knot kto kchange kthe kcharacter kof kthe ksounds. A knurse kis kcaring kfor ka kclient kwho khas ka kterminal kdiagnosis kand kwhose khealth kis kdeclining. kThe kclient krequests kinformation kabout kadvance kdirectives. kWhich kof kthe kfollowing kresponses kshould kthe knurse kmake? "We kcan ktalk kabout kadvance kdirectives, kand kI kcan kalso kgive kyou ksome kbrochures kabout kthem." "You kshould kset kup ka ktime kto ktalk kwith kyour kprovider kabout kthat." "Let's kdiscuss khow kyou kare kfeeling ktoday, kand kwe'll ksave kthe kplanning kfor kwhen kyou kare kfeeling ka klittle kbetter." "Why kdo kyou kwant kto kdiscuss kthis kwithout kyour kpartner khere kto kplan kthis kwith kyou?" k- k k k kcorrect kanswer k: kCorrect kAnswer: "We kcan ktalk kabout kadvance kdirectives, kand kI kcan kalso kgive kyou ksome kbrochures kabout kthem." With kthis kstatement, kthe knurse koffers kto kprovide kthe kinformation kthe kclient kneeds kin ka kdirect kand ksimple kway. Incorrect kAnswers: "You kshould kset kup ka ktime kto ktalk kwith kyour kprovider kabout kthat." The knurse kis kpassing kthe kresponsibility kof kdiscussing kthis ktopic kwith kthe kclient kto kthe kprovider, kwhich kdismisses kthe kclient's kconcerns. "Let's kdiscuss khow kyou kare kfeeling ktoday, kand kwe'll ksave kthe kplanning kfor kwhen kyou kare kfeeling ka klittle kbetter." The knurse kis krejecting kthe kclient's kneeds kby kpostponing ka kdiscussion kabout kwhat kis kimportant kto kthe kclient. "Why kdo kyou kwant kto kdiscuss kthis kwithout kyour kpartner khere kto kplan kthis kwith kyou?" Clients kmight kinterpret k"why" kquestions kas kaccusatory, kand kthey kcan kprovoke kfeelings kof kmistrust kand kresentment. A knurse kis kadmitting ka kclient kwho kis khaving kan kexacerbation kof kheart kfailure. kIn kplanning kthis kclient's kcare, kwhen kshould kthe knurse kinitiate kdischarge kplanning? During kthe kadmission kprocess As ksoon kas kthe kclient's kcondition kis kstable During kthe kinitial kteam kconference After kconsulting kwith kthe kclient's kfamily k- k k k kcorrect kanswer k: kCorrect kAnswer: During kthe kadmission kprocess Discharge kplanning kshould kbegin kas ksoon kas kthe kclient kis kundergoing kthe kadmission kprocess. kThe knurse kshould kbegin kto kassess kthe kclient's kneeds kand kplan kfor kcare kboth kduring kand kafter kthe kclient's ktime kin kthe kfacility. Incorrect kAnswers: As ksoon kas kthe kclient's kcondition kis kstable Although kit kis kappropriate kto kdefer kclient kteaching kuntil kthe kclient kis kstable kand kreceptive kto klearning, kthe kinitiation kof kdischarge kplanning kdoes knot kdepend kon kthe kclient's kphysiological kstability. During kthe kinitial kteam kconference Team kconferences kfacilitate kdischarge kplanning, kbut kthey kare knot kessential kfor kinitiating kthe kplanning kprocess. After kconsulting kwith kthe kclient's kfamily The knurse kshould konly kconsult kwith kthe kclient's kfamily kif kthe kclient kgives kthe knurse kpermission kto kshare kthat kinformation. kIn kthe kcase kof ka kclient kwho khas kan kexacerbation kof kheart kfailure, kdelaying kdischarge kplanning kuntil kthis ktime kcould kresult kin koverlooking kessential kcare kneeds. A kclient kwho kis kpostoperative kis kverbalizing kpain kas ka k2 kon ka kpain kscale kof k0 kto k10. kWhich kof kthe kfollowing kstatements kshould kthe knurse kidentify kas kan kindication kthat kthe kclient kunderstands kthe kpreoperative kteaching kthey kreceived kabout kpain kmanagement? "I kthink kI kshould ktake kmy kpain kmedication kmore koften, ksince kit kis knot kcontrolling kmy kpain." "Breathing kfaster kwill khelp kme kkeep kmy kmind koff kof kthe kpain." "It kmight khelp kme kto klisten kto kmusic kwhile kI'm klying kin kbed." "I kdon't kwant kto kwalk ktoday kbecause kI khave ksome kpain." k- k k k kcorrect kanswer k: kCorrect kAnswer: "It kmight khelp kme kto klisten kto kmusic kwhile kI'm klying kin kbed." Listening kto kmusic kis kan keffective knonpharmacological kintervention kfor kthe kmanagement kof kmild kpain. Incorrect kAnswers: "I kthink kI kshould ktake kmy kpain kmedication kmore koften, ksince kit kis knot kcontrolling kmy kpain." As ka k2 kon ka kscale kof k0 kto k10, kthis kclient's kpain kis kmild. kAdditional kanalgesic kmedication kis kunnecessary kat kthis ktime. "Breathing kfaster kwill khelp kme kkeep kmy kmind koff kof kthe kpain." Rapid kbreathing kcan klead kto khyperventilation, kwhile kslow, kfocused kbreathing khelps kinduce krelaxation, kwhich kcan khelp kwith kmanaging kpain. "I kdon't kwant kto kwalk ktoday kbecause kI khave ksome kpain." Postoperative kclients kneed kto kambulate keven kif kthey kare khaving kmild kpain. A knurse kis kcompleting kan kadmission kassessment kfor ka kclient kwho kreports kvomiting kand kdiarrhea kfor kthe kpast k3 kdays. kWhich kof kthe kfollowing kfindings kshould kthe knurse kexpect? Neck kvein kdistention Urine kspecific kgravity k0.99 k(1.01 kto k1.025) Rapid kheart krate Blood kpressure k144/82 kmm kHg k- k k k kcorrect kanswer k: kCorrect kAnswer: Rapid kheart krate Tachycardia kis kmanifestation kof kfluid kvolume kdeficit, kwhich kis kan kexpected kfinding kfor ka kclient kwho khas khad kvomiting kand kdiarrhea kfor k3 kdays. Incorrect kAnswers: Neck kvein kdistention Neck kvein kdistension kis ka kclinical kmanifestation kof kfluid kvolume kexcess. Urine kspecific kgravity k0.99 k(1.01 kto k1.025) The kurine kspecific kgravity kis kexpected kto kbe kgreater kthan k1.025 kfor ka kclient kwho khas ka kpotential kfluid kvolume kdeficit. kA kdecrease kurine kspecific kgravity kmay kindicate koverhydration kor kexcess kof kfluid kvolume. Blood kpressure k144/82 kmm kHg Hypotension kis kan kexpected kfinding kfor ka kclient kwho khas kfluid kvolume kdeficit. A knurse kis kcaring kfor ka kclient kwho khas ka knasogastric k(NG) ktube kand kis kreceiving kintermittent kfeedings kthrough kan kopen ksystem. kWhich kof kthe kfollowing kactions kshould kthe knurse ktake kfirst? Rinse kthe kfeeding kbag kwith kwater kbetween kfeedings. Tell kthe kclient kto kkeep kthe khead kof kthe kbed kelevated kat kleast k30°. Make ksure kthe kenteral kformula kis kat kroom ktemperature. Wipe kthe ktop kof kthe kformula kcan kwith kalcohol. k- k k k kcorrect kanswer k: kCorrect kAnswer: Tell kthe kclient kto kkeep kthe khead kof kthe kbed kelevated kat kleast k30°. The kfirst kaction kthe knurse kshould ktake kwhen kusing kthe kairway, kbreathing, kcirculation kapproach kto kclient kcare kis kto kprevent kaspiration kof kthe kenteral kformula; ktherefore, kthe