ATI Pre-assessment #1 questions & correct solutions

ATI Pre-assessment #1 questions & correct solutionsA client is prescribed antibiotic "A" 50 mg IV. The mixed IV solution contains 100 mL. The nurse is to administer the medication over ½ hour. The drip factor of the available IV tubing is 15gtt/mL. What is the drip rate in drops per minute? (Round to nearest whole number and enter only the number in the answer box). 50 100 x 15 --------- 30 A nurse is providing education to a client with a fractured femur who will need to use crutches for the next 6 weeks. Identify if the following directions provided by the nurse for walking up stairs using crutches are true or false. 1. Hold to rail with one hand and crutches with the other hand. 2. Push down on the stair rail and the crutches and step up with the 'unaffected' leg. 3. If not allowed to place weight on the 'affected' leg, hop up with the 'unaffected' leg. 4. Bring the 'affected' leg and the crutches up beside the 'unaffected' leg. 5. Remember, the 'unaffected' leg goes up first and the crutches move with the 'affected' leg. True Personalize values and beliefs and base reasoning on ethical fairness principles. Establish close relationships. Have influences that help with formation of healthy self-concept, such family and friends. Develop sense of personal identity that family expectations influence. Peer relationships develop as support system. Concerned with body images that media portray. Take on new experiences and when unable to accomplish task may feel guilty or misbehave. Generally do not exhibit stranger anxiety. Understand behavior in terms of what is socially acceptable. Develop sense of industry through advances in learning. Strive to develop healthy self- respect by finding out in what areas they excel. Peer groups play important role in social development. 1) Young adults 20-35 2) Adolescents 12-20 3) Preschoolers 3-6 4) School aged children 6-12 Droplet precautions: A private room or a room with other clients with the same infectious disease. Masks for providers and visitors. Contact precautions: A private room or a room with other clients with the same infection. Gloves and gowns worn by the caregivers and visitors. Airborne precautions: A private room. Masks or respiratory protection devices for caregivers and visitors. An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known or suspected to have tuberculosis. Negative pressure airflow exchange in the room of at least six exchanges per hour. 1) Pertussis 2) VRE 3) Measles Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. 1) Stage 4 2) Stage 2 3) Stage 1 4) Stage 3 What is the name of a legal document that instructs health care providers and family members about what, if any, life-sustaining treatment an individual wants if at some time the individual is unable to make decisions? Select one: a. Do Not Resuscitate b. Informed consent c. Durable power of attorney for health care IncorrectIncorrect. A durable power of attorney for health care is a legal document that designates another person to make health care decisions for the client when the client becomes unable to make decisions independently. d. Living will D. Living will? 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 meal selections is appropriate for this client? Select one: a. Grilled cheese sandwich, potato chips, chocolate pudding. IncorrectAlthough this option is high in calories, it is high in protein content and low in vitamins. b. Steak, french fries, corn. c. Scrambled eggs, bacon and pancakes. d. Chicken breast, mashed potatoes, spinach. D. Chicken breast, mashes potatoes, spinach A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls? Select one: a. Demonstrate how to use the call light. b. Hourly rounding by the nurse. c. Place bedside table in close proximity. d. Use of a night-light. IncorrectWhile use of a night-light is an effective intervention for reducing a client's fall risk, it is not as effective as frequent observations of the client who is at risk for falls . B. Hourly rounding by the nurse A nurse is caring for a client with a closed head injury. When pressure is applied to the client's nail beds, the client's eyes open and adduction of the arms with flexion of the elbows and wrists is noted. The client also moans with stimulation. What is this client's Glasgow Coma Score? 7 Eye opening (E) - The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice. 2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur. Verbal (V) - The best verbal response, with responses ranging from 5 to 1 5 = Conversation is coherent and oriented. 4 = Conversation is incoherent and disoriented. 3 = Words are spoken, but inappropriately. 2 = Sounds are made, but no words. 1 = Vocalization does not occur. Motor (M) - The best motor response, with responses ranging from 6 to 1 6 = Commands are followed. 5 = Local reaction to pain occurs. 4 = There is a general withdrawal to pain. 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present. 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present. 1 = Motor response does not occur. A nurse is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of the following pH values provides a good indication of correct tube placement? Select one: a. 5 b. 2 c. 7 d. 9 B. 2 A good indication of appropriate placement is obtaining gastric contents with a pH between 0 and 4. A nurse is caring for a client receiving chemotherapy that is experiencing neutropenia. Which of the following should the nurse include in this client's education? Select one: a. Gardening is a good form of mild exercise. b. Avoid crowded events. c. Take temperature weekly. d. Eat plenty of fresh fruits and vegetables. B Avoid crowded events Clients with neutropenia do not have enough circulating neutrophils to fight off infections. This client should avoid crowds to prevent exposure to colds/viruses.