ATI capstone pre-assignment quiz -fundamentals- Questions and Answers

ATI capstone pre-assignment quiz -fundamentals- Questions and Answers 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. Pre-schoolers 3-6 years 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. School-age children 6-12 years 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. Young adults 20-35 years Match the following isolation precautions to the correct disease process. 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. Measles Contact precautions: A private room or a room with other clients with the same infection. Gloves and gowns worn by the caregivers and visitors. Vancomycin resistant enterococcus (VRE) Droplet precautions: A private room or a room with other clients with the same infectious disease. Masks for providers and visitors. Pertussis Match the description to the correct stage of pressure ulcer. 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. Stage 3 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). Stage 4 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. Stage 1 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. Stage 2 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. Living will b. Informed consent c. Durable power of attorney for health care d. Do Not Resuscitate A. living will a living will is a legal document that specifically outlines a clients wishes regarding life-sustaining treatment. 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. b. Chicken breast, mashed potatoes, spinach. c. Scrambled eggs, bacon and pancakes. d. Steak, french fries, corn. b. Chicken breast, mashed potatoes, spinach. This option meets the prescribed diet. It is high in calories and while chicken does provide protein it is a low-fat source and can be eaten in moderation on a low-protein diet. Spinach will provide additional vitamin K for this client at risk for bleeding due to liver failure. 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. Hourly rounding by the nurse. b. Place bedside table in close proximity. c. Use of a night-light. d. Demonstrate how to use the call light. a. Hourly rounding by the nurse In the health care environment, hourly rounding by nurses significantly reduces the occurrence of client falls, as well as reducing call light usage and increasing client satisfaction. 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? Select one: a. 10 b. 4 c. 7 d. 9 c. 7 The GCS is calculated by using appropriate stimuli (a painful stimulus may be necessary such as pressure to the nail beds) and then assessing the client's response in three areas. 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 caring for several clients prescribed heat/cold therapies. Which of the following clients are at risk of injury from these therapies? Select all that apply. Select one or more: a. A cognitively impaired older adult prescribed alternating heat and cold therapy. b. A client with diabetes prescribed cold therapy for a fractured toe. c. An older adult client prescribed heat therapy for hip pain. d. A fair-skinned, school age client prescribed heat therapy after a soccer injury. e. A middle age adult client prescribed cold therapy for muscle spasms. a. A cognitively impaired older adult prescribed alternating heat and cold therapy. This client is at risk. Cognitively impaired, older adult clients are at risk for injury related to heat and cold therapies due to decreased perception. b. A client with diabetes prescribed cold therapy for a fractured toe. Clients who have impaired sensory perception such as those with diabetes may not feel pain or burning. c. An older adult client prescribed heat therapy for hip pain. This client is at risk. The nurse should use extreme caution with clients who are very young, fair-skinned, and older because they have fragile skin. d. A fair-skinned, school age client prescribed heat therapy after a soccer injury. This client is at risk. The nurse should use extreme caution with clients who are very young, fair-skinned, and older because they have fragile skin. 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? Select one: a. Macaroni and cheese, salad, pudding b. Roast turkey, rice pilaf, green beans c. Roast beef with gravy, mashed potatoes, ice cream d. Creamed chicken on a roll with peas b. Roast turkey, rice pilaf, green beans Roast turkey is a low-fat protein option that would be an excellent choice for a low-fat diet. 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. 2 b. 7 c. 9 d. 5 a. 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. Avoid crowded events. b. Take temperature weekly. c. Gardening is a good form of mild exercise. d. Eat plenty of fresh fruits and vegetables. a. 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. A nurse is caring for a client receiving opiates for pain management. Initially after the pain management plan was started, the client was sedated and sleeping most of the time. After three days on the plan the client is no longer sedated and sleeping regularly. What action should the nurse take? Select one: a. Initiate additional non-pharmacological pain management techniques. b. No action is needed at this time. c. Contact the provider to request an alternate method of pain management. d. Notify the provider that a dosage adjustment is needed. b. No action is needed at this time. Opiates initially cause sedation but this effect subsides with maintenance pain control. The pain mangement plan is working. There is no need to change or add additional methods at this time. 