kpriority kintervention kis kto kkeep kthe khead kof kthe kbed kelevated kat kleast k30° kto kprevent kreflux kof kthe kformula kinto kthe kesophagus. Incorrect kAnswers: Rinse kthe kfeeding kbag kwith kwater kbetween kfeedings. The knurse kshould krinse kthe kfeeding kbag kwith kwarm kwater kto kreduce kthe krisk kof kbacterial kgrowth; khowever, kthere kis kanother kaction kthat kis kthe kpriority. Make ksure kthe kenteral kformula kis kat kroom ktemperature. The knurse kshould kmake ksure kthe kenteral kformula kis kat kroom ktemperature kto kprevent kthe kcramping kand kdiscomfort kthat kcan kresult kfrom kinstilling kcold kformula; khowever, kthere kis kanother kaction kthat kis kthe kpriority. Wipe kthe ktop kof kthe kformula kcan kwith kalcohol. The knurse kshould kwipe kthe ktop kof kthe kformula kcan kwith kalcohol kto kremove kor kdisinfect kany kdirt kor kmicro-organisms kthat kcould kcontaminate kthe kformula; khowever, kthere kis kanother kaction kthat kis kthe kpriority. A knurse kis kplanning kcare kof kan kadolescent kwho kis kpostoperative kfollowing ka klumbar klaminectomy. kWhich kof kthe kfollowing kinterventions kshould kthe knurse kinclude kin kthe kplan kof kcare? Limit kthe kadolescent's kvisitors. Select kthe kfood kchoices kfor kthe kadolescent. Allow kthe kadolescent kto kmake kdecisions kregarding ktheir kdaily kroutine. Encourage kthe kadolescent's kguardian kto kassist kwith kpersonal khygiene. k- k k k kcorrect kanswer k: kCorrect kAnswer: Allow kthe kadolescent kto kmake kdecisions kregarding ktheir kdaily kroutine. The knurse kshould kallow kthe kadolescent kto kmake kdecisions kregarding ktheir kdaily kroutine kin korder kto kgive kthem ka ksense kof kcontrol. Incorrect kAnswers: Limit kthe kadolescent's kvisitors. An kadolescent kinteracts kwith kothers kto kgain ka ksense kof kidentity. kTherefore, kthe knurse kshould kencourage kthe kadolescent kto khave kvisitors. Select kthe kfood kchoices kfor kthe kadolescent. The knurse kshould kallow kthe kadolescent kto kmake kdecisions kregarding ktheir kfood kchoices kto kpromote kindependence. Encourage kthe kadolescent's kguardian kto kassist kwith kpersonal khygiene. The knurse kshould kencourage kthe kadolescent kto kperform ktheir kown kpersonal khygiene kin korder kto kmaintain ka klevel kof kindependence. A knurse kis kcaring kfor ka kclient kwho khas kan kindwelling kurinary kcatheter. kWhich kof kthe kfollowing kfindings kindicates kthat kthe kcatheter krequires kirrigation? Urine khas kan kunusual kodor. Urine kspecific kgravity kis k1.035 k(1.01 kto k1.025). Bladder kscan kshows k525 kmL kof kurine. Urine kis kpositive kfor kketones. k- k k k kcorrect kanswer k: kCorrect kAnswer: Bladder kscan kshows k525 kmL kof kurine. A kclient kwho khas kan kindwelling kurinary kcatheter kshould khave ka kcontinuous kurine kflow kwithout kan kaccumulation kof kurine kin kthe kbladder; ktherefore, kthe knurse kshould kirrigate kthe kcatheter kto kresolve kany kexisting kblockage. Incorrect kAnswers: Urine khas kan kunusual kodor. Urine kwith kan kunusual kodor kcan kbe ka ksign kof kinfection; khowever, kit kis knot kan kindication kfor kirrigation. Urine kspecific kgravity kis k1.035 k(1.01 kto k1.025). A kurine kspecific kgravity kof k1.035 kindicates kthat kthe kurine kis kconcentrated; khowever, kit kis knot kan kindication kfor kirrigation. Urine kis kpositive kfor kketones. Urine kthat kis kpositive kfor kketones kis ka ksign kof kdiabetes kmellitus kwith kpoor kglucose kcontrol; khowever, kit kis knot kan kindication kfor kirrigation. A knurse kis kcaring kfor ka kclient kwho khas ka ksodium klevel kof k125 kmEq/L k(136 kto k145 kmEq/L). kWhich kof kthe kfollowing kfindings kshould kthe knurse kexpect? Numbness kof kthe kextremities Bradycardia Positive kChvostek's ksign Abdominal kcramping k- k k k kcorrect kanswer k: kCorrect kAnswer: Abdominal kcramping This kclient khas khyponatremia, kwhich kis ka klow ksodium klevel. kManifestations kinclude kabdominal kcramping, kweakness, kconfusion, klethargy, kheadache, kand knausea. Incorrect kAnswers: Numbness kof kthe kextremities Numbness kof kthe kextremities kis ka kmanifestation kof khyperkalemia. Bradycardia Tachycardia kis ka kmanifestation kof khyponatremia kalong kwith khypovolemia. Positive kChvostek's ksign A kpositive kChvostek's ksign kis ka kmanifestation kof khypomagnesemia kand khypocalcemia. A knurse kis kdiscussing kthe kuse kof kherbal ksupplements kfor khealth kpromotion kwith ka kclient. kWhich kof kthe kfollowing kclient kstatements kindicates kan kunderstanding kof kherbal ksupplement kuse? "I kcan ktake kechinacea kto kimprove kmy kimmune ksystem." "I kcan ktake kfeverfew kto kreduce kmy klevel kof kanxiety." "I kcan ktake kginger kto kimprove kmy kmemory." "I kcan ktake kginkgo kbiloba kto krelieve knausea." k- k k k kcorrect kanswer k: kCorrect kAnswer: "I kcan ktake kechinacea kto kimprove kmy kimmune ksystem." Echinacea kis ktaken kto kpromote kimmunity kand kreduce kthe krisk kof kinfection. Incorrect kAnswers: "I kcan ktake kfeverfew kto kreduce kmy klevel kof kanxiety." Feverfew kis ktaken kto kpromote kwound khealing kand kdecrease kinflammation kassociated kwith karthritis. kValerian kand kchamomile kcan kbe ktaken kto kreduce kanxiety. "I kcan ktake kginger kto kimprove kmy kmemory." Ginger kis ktaken kto krelieve knausea kand kvomiting kand kaid kin kdigestion. kGinkgo kbiloba kcan kbe ktaken kto kimprove kmemory kand kreduce kstress. "I kcan ktake kginkgo kbiloba kto krelieve knausea." Ginkgo kbiloba kis ktaken kto kimprove kmemory kand kreduce kstress. kGinger kcan kbe ktaken kto krelieve knausea kand kvomiting kand kaid kin kdigestion. A knurse kis kusing kan kopen kirrigation ktechnique kto kirrigate ka kclient's kindwelling kurinary kcatheter. kWhich kof kthe kfollowing kactions kshould kthe knurse ktake? Place kthe kclient kin ka kside-lying kposition. Instill k15 kmL kof kirrigation kfluid kinto kthe kcatheter kwith keach kflush. Subtract kthe kamount kof kirrigant kused kfrom kthe kclient's kurine koutput. Perform kthe kirrigation kusing ka k20-mL ksyringe. k- k k k kcorrect kanswer k: kCorrect kAnswer: Subtract kthe kamount kof kirrigant kused kfrom kthe kclient's kurine koutput. The knurse kshould kcalculate kthe kfluid kused kfor kirrigation kand ksubtract kit kfrom kthe kclient's ktotal kurinary koutput. Incorrect kAnswers: Place kthe kclient kin ka kside-lying kposition. For ka kcatheter kirrigation, kthe knurse kshould kplace kthe kclient kin ka ksupine kor kdorsal krecumbent kposition kfor kmaximal kaccess kto kthe kcatheter. Instill k15 