Exit ATI/93 Questions and answers
Hypovolemia (S&S) - --elevated hematocrit (ex=55%)
-weak pulse
-tachycardia
-hypotension
-tachypnea
-slow cap refill
-elevated BUN
-increased urine specific gravity
-decreased urine output
-*A- measure pts daily weight*; daily weights are the most sensitive
indicator of fluid balance in clients of all ages, especially critical for infants &
children bc fluid accounts for a > portion of body weight
INCORRECT:
b-checking for the absence of tears is part of the hydration assessment BUT
doesn't give the nurse precise information about the degree or severity of
the infant's dehydration
c-palpating the fontanel is part of the hydration assessment BUT unless
fontanel is extremely sunken, this assessment doesn't give the nurse precise
info about the degree/severity of the dehydration
d-assessing skin turgor is part of hydration assessment BUT unless skin is
extremely slow to respond, this isn't precise enough - -A nurse is caring for
an infant who is experiencing dehydration; which assessment is priority?
A- measure the pts daily weight
B- check for tears
c- palpate the fontanel
d-assess skin turgor
-*C-instruct clients who are able to ambulate to leave*; pts who are able to
ambulate should leave 1st in the evacuation process bc it quickly reduces
the # of pts who require evacuation assistance - -A charge nurse is
coordinating the evacuation of pts from a facility following a bomb threat;
which action should the nurse take in evacuation process?
A-call in the pts' family members to provide additional help with moving
clients
B-ask pts who are able to ambulate to assist in moving unstable pts
C-instruct clients who are able to ambulate to leave
D-direct staff members to close the doors & windows as each room is
evacuated
-1. Denial; refusing to acknowledge the existence of her substance use
disorder
,2. Rationalization; attempting to make excuses to justify socially or
professionally unacceptable behavior
3.Intellectualization; an attempt to use the intellectual processes to avoid
expressing the emotions that stem from stressful situations
4. Suppression; pt is consciously avoiding a discussion of the substance use
disorder - -A nurse in a substance use disorder program is interacting w/ a
pt; identify the coping strategy/defense mechanism used in each statement
1: "I was just using the medication to help me out during a rough time in my
life. I can stop whenever I want."
2. "This all happened because my spouse is unemployed. That puts an
enormous amt of stress on me"
3. "I have read that problems w/ substances can have a variety of
predisposing factors."
4. "I just don't want to talk about it. There's nothing you can do about it
anyways."
-Sweat chloride - -Children who have cystic fibrosis have an elevated....
-Steatorrhea - --foul, fatty, frothy stools
-manifestation of celiac disease (a malabsorption syndrome)
-Clubbing - -Children who have cardiovascular disorders develop ______ of
the fingers & toes due to chronic hypoxemia of the tissues
-Jaundice - -Results from liver dysfunction
-Correct answers:
*A-sit with your back supported*; sitting w/ back supported while at the
computer helps to prevent back strain, which can lead to lower-back disc
disease
*B-keep knees at hip level*; helps to prevent unnecessary strain on the hips
and lower back
*c-use an ergonomically designed keyboard*
Incorrect:
D-keep your elbows away from your body
E-adjust the monitor screen so that you have to tilt your head slightly to look
at it - -A community health nurse is conducting a class about body
mechanics for county office workers. The nurse should include..... (select all
that apply)
A-"sit with your back supported"
B-"keep your knees at hip level"
C-"use an ergonomically designated computer keyboard"
D-"keep your elbows away from your body"
E-"adjust the monitor screen so that you have to tilt your head slightly to
look at it"
, -Correct:
*A-arrange for social services*; appropriate for a pt who faces challenges w/
self-care, as well as w/ paying for medical equipment & supplies
*B-initiate a consult w/ an enterostomal therapist*; can assist the pt in
learning to care for the colostomy
*C-provide the pt w/ information about the American Cancer Society*; pt can
learn about helpful resources from the ACS
*E-give the pt info about local support groups*; a pt who has cancer & a new
colostomy can get help w/ coping from a support group - -A nurse is
planning discharge teaching for a pt who has colorectal cancer & is post op
following a new colostomy. The pt expresses concern about discharge &
states "I have no health insurance & cannot pay for the ostomy supplies."
Which actions should the nurse take?
A- arrange for social services
B-initiate a consult w/ an enterostomal therapist
C-provide the pt w/ information about the American Cancer Society
D-postpone the pt's discharge
E-give the pt info about local support groups
-Flow-oriented incentive spirometer - -Instructions include:
-instruct pt to inhale deeply to elevate the balls in the device
-proper use of the ______ loosens secretions in the pt's lungs; pt should cough
deeply to facilitate removal of secretions from their lungs
-instruct the pt to clean the mouth piece w/ H2O & dry it after each use
-use ______ several times every hr while awake
-Clostridium difficile (C-diff) pt in contact isolation
1. contact isolation
2. c. diff - -Nurse should:
-wear gloves when handling articles that have the potential to contaminate
the hands when caring for a pt who is in __1__
-use soap and water to cleanse the hands; alcohol-based hand sanitizer is
ineffective against the spores of __2__
-shouldn't put pt on complete bed rest bc this places them at risk for the
hazards of immobility such as impaired skin integrity & retained respiratory
secretions; should instruct pt to remain in room but to move, cough, & DB at
least q2hr
-Wear a mask - -Nurse should _______ when working w/in 3 ft of a pt who
has an infection such as influenza and droplet precautions are required
-S/S that *death is imminent* - -S/S indicating ________:
-urinary incontinence
-cold extremities, first in the feet & hands
-hypotension
Hypovolemia (S&S) - --elevated hematocrit (ex=55%)
-weak pulse
-tachycardia
-hypotension
-tachypnea
-slow cap refill
-elevated BUN
-increased urine specific gravity
-decreased urine output
-*A- measure pts daily weight*; daily weights are the most sensitive
indicator of fluid balance in clients of all ages, especially critical for infants &
children bc fluid accounts for a > portion of body weight
INCORRECT:
b-checking for the absence of tears is part of the hydration assessment BUT
doesn't give the nurse precise information about the degree or severity of
the infant's dehydration
c-palpating the fontanel is part of the hydration assessment BUT unless
fontanel is extremely sunken, this assessment doesn't give the nurse precise
info about the degree/severity of the dehydration
d-assessing skin turgor is part of hydration assessment BUT unless skin is
extremely slow to respond, this isn't precise enough - -A nurse is caring for
an infant who is experiencing dehydration; which assessment is priority?