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? Select one: a. White wine b. Table salt c. Oranges d. Egg yolks c. Oranges Clients prescribed potassium-wasting diurectics should be encouraged to eat foods high in potassium. Oranges, dried fruits, tomatoes, avocados, dried peas, meats, broccoli, and bananas are all good sources of potassium. A nurse is assisting a client with his meal that is at risk for aspiration due to a stroke. What interventions should the nurse take to prevent aspiration? Select all that apply. Select one or more: a. Support client's upper back, neck and head during feeding. b. Position the client in Fowler's position. c. Keep the client in semi-Fowler's position for at least 1 hour after the meal. d. Instruct the client to tuck his chin when swallowing. e. Provide oral hygiene before meals. a. Support client's upper back, neck and head during feeding. The nurse should ensure adequate support of the client's upper body during feeding. b. Position the client in Fowler's position. Positioning the client in Fowler's position or in a chair can help prevent aspiration. c. Keep the client in semi-Fowler's position for at least 1 hour after the meal. Maintaining the client in a semi upright position following meals can prevent aspiration in the event of reflux. d. Instruct the client to tuck his chin when swallowing. Tucking in the chin when swallowing can help propel food down the esophagus and prevent aspiration. Which of the following can cause a low pulse oximetry reading? Select one: a. Low altitudes b. Increased hemoglobin level c. Hyperthermia d. Inadequate peripheral circulation d. Inadequate peripheral circulation Inadequate peripheral circulation can generate a low reading. 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? Select one: a. Sit in the sun for 15 minutes per day. b. Wash the affected area daily with antimicrobial soap. c. Liberally apply prescribed lotion to the area. d. Apply moist heat to the area twice daily. c. Liberally apply prescribed lotion to the area. Hydrating lotions are commonly prescribed to treat irratdiated areas. The client should avoid applying other lotions not prescribed by the radiologist to affected areas. A nurse manager is providing staff education on the correct use of restraints. Which of the following should be included in this education? Select all that apply. Select one or more: a. It is not necessary to document the behaviors making restraint necessary. b. Restraints should never be used because of short staffing. c. Staff must document type and location of the restraint and time applied. d. Assess neurovascular and neurosensory status every 2 hours. e. Restraints should never interfere with treatment. b. Restraints should never be used because of short staffing. c. Staff must document type and location of the restraint and time applied. d. Assess neurovascular and neurosensory status every 2 hours. e. Restraints should never interfere with treatment. A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering? Select one: a. The TPN solution contains added electrolytes, vitamins and trace elements. b. The bag of TPN was prepared by the pharmacy 12 hours prior. c. The bag of TPN is labeled with the client's name, medical record number and prescription. d. The TPN solution has an oily appearance and a layer of fat on top of the solution. d. The TPN solution has an oily appearance and a layer of fat on top of the solution. Before administration of TPN, the nurse should look for "cracking" of TPN solution. This occurs if the calcium or phosphorous content is high or if poor-salt albumin is added. A "cracked" TPN solution has an oily appearance or a layer of fat on top of the solution and should not be used. Dehydration in clients leads to increased registered levels of glucose, electrolytes and hematocrit. Select one: True False True A nurse is completing a nutritional assessment on a client and measures body mass index (BMI). Which of the following readings correlates with a BMI of an overweight client? Select one: a. 25 b. 18.5 c. 32 d. 24.9 a. 25 Overweight is defined as an increased body weight in relation to height. It is indicated by a BMI of 25 to 29.9. 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? Select one: a. Take an afternoon nap. b. Take an evening walk before bedtime. c. Consume a warm drink at bedtime. d. Limit alcohol and nicotine prior to bedtime. d. Limit alcohol and nicotine prior to bedtime. Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime. 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? Select one: a. Use mild soap and water to clean the ear mold. b. Use the highest setting to promote full auditory comprehension. c. Turn the hearing aid off to conserve battery life during hours of sleep only. d. Immerse the hearing aid in saline solution to keep it hygienic. a. Use mild soap and water to clean the ear mold. True; To clean the ear mold, use mild soap and water while keeping the hearing aid dry. 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? Select one: a. Bedside Commode b. Bedpan c. Client Bathroom d. Urinal c. Client Bathroom True; The goal is to encourage clients to maintain independence and privacy if the client has full function and is able to safely complete ADLs. A nurse is caring for a client with heart failure who has evidence of dyspnea, bibasilar crackles and frothy sputum. What dietary recommendations should be provided to this client in management of their heart failure? Select one: a. Reduce sodium intake. b. Decrease calcium intake. c. Increase fluid intake. d. Decrease protein intake. a. Reduce sodium intake. True; It is encouraged to stop smoking, reduce sodium intake, monitor fluid intake, restricting intake to 2 L per day. It is also encouraged to increase protein intake to 1.12 g/kg and consume small, frequent meals that are soft, easy-to-chew foods. There are no recommendations on calcium intake associated with heart failure. A client with COPD is using accessory muscles to breath and has a productive cough. To promote energy, the nurse should encourage high-calorie foods. Select one: True False True A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform? Select one: a. Uterine extension exercises b. Isometric exercises c. Kegel exercises d. Circumduction exercises c. Kegel exercises Kegel exercises strengthen the pelvic floor muscles, which results in reduction or prevention of pelvic prolapse and stress urinary incontinence. The other mentioned exercises have no direct effect on prevention or reduction of a cystocele. A nurse is caring for a client with celiac disease. Which food should be removed from the meal tray? Select one: a. Lentils b. Tortillas c. Mashed potato d. Corn bread b. Tortillas Tortillas contain gluten. Corn bread, mashed potatoes and lentils do not contain gluten. A client with Parkinson's Disease has muscle rigidity. The nurse should encourage the client to stop occasionally when walking to slow down speed and reduce risk of injury. Select one: True False True