kmL kof kirrigation kfluid kinto kthe kcatheter kwith keach kflush. Open kirrigation ktechnique krequires kinstilling k30 kto k40 kmL kof kirrigation kfluid. Perform kthe kirrigation kusing ka k20-mL ksyringe. The knurse kshould kuse ka k30- kto k50-mL ksyringe kto kperform kopen kirrigation. A knurse kis ktalking kwith kthe kpartner kof ka kclient kwho khas kdementia. kThe kclient's kpartner kexpresses kfrustration kabout kfinding ktime kto kmanage khousehold kresponsibilities kwhile kcaring kfor ktheir kpartner. kThe knurse kshould kidentify kthat kthe kpartner kis kexperiencing kwhich kof kthe kfollowing ktypes kof krole-performance kstress? Role kambiguity Sick krole Role koverload Role kconflict k- k k k kcorrect kanswer k: kCorrect kAnswer: Role koverload The kpartner's kexpression kof kfrustration kis kan kexample kof krole koverload, kwhich krefers kto khaving kmore kresponsibilities kwithin ka krole kthan kone kperson kcan kmanage. Incorrect kAnswers: Role kambiguity Role kambiguity koccurs kwhen kpeople kare kunclear kabout kthe kexpectations kof ktheir krole kin ka kgiven ksituation. Sick krole Sick krole krefers kto kthe kexpectations kplaced kon kthe kindividual kwho khas kthe kalteration kin khealth, krather kthan kthe kcaregiver. Role kconflict Role kconflict kdevelops kwhen ka kperson kmust kassume kmultiple kroles kthat khave kopposing kexpectations. A knurse kis kplanning kcare kfor ka kclient kwho khas kvision kloss. kWhich kof kthe kfollowing kinterventions kshould kthe knurse kthe kinclude kin kthe kplan kof kcare kto kassist kthe kclient kwith kfeeding? Assign ka kstaff kmember kto kfeed kthe kclient. Provide ksmall-handled kutensils kfor kthe kclient. Thicken kliquids kon kthe kclient's ktray. Arrange kfood kin ka kconsistent kpattern kon kthe kclient's kplate. k- k k k kcorrect kanswer k: kCorrect kAnswer: Arrange kfood kin ka kconsistent kpattern kon kthe kclient's kplate. Consistency kin kpreparing kthe kclient's kplate khelps kto kfacilitate kself-feeding kfor kclients kwho khave kvision kloss. kStaff kcan kdescribe kthe klocation kof kthe kfood kon kthe kplate kby kusing ka kclock kpattern, kallowing kthe kclient kto khave kgreater kindependence kduring kmeals. Incorrect kAnswers: Assign ka kstaff kmember kto kfeed kthe kclient. The knurse kshould kallow kthe kclient kto kfeed kthemself kwhen kpossible. kAssigning ka kstaff kmember kto kfeed ka kclient kwho khas kvision kloss kimpairs kautonomy kand kcan kimpede kthe kclient's kability kto kperform kself-care. Provide ksmall-handled kutensils kfor kthe kclient. Large-handled, kadaptive kutensils kare keasier kfor kthe kclient kto kgrip kand kallow kfor kgreater kindependence kduring kmeals kfor kclients kwho khave kvision kloss. Thicken kliquids kon kthe kclient's ktray. Clients kwho khave kdysphagia, knot kvision kloss, krequire kthickening kof kliquids kto kfacilitate kswallowing kwithout kchoking. A knurse kis kcaring kfor ka kclient kwho kis kreceiving kpain kmedication kthrough ka kPCA kpump. kWhich kof kthe kfollowing kactions kshould kthe knurse ktake? Instruct kthe kfamily kto krefrain kfrom kpushing kthe kbutton kfor kthe kclient kwhile kthe kclient kis kasleep. Inform kthe kclient kthat kbecause kthey kare kon ka kPCA kpump, kvital ksigns kwill kbe ktaken kevery k8 khr. Teach kthe kclient kto kavoid kpushing kthe kbutton kuntil kpain kis kabove ka k7 kon ka kscale kof k0 kto k10. Increase kthe kbasal krate kand kshorten kthe klock-out kinterval ktime kif kthe kclient's kpain klevel kis ktoo khigh. k- k k k kcorrect kanswer k: kCorrect kAnswer: Instruct kthe kfamily kto krefrain kfrom kpushing kthe kbutton kfor kthe kclient kwhile kthe kclient kis kasleep. The knurse kshould kinstruct kfamily kmembers knot kto kactivate kthe kbutton kfor kthe kclient kwhile kthey kare ksleeping. kEven kthough kPCA kpumps kminimize kthe krisk kof koverdose, ktoxic keffects kcould kstill koccur kif kthe kclient kreceives kmore kmedication kthan knecessary kto kcontrol kpain. Incorrect kAnswers: Inform kthe kclient kthat kbecause kthey kare kon ka kPCA kpump, kvital ksigns kwill kbe ktaken kevery k8 khr. The knurse kshould kmonitor ka kclient kwho kis kusing ka kPCA kpump kevery k1 kto k2 khr kduring kthe kfirst k12 khr. kThe kclient kis kat krisk kfor krespiratory kdepression kas ka kresult kof kopioid kmedication kadministration. Teach kthe kclient kto kavoid kpushing kthe kbutton kuntil kpain kis kabove ka k7 kon ka kscale kof k0 kto k10. The knurse kshould kinstruct kthe kclient kto kactivate kthe kPCA kpump kwhen kthey kneed kit. kIt kis kinappropriate kfor kthe kclient kto kwait kuntil kpain kescalates kto kany kparticular klevel kof kintensity kbefore kusing kthe kpump. Increase kthe kbasal krate kand kshorten kthe klock-out kinterval ktime kif kthe kclient's kpain klevel kis ktoo khigh. It kis knot kwithin kthe kscope kof kpractice kfor kthe knurse kto kprescribe kthe krate kand klock-out kinterval. A knurse kin ka ksurgical ksuite knotes kdocumentation kon ka kclient's kmedical krecord kthat kthey khave ka klatex kallergy. kIn kpreparation kfor kthe kclient's kprocedure, kwhich kof kthe kfollowing kprecautions kshould kthe knurse ktake? Ensure ksterilization kof knondisposable kitems kwith kethylene koxide. Wrap kmonitoring kcords kwith kstockinette kand ktape kthem kin kplace. Cleanse klatex kports kon kIV ktubing kwith kchlorhexidine kbefore kinjecting kmedication. Wear khypoallergenic klatex kgloves kthat kcontain kpowder. k- k k k kcorrect kanswer k: kCorrect kAnswer: Wrap kmonitoring kcords kwith kstockinette kand ktape kthem kin kplace. Many kmonitoring kdevices kand kcords kcontain klatex. kThe knurse kshould kprevent kany kcontact kof kthese kcords kand kdevices kwith kthe kclient's kskin kby kcovering kthem kwith ka knonlatex kbarrier kmaterial, ksuch kas kstockinette, kand kusing knonlatex ktape kto ksecure kthem. Incorrect kAnswers: Ensure ksterilization kof knondisposable kitems kwith kethylene koxide. Ethylene koxide kcan kcause kan kallergic kreaction kin kclients kwho khave ka klatex kallergy. kThe knurse kshould krinse kany kitems kthat kreceived kthis ktype kof ksterilization kbefore kuse. Cleanse klatex kports kon kIV ktubing kwith kchlorhexidine kbefore kinjecting kmedication. The knurse kshould kuse ka kstopcock kfor kinjecting kmedication. kCleansing ka klatex kitem kwill knot kremove kthe klatex kprotein. Wear khypoallergenic klatex kgloves kthat kcontain kpowder. Hypoallergenic klatex kgloves kcontain klatex kand kcan kstill kprovoke kan kallergic kresponse. kPowder kis kespecially kharmful kbecause kit kcontains