A- measure the pts daily weight
B- check for tears
c- palpate the fontanel
d-assess skin turgor
-*C-instruct clients who are able to ambulate to leave*; pts who are able to
ambulate should leave 1st in the evacuation process bc it quickly reduces
the # of pts who require evacuation assistance - -A charge nurse is
coordinating the evacuation of pts from a facility following a bomb threat;
which action should the nurse take in evacuation process?
A-call in the pts' family members to provide additional help with moving
clients
B-ask pts who are able to ambulate to assist in moving unstable pts
C-instruct clients who are able to ambulate to leave
D-direct staff members to close the doors & windows as each room is
evacuated
-1. Denial; refusing to acknowledge the existence of her substance use
disorder
,2. Rationalization; attempting to make excuses to justify socially or
professionally unacceptable behavior
3.Intellectualization; an attempt to use the intellectual processes to avoid
expressing the emotions that stem from stressful situations
4. Suppression; pt is consciously avoiding a discussion of the substance use
disorder - -A nurse in a substance use disorder program is interacting w/ a
pt; identify the coping strategy/defense mechanism used in each statement
1: "I was just using the medication to help me out during a rough time in my
life. I can stop whenever I want."
2. "This all happened because my spouse is unemployed. That puts an
enormous amt of stress on me"
3. "I have read that problems w/ substances can have a variety of
predisposing factors."
4. "I just don't want to talk about it. There's nothing you can do about it
anyways."
-Sweat chloride - -Children who have cystic fibrosis have an elevated....
-Steatorrhea - --foul, fatty, frothy stools
-manifestation of celiac disease (a malabsorption syndrome)
-Clubbing - -Children who have cardiovascular disorders develop ______ of
the fingers & toes due to chronic hypoxemia of the tissues
-Jaundice - -Results from liver dysfunction
-Correct answers:
*A-sit with your back supported*; sitting w/ back supported while at the
computer helps to prevent back strain, which can lead to lower-back disc
disease
*B-keep knees at hip level*; helps to prevent unnecessary strain on the hips
and lower back
*c-use an ergonomically designed keyboard*
Incorrect:
D-keep your elbows away from your body
E-adjust the monitor screen so that you have to tilt your head slightly to look
at it - -A community health nurse is conducting a class about body
mechanics for county office workers. The nurse should include..... (select all
that apply)
A-"sit with your back supported"
B-"keep your knees at hip level"
C-"use an ergonomically designated computer keyboard"
D-"keep your elbows away from your body"
E-"adjust the monitor screen so that you have to tilt your head slightly to
look at it"
, -Correct:
*A-arrange for social services*; appropriate for a pt who faces challenges w/
self-care, as well as w/ paying for medical equipment & supplies
*B-initiate a consult w/ an enterostomal therapist*; can assist the pt in
learning to care for the colostomy
*C-provide the pt w/ information about the American Cancer Society*; pt can
learn about helpful resources from the ACS
*E-give the pt info about local support groups*; a pt who has cancer & a new
colostomy can get help w/ coping from a support group - -A nurse is
planning discharge teaching for a pt who has colorectal cancer & is post op
following a new colostomy. The pt expresses concern about discharge &
states "I have no health insurance & cannot pay for the ostomy supplies."
Which actions should the nurse take?
A- arrange for social services
B-initiate a consult w/ an enterostomal therapist
C-provide the pt w/ information about the American Cancer Society
D-postpone the pt's discharge
E-give the pt info about local support groups
-Flow-oriented incentive spirometer - -Instructions include:
-instruct pt to inhale deeply to elevate the balls in the device
-proper use of the ______ loosens secretions in the pt's lungs; pt should cough
deeply to facilitate removal of secretions from their lungs
-instruct the pt to clean the mouth piece w/ H2O & dry it after each use
-use ______ several times every hr while awake
-Clostridium difficile (C-diff) pt in contact isolation
1. contact isolation
2. c. diff - -Nurse should:
-wear gloves when handling articles that have the potential to contaminate
the hands when caring for a pt who is in __1__
-use soap and water to cleanse the hands; alcohol-based hand sanitizer is
ineffective against the spores of __2__
-shouldn't put pt on complete bed rest bc this places them at risk for the
hazards of immobility such as impaired skin integrity & retained respiratory
secretions; should instruct pt to remain in room but to move, cough, & DB at
least q2hr
-Wear a mask - -Nurse should _______ when working w/in 3 ft of a pt who
has an infection such as influenza and droplet precautions are required
-S/S that *death is imminent* - -S/S indicating ________:
-urinary incontinence
-cold extremities, first in the feet & hands
-hypotension