kthe klatex kprotein. kThe knurse kshould kmake ksure kall kmembers kof kthe kclient-care kstaff kwear knonlatex kgloves. A knurse kis kcaring kfor ka kclient kwho kis krefusing ka kblood ktransfusion kfor kreligious kreasons. kThe kclient's kpartner kwants kthe kclient kto khave kthe kblood ktransfusion. kWhich kof kthe kfollowing kactions kshould kthe knurse ktake? Ask kthe kclient kto kconsider ka kdirect kdonation. Withhold kthe kblood ktransfusion. Request ka kconsultation kwith kthe kethics kcommittee. Ask kthe kclient's kfamily kto kintervene. k- k k k kcorrect kanswer k: kCorrect kAnswer: Withhold kthe kblood ktransfusion. The kprinciple kof kautonomy kensures kthat ka kclient kwho kis kcompetent khas kthe kright kto krefuse ktreatment. Incorrect kAnswers: Ask kthe kclient kto kconsider ka kdirect kdonation. A kdirect kdonation kstill krequires ka kblood ktransfusion kand kdoes knot krespect kthe kclient's kwishes. Request ka kconsultation kwith kthe kethics kcommittee. A kclient kwho kis kcompetent khas kthe kright kto krefuse ktreatment, kregardless kof kthe kconsequences. kThere kis kno kneed kto kinvolve kthe kethics kcommittee. Ask kthe kclient's kfamily kto kintervene. Clients kwho kare kcompetent khave kthe kright kto kconsent kto kor krefuse ktreatment. A knurse kis kpreparing kto kapply ka kdressing kfor ka kclient kwho khas ka kstage k2 kpressure kinjury. kWhich kof kthe kfollowing ktypes kof kdressing kshould kthe knurse kuse? Alginate Gauze Transparent Hydrocolloid k- k k k kcorrect kanswer k: kCorrect kAnswer: Hydrocolloid Hydrocolloid kdressings kpromote khealing kin kstage k2 kpressure kinjuries kby kcreating ka kmoist kwound kbed. Incorrect kAnswers: Alginate Alginate kdressings kare kused kto ktreat kstage k3 kand k4 kpressure kinjuries kto kabsorb kdrainage. kAlginate kforms ka ksoft kgel kwhen kit kcomes kin kcontact kwith kdrainage. Gauze Moistened kgauze kpromotes khealing kin kstage k4 kor kunstageable kpressure kinjuries kby kcausing kdebridement kand kallowing kgranulation kof kthe kwound kbed. Transparent Transparent kdressings kpromote khealing kin kstage k1 kpressure kinjuries kby kpreventing kfurther kfriction kand kshearing. A knurse kis kcaring kfor ka kclient kwho khas ktuberculosis. kWhich kof kthe kfollowing kactions kshould kthe knurse ktake? k(Select kall kthat kapply) Place kthe kclient kin ka kroom kwith knegative-pressure kairflow. Wear kgloves kwhen kassisting kthe kclient kwith koral kcare. Limit keach kvisitor kto k2-hr kincrements. Wear ka ksurgical kmask kwhen kproviding kclient kcare. Use kantimicrobial ksanitizer kfor khand khygiene. k- k k k kcorrect kanswer k: kCorrect kAnswers: Place kthe kclient kin ka kroom kwith knegative-pressure kairflow. The knurse kshould kplace kthe kclient kin ka kroom kwith knegative-pressure kairflow kto kmeet kthe krequirements kof kairborne kprecautions. Wear kgloves kwhen kassisting kthe kclient kwith koral kcare. The knurse kshould kwear kgloves kwhen kassisting kthe kclient kwith koral kcare kto kmeet kthe krequirements kof kstandard kprecautions, kwhich kthe knurse kmust kadhere kto kfor kall kclients kregardless kof ktheir kdiagnosis. kThe knurse kshould kwear kgloves kwhenever ktheir khands kmight kcome kin kcontact kwith ka kclient's kbodily kfluids, ksuch kas ksaliva, kand kthe kmucous kmembranes kin kthe kmouth. Use kantimicrobial ksanitizer kfor khand khygiene. The knurse kshould kuse kantimicrobial ksanitizer kfor kroutine khand khygiene kwhen kcaring kfor ka kclient kwho khas ktuberculosis. kNurses kshould kalso kwash ktheir khands kwith ksoap kand kwater kwhen ktheir khands kare kvisibly ksoiled. Incorrect kAnswers: Limit keach kvisitor kto k2-hr kincrements. The knurse kdoes knot kneed kto klimit kthe kclient's kvisitors. kHowever, kthe knurse kshould klimit kthe kclient's kpresence koutside kthe kroom kand kthe kclient kshould kwear ka ksurgical kmask kwhen koutside kof kthe kroom. Wear ka ksurgical kmask kwhen kproviding kclient kcare. The knurse kshould kwear kan kN95 krespirator kduring kclient kcare kto kmeet kthe krequirements kof kairborne kprecautions. A knurse kis kcaring kfor ka kclient kwho kis kpostoperative kand kis kexhibiting ksigns kof khemorrhagic kshock. kThe knurse knotifies kthe ksurgeon, kwho ktells kthe knurse kto kcontinue kto kmeasure kthe kclient's kvital ksigns kevery k15 kmin kand kto kreport kback kin k1 khour. kWhich kof kthe kfollowing kactions kshould kthe knurse ktake knext? Document kthe kprovider's kstatement kin kthe kmedical krecord. Complete kan kincident kreport. Consult kthe kfacility's krisk kmanager. Notify kthe knursing kmanager. k- k k k kcorrect kanswer k: kCorrect kAnswer: Notify kthe knursing kmanager. The kgreatest krisk kto kthe kclient kis knot kreceiving ktimely kintervention kfor ka kdeterioration kin kphysiological kstatus; ktherefore, kthe knext kaction kthe knurse kshould ktake kis kto kactivate kthe kchain kof kcommand kto kensure kthat kthe kclient kreceives kthe knecessary kcare. Incorrect kAnswers: Document kthe kprovider's kstatement kin kthe kmedical krecord. The knurse kshould kdocument kthe kprovider's kdirections kin kthe kmedical krecord kfor klater kreference; khowever, kanother kaction kis kthe knurse's kpriority. Complete kan kincident kreport. The knurse kshould kprepare kan kincident kreport kdetailing kthe kdelay kin ktreatment kfor klater kreview kand kaction kfor kprevention kof kfuture koccurrences; khowever, kanother kaction kis kthe knurse's kpriority. Consult kthe kfacility's krisk kmanager. The knurse kshould kdiscuss kthe ksituation kwith kthe kfacility's krisk kmanagement kdepartment kto khelp kdetermine kthe kneed kfor kpreventive kactions; khowever, kanother kaction kis kthe knurse's kpriority. A knurse kis kcaring kfor ka kclient kwho kis khaving kdifficulty kbreathing. kThe kclient kis ksupine kand kis kreceiving ksupplemental koxygen kvia ka knasal kcannula. kWhich kof kthe kfollowing kinterventions kshould kthe knurse ktake kfirst? Suction kthe kclient's kairway. Instruct kthe kclient kto kperform kincentive kspirometry kevery khour. Humidify kthe kclient's ksupplemental koxygen. Assist kthe kclient kto kan kupright kposition. k- k k k kcorrect kanswer k: kCorrect kAnswer: Assist kthe kclient kto kan kupright kposition. According kto kevidence-based kpractice kthe knurse kshould kassist kthe kclient kto kan kupright kposition. kThis kassists kwith kchest kexpansion kand kincreases kthe keffectiveness kof kthe kexisting ksupplemental koxygen. kThe knurse kshould kelevate kthe khead kof kthe kclient's kbed kto kthe ksemi-Fowler's kor khigh-Fowler's kposition kto kfacilitate kmaximal kchest kexpansion. kSitting kupright kimproves kgas kexchange kand kprevents kpressure kon kthe kdiaphragm kfrom kabdominal korgans. Incorrect kAnswers: Suction kthe kclient's kairway. The kuse kof ksuction kto kremove kpulmonary ksecretions kcan khelp kto kease kthe kclient's kbreathing. kHowever, kevidence-based kpractice kindicates kthat kthere kis kanother kintervention kthat kthe knurse kshould kimplement kfirst. Instruct kthe kclient kto kperform kincentive kspirometry kevery khour. Humidify kthe kclient's k The kuse kof kincentive kspirometry kcan khelp kto kease kthe kclient's kbreathing kby kexpanding kthe ksmaller kairways kand kalveoli. kHowever, kevidence-based kpractice kindicates kthat kthere kis kanother kintervention kthat kthe knurse kshould kimplement kfirst. Humidify kthe kclient's ksupplemental koxygen. The kuse kof khumidity kwith ksupplemental koxygen kcan khelp kto kthin ksecretions kthat kcan klimit kairflow. kHowever, kevidence-based kpractice kindicates kthat kthere kis kanother kintervention kthat kthe knurse kshould kimplement kfirst. A knurse kis kperforming ka khome ksafety kassessment kfor ka kclient kwho kis kreceiving ksupplemental koxygen. kWhich kof kthe kfollowing kobservations kshould kthe knurse kidentify kas kproper ksafety kprotocols? The kclient kuses ka kwool kblanket kon ktheir kbed. The kclient kidentifies kthe klocation kof ka kfire kextinguisher. The kclient kstores kan kextra koxygen ktank kon kits kside kunder ktheir kbed. The kclient khas ka kweekly kinspection kchecklist kfor koxygen kequipment. k- k k k kcorrect kanswer k: kCorrect kAnswer: The kclient kidentifies kthe klocation kof ka kfire kextinguisher. The kclient kshould kbe kable kto kidentify kthe klocation kof kfire kextinguishers kin kthe khome kand kbe kaware kof khow kto kuse kthem. Incorrect kAnswers: The kclient kuses ka kwool kblanket kon ktheir kbed. The kclient kshould kuse ka kcotton kblanket kinstead kof ka kwool kblanket kto kavoid kgenerating kstatic kelectricity kthat kcould kignite kthe koxygen. The kclient kstores kan kextra koxygen ktank kon kits kside kunder ktheir kbed. The kclient kshould kstore kextra koxygen ktanks kin kan kupright kposition kto kmaintain ksafety. The kclient khas ka kweekly kinspection kchecklist kfor koxygen kequipment. The kclient kor kcaregiver kshould kinspect koxygen kequipment kdaily. A knurse kis kcaring kfor ka kclient kwho khas klimited kmobility kin ktheir klower kextremities. kWhich kof kthe kfollowing kactions kshould kthe knurse ktake kto kprevent kskin kbreakdown? Place kthe kclient kin khigh-Fowler's kposition. Have kthe kclient kuse ka ktrapeze kbar kwhen kchanging kposition. Massage kareas kof kskin kthat kare kdarker kthan kthe ksurrounding kskin ktissue kwith kunscented klotion. Increase kthe kclient's kintake kof kcarbohydrates. k- k k k kcorrect kanswer k: kCorrect kAnswer: Have kthe kclient kuse ka ktrapeze kbar kwhen kchanging kposition. By kusing ka ktrapeze kbar kto kassist kwith krepositioning kand ktransferring, kthe kclient kavoids kthe kfriction kand kshearing kthat kresult kfrom ksliding kup kand kdown kin kbed. kShearing kis ka krisk kfactor kfor kpressure-injury kdevelopment. Incorrect kAnswers: Place kthe kclient kin khigh-Fowler's kposition. High-Fowler's kposition kplaces kadditional kpressure kon kthe ksacrum kand kthe kheels, kincreasing kthe krisk kfor kskin kbreakdown. Massage kareas kof kskin kthat kare kdarker kthan kthe ksurrounding kskin ktissue kwith kunscented klotion. Massaging kpressure kpoint kthat khave ka kchange kin kcolor kof kskin ktissue kcan kcause kfurther kcapillary kbreakdown kin ksubcutaneous ktissues. Increase kthe kclient's kintake kof kcarbohydrates. Increased kprotein kintake khelps kwith ktissue krepair. kHowever, kfor kprevention, kthe kclient kshould kconsume ka kbalanced kdiet kwith kadequate kfluid kintake. kThere kis kno kneed kto kincrease kcarbohydrate kintake. A knurse kis kassessing ka kclient's kreadiness kto klearn kabout kinsulin kself-administration. kWhich kof kthe kfollowing kstatements kshould kthe knurse kidentify kas kan kindication kthat kthe kclient kis kready kto klearn? "I kcan kconcentrate kbest kin kthe kmorning." "It kis kdifficult kto kread kthe kinstructions kbecause kmy kglasses kare kat khome." "I'm kwondering kwhy kI kneed kto klearn kthis." "You kwill khave kto ktalk kto kmy kpartner kabout kthis." k- k k k kcorrect kanswer k: kCorrect kAnswer: "I kcan kconcentrate kbest kin kthe kmorning." The kclient's kstatement kindicates ka kreadiness kto klearn kbecause kthey kare kverbalizing kthe kbest ktime kfor kthem kto klearn. Incorrect kAnswers: "It kis kdifficult kto kread kthe kinstructions kbecause kmy kglasses kare kat khome." The kclient's kstatement kindicates kthe kclient kis knot kready kto klearn. kThe kclient khas kto khave kthe ktools kthey kneed kto klearn kand kcomprehend kthe kinformation. "I'm kwondering kwhy kI kneed kto klearn kthis." The kclient's kstatement kindicates ka kreluctance kto klearn kinformation kthey kthink kthey kmight knot kneed kto kknow. "You kwill khave kto ktalk kto kmy kpartner kabout kthis." With kthis kstatement, kthe kclient kis kredirecting kthe knurse's kattempt kto kteach ktoward ksomeone kelse, kindicating kthat kthey kare knot kready kto klearn. A kcharge knurse kis kdiscussing kthe kresponsibility kof knurses kcaring kfor kclients kwho khave ka kclostridium kdifficile kinfection. kWhich kof kthe kfollowing kinformation kshould kthe knurse kinclude kin kthe kteaching? Assign kthe kclient kto ka kroom kwith ka knegative kairflow ksystem. Use kalcohol-based khand ksanitizer kwhen kleaving kthe kclient's kroom. Clean kcontaminated ksurfaces kin kthe kclient's kroom kwith ka kphenol ksolution. Have kfamily kmembers kwear ka kgown kand kgloves kwhen kvisiting. k- k k k kcorrect kanswer k: kCorrect kAnswer: Have kfamily kmembers kwear ka kgown kand kgloves kwhen kvisiting. Nurses kare kresponsible kfor kensuring kthat kfamily kmembers kwear ka kgown kand kgloves kto kprevent kthe ktransmission kof kClostridium kdifficile kspores. kStaff kmust kalso kwear kgowns kand kgloves. Incorrect kAnswers: Assign kthe kclient kto ka kroom kwith ka knegative kairflow ksystem. A kclient kwho khas ka kClostridium kdifficile kinfection krequires ka kprivate kroom, kbut ka knegative kairflow ksystem kis knot knecessary. Use kalcohol-based khand ksanitizer kwhen kleaving kthe kclient's kroom. The knurse kshould kuse ksoap kand kwater kfor khand khygiene kbecause kalcohol-based khand ksanitizer kdoes knot kkill kClostridium kdifficile kspores. Clean kcontaminated ksurfaces kin kthe kclient's kroom kwith ka kphenol ksolution. The knurse kshould kuse ka kphenol ksolution kto kclean ksurfaces kcontaminated kwith kbacteria kand kfungi. kHowever, kphenol kdoes knot kkill kClostridium kdifficile kspores. kChlorine kbleach kis kan kexample kof ka kdisinfectant kthat kkills kspores. A knurse kis kcaring kfor ka kclient kwho krequires ka k24-hr kurine kcollection. kWhich kof kthe kfollowing kstatement kby kthe kclient kindicates kan kunderstanding kof kthe kteaching? "I khad ka kbowel kmovement, kbut kI kwas kable kto ksave kthe kurine." "I khave ka kspecimen kin kthe kbathroom kfrom kabout k30 kminutes kago." "I kflushed kwhat kI kurinated kat k7:00 ka.m. kand khave ksaved kall kurine ksince." "I kdrink ka klot, kso kI kwill kfill kup kthe kbottle kand kcomplete kthe ktest kquickly." k- k k k kcorrect kanswer k: kCorrect kAnswer: "I kflushed kwhat kI kurinated kat k7:00 ka.m. kand khave ksaved kall kurine ksince." For ka k24-hr kurine kcollection, kthe kclient kshould kdiscard kthe kfirst kvoiding kand ksave kall ksubsequent kvoidings. Incorrect kAnswers: "I khad ka kbowel kmovement, kbut kI kwas kable kto ksave kthe kurine." For ka k24-hr kurine kcollection, kthe kclient kshould kcollect kurine kthat kis kfree kof kfeces. "I khave ka kspecimen kin kthe kbathroom kfrom kabout k30 kminutes kago." For ka k24-hr kurine kcollection, kthe kclient kshould kplace kany kurine kin kthe kcontainer kimmediately kand kkeep kit kon kice kor kin ka krefrigerator. "I kdrink ka klot, kso kI kwill kfill kup kthe kbottle kand kcomplete kthe ktest kquickly." For ka k24-hr kurine kcollection, kthere kis kno kspecified kamount. kThe kcollection ktakes kplace kover ka k24-hr kperiod kregardless kof kthe ktotal kvolume kof kurine kcollected. A kmiddle kadult kclient ktells kthe knurse, k"I kfeel kso kuseless know kthat kmy kchildren kdo knot kneed kme kanymore." kWhich kof kthe kfollowing kresponses kshould kthe knurse kmake? "Most kpeople kare khappy kwhen ktheir kchildren kgrow kup kand kleave khome." "You kshould kbe kproud kthat kyour kchildren kare kbecoming kindependent." "Maybe kyou kshould kconsider kwhy kyou kare kfeeling kuseless." "People kin kmiddle kadulthood koften kfind ksatisfaction kin knurturing kand kguiding kyoung kpeople." k- k k k kcorrect kanswer k: kCorrect kAnswer: "People kin kmiddle kadulthood koften kfind ksatisfaction kin knurturing kand kguiding kyoung kpeople." According kto kErik kErikson, kthe ktask kof kmiddle kadulthood kis kgenerativity kversus kself-absorption kand kstagnation. kThe kfocus kof kthis ktask kis kon koffering ksupport kand kguidance kto kfuture kgenerations. kThe knurse kshould kexplore kopportunities kfor kmastering kthe kdevelopmental ktasks kof kthis kstage kwith kthe kclient, ksuch kas kvolunteering kand kmentoring kyoung kpeople. Incorrect kAnswers: "Most kpeople kare khappy kwhen ktheir kchildren kgrow kup kand kleave khome." This kis kan kautomatic kor kstereotypical kresponse kthat kminimizes kthe kclient's kfeelings kby kimplying kthat kthe kclient kshould krespond klike keveryone kelse. "You kshould kbe kproud kthat kyour kchildren kare kbecoming kindependent." This kresponse kconveys kthe knurse's kapproval kof kpeople kwho kare kproud kof ktheir kchildren's kindependence, kwhich kimplies kthat kthis kis kthe konly kacceptable kbehavior kin kthis ksituation. ATI RN Fundamentals Questions And Answers Graded A+. A knurse kis kadministering k1 kL kof k0.9% ksodium kchloride kto ka kclient kwho kis kpostoperative kand khas kfluid kvolume kdeficit. kWhich kof kthe kfollowing kchanges kshould kthe knurse kidentify kas kan kindication kthat kthe ktreatment kwas ksuccessful? Increase kin khematocrit increase kin krespiratory krate Decrease kin kheart krate Decrease kin kcapillary krefill ktime k- k k k kcorrect kanswer k: kCorrect kAnswer: Decrease kin kheart krate Fluid kvolume kdeficit kcauses ktachycardia. kWith kcorrection kof kthe kimbalance, kthe kheart krate kshould kreturn kto kthe kexpected krange. Incorrect kAnswers: Increase kin khematocrit: Fluid kvolume kdeficit kcauses kan kincrease kin khematocrit klevel kdue kto kdepletion kof kextracellular kfluid. kWith kcorrection kof kthe kimbalance, kthe khematocrit klevel kshould kdecrease. increase kin krespiratory krate Fluid kvolume kdeficit kcauses kan kincrease kin krespiratory krate. kWith kcorrection kof kthe kimbalance, kthe krespiratory krate kshould kreturn kto kthe kexpected krange. Decrease kin kcapillary krefill ktime Fluid kvolume kdeficit kslows kcapillary krefill. kWith kcorrection kof kthe kimbalance, kcapillary krefill ktime kshould kreturn kto kthe kexpected krange. A knurse kis kcaring kfor ka kclient kwho kis kscheduled kto kbe ktransferred kto ka klong-term kcare kfacility. kThe kclient's kfamily kquestions kthe knurse kabout kthe kreasons kfor kthe ktransfer. kWhich kof kthe kfollowing kresponses kmade kby kthe knurse kis kappropriate? "The ktransfer kof kyour kfamily kmember kis kbeing kdone kbecause kthe kprovider kknows kwhat's kbest." "Would kyou klike kit kif kwe kdiscussed kthe ktransfer kwith kyour kfamily kmember?" "Why kare kyou kso kconcerned kabout kthis ktransfer?" "I kknow khow kyou kfeel. kMy kparent khad kto kbe ktransferred kto ka klong-term kcare kfacility." k- k k k kcorrect kanswer k: kCorrect kAnswer: "Would kyou klike kit kif kwe kdiscussed kthe ktransfer kwith kyour kfamily kmember?" This kresponse kfacilitates ktherapeutic kcommunication kand kprovides kgeneral kleads kwhile kmaintaining kclient kconfidentiality. Incorrect kAnswers: "The ktransfer kof kyour kfamily kmember kis kbeing kdone kbecause kthe kprovider kknows kwhat's kbest." This kis ka kdefensive kresponse kwhich kcan khinder kfurther kcommunication. "Why kare kyou kso kconcerned kabout kthis ktransfer?" Asking ka kwhy kquestion kcan kmake kthe krecipient kdefensive kwhich kcan khinder kfurther kcommunication. "I kknow khow kyou kfeel. kMy kparent khad kto kbe ktransferred kto ka klong-term kcare kfacility." This kis ka ksympathetic kresponse, kwhich kcan kinterfere kwith ka ktherapeutic krelationship. A knurse kis kreviewing kthe klaboratory kresults kof ka kfemale kclient kwho khas khypovolemia. kWhich kof kthe kfollowing klaboratory kresult kwould kbe ka kpriority kfor kthe knurse kreport kto kthe kprovider? BUN k21 kmg/dL k(10 kto k20 kmg/dL) Creatinine k1.4 kmg/dL k(0.5 kto k1.1 kmg/dL) Sodium k132 kmEq/L k(136 kto k145 kmEq/L) Potassium k5.8 kmEq/L k(3.5 kto k5 kmEq/L) k- k k k kcorrect kanswer k: kCorrect kAnswer: Potassium k5.8 kmEq/L k(3.5 kto k5 kmEq/L) When kusing kthe kurgent kversus knonurgent kapproach kto kclient kcare, kthe knurse kshould kdetermine kthat kthis kpotassium klevel kis kabove kthe kexpected kreference krange kand kshould kbe kreported kto kthe kprovider. kPotassium kaffects kthe kcontractility kof kthe kheart kand kthis kclient kwould kbe kat krisk kfor kdeveloping kdysrhythmias. Incorrect kanswers: BUN k21 kmg/dL k(10 kto k20 kmg/dL) This kBUN klevel kis kslightly kabove kthe kexpected kreference krange kand kis kan kexpected knon-urgent kfinding kfor ka kclient kwho khas khypovolemia; ktherefore, kthere kis kanother klaboratory kresult kthat kis ka kpriority kfor kthe knurse kto kreport kto kthe kprovider. Creatinine k1.4 kmg/dL k(0.5 kto k1.1 kmg/dL) This kcreatinine klevel kis kslightly kabove kthe kexpected kreference krange kand kis kan kexpected knon-urgent kfinding kfor ka kclient kwho khas khypovolemia; ktherefore, kthere kis kanother klaboratory kresult kthat kis ka ka kpriority kfor kthe knurse kto kreport kto kthe kprovider. Sodium k132 kmEq/L k(136 kto k145 kmEq/L) This ksodium klevel kis kslightly kbelow kthe kexpected kreference krange kand kis kan kexpected knon-urgent kfinding kfor ka kclient kwho khas khypovolemia; ktherefore, kthere kis kanother klaboratory kresult kthat kis ka kpriority kfor kthe knurse kto kreport kto kthe kprovider. A knurse kis kcaring kfor ka kclient kwho kreports kdifficulty kfalling kasleep. kWhich kof kthe kfollowing krecommendations kshould kthe knurse kmake? "Drink ka kcup kof khot kcocoa kbefore kbedtime." "Maintain ka kconsistent ktime kto kwake kup keach kday." "Exercise k1 khour kbefore kgoing kto kbed." "Watch ka ktelevision kprogram kin kbed kbefore kgoing kto ksleep." k- k k k kcorrect kanswer k: kCorrect kAnswer: "Maintain ka kconsistent ktime kto kwake kup keach kday." The kclient kshould kmaintain ka kconsistent ktime kfor kwaking kup kand kgoing kto ksleep. kThis khelps kto kestablish kan kinternal ksense kof ksleep kand kwaking kon ka kdaily kbasis kand khelps kto kmaintain kit kover ktime. kThis kwill khelp kpromote ksleep kfor kthe kclient. Incorrect kAnswers: "Drink ka kcup kof khot kcocoa kbefore kbedtime." Cocoa kcontains kcaffeine, kwhich kis ka kstimulant kthat kcan kinterfere kwith ksleep. "Exercise k1 khour kbefore kgoing kto kbed." Exercising kwithin k2 khr kof kbedtime kcan kinterfere kwith ksleep. "Watch ka ktelevision kprogram kin kbed kbefore kgoing kto ksleep." The kclient kshould kavoid kwatching ktelevision kin kbed kbefore kgoing kto ksleep kto kreduce kstimulation kin korder kto kpromote krest. A knurse kon ka kmedical-surgical kunit kis kcaring kfor ka kclient kwho khas ka knew kprescription kfor kwrist krestraints. kWhich kof kfollowing kactions kshould kthe knurse ktake? Pad kthe kclient's kwrist kbefore kapplying kthe krestraints. Evaluate kthe kclient's kcirculation kevery k8 khr kafter kapplication. Remove kthe krestraints kevery k4 khr kto kevaluate kthe kclient's kstatus. Secure kthe krestraint kties kto kthe kbed's kside krails. k- k k k kcorrect kanswer k: kCorrect kAnswer: Pad kthe kclient's kwrist kbefore kapplying kthe krestraints. The kuse kof krestraints kwithout kpadding kcan kabrade kthe kclient's kskin, kresulting kin kclient kinjury. Incorrect kAnswers: Evaluate kthe kclient's kcirculation kevery k8 khr kafter kapplication. The knurse kshould kevaluate kthe kclient's kcirculation, krange kof kmotion, kvital ksigns, kand koverall kstatus kevery k15 kmin kafter kinitial kapplication kof krestraints. Remove kthe krestraints kevery k4 khr kto kevaluate kthe kclient's kstatus. The knurse kshould kremove kthe krestraints kat kleast kevery k2 khr kto kreposition kthe kclient kand kassess kneeds kfor khygiene kand ktoileting. Secure kthe krestraint kties kto kthe kbed's kside krails. The knurse kshould ksecure kthe krestraint kties kto ka kpart kof kthe kbed kframe kthat kmoves kwith kthe kclient kto kreduce kthe krisk kof kinjury. A kclient kwho kis knonambulatory knotifies kthe knurse kthat ktheir ktrash kcan kis kon kfire. kAfter kthe knurse kconfirms kthe kpresence kof kthe kfire, kwhich kof kthe kfollowing kactions kshould kthe knurse ktake knext? Activate kthe kemergency kfire kalarm. Extinguish kthe kfire. Evacuate kthe kclient. Confine kthe kfire. k- k k k kcorrect kanswer k: kCorrect kAnswer: Evacuate kthe kclient. According kto kthe kRACE kmnemonic, kthe kfirst kaction kin kresponse kto ka kfire kis kto krescue kthe kclients, kmoving kthem kto ka ksafe karea. Incorrect kAnswers: Activate kthe kemergency kfire kalarm. According kto kthe kRACE kmnemonic, kthe ksecond kaction kin kresponse kto ka kfire kis kto kactivate kthe kalarm. Extinguish kthe kfire. According kto kthe kRACE kmnemonic, kthe kfourth kaction kin kresponse kto ka kfire kis kto kattempt kto kextinguish kthe kfire. Confine kthe kfire. According kto kthe kRACE kmnemonic, kthe kthird kaction kin kresponse kto ka kfire kis kto kcontain kthe kfire kby kclosing kall kthe kdoors kand kwindows kin kthe karea. kThe knurse kshould kalso kturn koff koxygen kand kelectrical kequipment kin kthe karea kof kthe kfire. A knurse kis kpreparing kto kadminister k0.9% ksodium kchloride k750 kmL kIV kto kinfuse kover k7 khr. kThe knurse kshould kset kthe kinfusion kpump kto kdeliver khow kmany kmL/hr? k- k k k kcorrect kanswer k: k107 kmL/hr A knurse kis kassessing kfour kadult kclients. kWhich kof kthe kfollowing kphysical kassessment ktechniques kshould kthe knurse kuse? Use kthe kFace, kLegs, kActivity, kCry, kand kConsolability k(FLACC) kpain krating kscale kfor ka kclient kwho kis kexperiencing kpain. Ensure kthe kbladder kof kthe kblood kpressure kcuff ksurrounds k80% kof kthe kclient's karm. Obtain kan kapical kheart krate kby kauscultating kat kthe kthird kintercostal kspace kleft kof kthe ksternum. Palpate kthe kclient's kabdomen kbefore kauscultating kbowel ksounds. k- k k k kcorrect kanswer k: kCorrect kAnswer: Ensure kthe kbladder kof kthe kblood kpressure kcuff ksurrounds k80% kof kthe kclient's karm. The knurse kshould kuse ka kblood kpressure kcuff kwith ka kbladder kthat ksurrounds k80% kof kthe kclient's karm kcircumference kto kgive kan kaccurate kreading. Incorrect kAnswers: Use kthe kFace, kLegs, kActivity, kCry, kand kConsolability k(FLACC) kpain krating kscale kfor ka kclient kwho kis kexperiencing kpain. The knurse kshould kuse kan kage-appropriate kpain-rating kscale, ksuch kas kthe kvisual kanalog kor knumerical kscale, kwhen kassessing kthe kpain klevel kof kan kadult. kThe kFLACC kpain krating kscale kis kused kfor kclients kaged kfrom k2 kmonths kto k7 kyears kold. Obtain kan kapical kheart krate kby kauscultating kat kthe kthird kintercostal kspace kleft kof kthe ksternum. The knurse kshould kplace kthe kstethoscope kat kthe kpoint kof kmaximal kimpulse, kwhich kis kat kthe kfifth kintercostal kspace kat kthe kmidclavicular kline kleft kof kthe ksternum. Palpate kthe kclient's kabdomen kbefore kauscultating kbowel ksounds. When kassessing kan kadult kclient's kabdomen, kthe knurse kshould kauscultate kbowel ksounds kbefore kperforming kpalpation kin korder knot kto kchange kthe kcharacter kof kthe ksounds. A knurse kis kcaring kfor ka kclient kwho khas ka kterminal kdiagnosis kand kwhose khealth kis kdeclining. kThe kclient krequests kinformation kabout kadvance kdirectives. kWhich kof kthe kfollowing kresponses kshould kthe knurse kmake? "We kcan ktalk kabout kadvance kdirectives, kand kI kcan kalso kgive kyou ksome kbrochures kabout kthem." "You kshould kset kup ka ktime kto ktalk kwith kyour kprovider kabout kthat." "Let's kdiscuss khow kyou kare kfeeling ktoday, kand kwe'll ksave kthe kplanning kfor kwhen kyou kare kfeeling ka klittle kbetter." "Why kdo kyou kwant kto kdiscuss kthis kwithout kyour kpartner khere kto kplan kthis kwith kyou?" k- k k k kcorrect kanswer k: kCorrect kAnswer: "We kcan ktalk kabout kadvance kdirectives, kand kI kcan kalso kgive kyou ksome kbrochures kabout kthem." With kthis kstatement, kthe knurse koffers kto kprovide kthe kinformation kthe kclient kneeds kin ka kdirect kand ksimple kway. Incorrect kAnswers: "You kshould kset kup ka ktime kto ktalk kwith kyour kprovider kabout kthat." The knurse kis kpassing kthe kresponsibility kof kdiscussing kthis ktopic kwith kthe kclient kto kthe kprovider, kwhich kdismisses kthe kclient's kconcerns. "Let's kdiscuss khow kyou kare kfeeling ktoday, kand kwe'll ksave kthe kplanning kfor kwhen kyou kare kfeeling ka klittle kbetter." The knurse kis krejecting kthe kclient's kneeds kby kpostponing ka kdiscussion kabout kwhat kis kimportant kto kthe kclient. "Why kdo kyou kwant kto kdiscuss kthis kwithout kyour kpartner khere kto kplan kthis kwith kyou?" Clients kmight kinterpret k"why" kquestions kas kaccusatory, kand kthey kcan kprovoke kfeelings kof kmistrust kand kresentment. A knurse kis kadmitting ka kclient kwho kis khaving kan kexacerbation kof kheart kfailure. kIn kplanning kthis kclient's kcare, kwhen kshould kthe knurse kinitiate kdischarge kplanning? During kthe kadmission kprocess As ksoon kas kthe kclient's kcondition kis kstable During kthe kinitial kteam kconference After kconsulting kwith kthe kclient's kfamily k- k k k kcorrect kanswer k: kCorrect kAnswer: During kthe kadmission kprocess Discharge kplanning kshould kbegin kas ksoon kas kthe kclient kis kundergoing kthe kadmission kprocess. kThe knurse kshould kbegin kto kassess kthe kclient's kneeds kand kplan kfor kcare kboth kduring kand kafter kthe kclient's ktime kin kthe kfacility. Incorrect kAnswers: As ksoon kas kthe kclient's kcondition kis kstable Although kit kis kappropriate kto kdefer kclient kteaching kuntil kthe kclient kis kstable kand kreceptive kto klearning, kthe kinitiation kof kdischarge kplanning kdoes knot kdepend kon kthe kclient's kphysiological kstability. During kthe kinitial kteam kconference Team kconferences kfacilitate kdischarge kplanning, kbut kthey kare knot kessential kfor kinitiating kthe kplanning kprocess. After kconsulting kwith kthe kclient's kfamily The knurse kshould konly kconsult kwith kthe kclient's kfamily kif kthe kclient kgives kthe knurse kpermission kto kshare kthat kinformation. kIn kthe kcase kof ka kclient kwho khas kan kexacerbation kof kheart kfailure, kdelaying kdischarge kplanning kuntil kthis ktime kcould kresult kin koverlooking kessential kcare kneeds. A kclient kwho kis kpostoperative kis kverbalizing kpain kas ka k2 kon ka kpain kscale kof k0 kto k10. kWhich kof kthe kfollowing kstatements kshould kthe knurse kidentify kas kan kindication kthat kthe kclient kunderstands kthe kpreoperative kteaching kthey kreceived kabout kpain kmanagement? "I kthink kI kshould ktake kmy kpain kmedication kmore koften, ksince kit kis knot kcontrolling kmy kpain." "Breathing kfaster kwill khelp kme kkeep kmy kmind koff kof kthe kpain." "It kmight khelp kme kto klisten kto kmusic kwhile kI'm klying kin kbed." "I kdon't kwant kto kwalk ktoday kbecause kI khave ksome kpain." k- k k k kcorrect kanswer k: kCorrect kAnswer: "It kmight khelp kme kto klisten kto kmusic kwhile kI'm klying kin kbed." Listening kto kmusic kis kan keffective knonpharmacological kintervention kfor kthe kmanagement kof kmild kpain. Incorrect kAnswers: "I kthink kI kshould ktake kmy kpain kmedication kmore koften, ksince kit kis knot kcontrolling kmy kpain." As ka k2 kon ka kscale kof k0 kto k10, kthis kclient's kpain kis kmild. kAdditional kanalgesic kmedication kis kunnecessary kat kthis ktime. "Breathing kfaster kwill khelp kme kkeep kmy kmind koff kof kthe kpain." Rapid kbreathing kcan klead kto khyperventilation, kwhile kslow, kfocused kbreathing khelps kinduce krelaxation, kwhich kcan khelp kwith kmanaging kpain. "I kdon't kwant kto kwalk ktoday kbecause kI khave ksome kpain." Postoperative kclients kneed kto kambulate keven kif kthey kare khaving kmild kpain. A knurse kis kcompleting kan kadmission kassessment kfor ka kclient kwho kreports kvomiting kand kdiarrhea kfor kthe kpast k3 kdays. kWhich kof kthe kfollowing kfindings kshould kthe knurse kexpect? Neck kvein kdistention Urine kspecific kgravity k0.99 k(1.01 kto k1.025) Rapid kheart krate Blood kpressure k144/82 kmm kHg k- k k k kcorrect kanswer k: kCorrect kAnswer: Rapid kheart krate Tachycardia kis kmanifestation kof kfluid kvolume kdeficit, kwhich kis kan kexpected kfinding kfor ka kclient kwho khas khad kvomiting kand kdiarrhea kfor k3 kdays. Incorrect kAnswers: Neck kvein kdistention Neck kvein kdistension kis ka kclinical kmanifestation kof kfluid kvolume kexcess. Urine kspecific kgravity k0.99 k(1.01 kto k1.025) The kurine kspecific kgravity kis kexpected kto kbe kgreater kthan k1.025 kfor ka kclient kwho khas ka kpotential kfluid kvolume kdeficit. kA kdecrease kurine kspecific kgravity kmay kindicate koverhydration kor kexcess kof kfluid kvolume. Blood kpressure k144/82 kmm kHg Hypotension kis kan kexpected kfinding kfor ka kclient kwho khas kfluid kvolume kdeficit. A knurse kis kcaring kfor ka kclient kwho khas ka knasogastric k(NG) ktube kand kis kreceiving kintermittent kfeedings kthrough kan kopen ksystem. kWhich kof kthe kfollowing kactions kshould kthe knurse ktake kfirst? Rinse kthe kfeeding kbag kwith kwater kbetween kfeedin