Med-Surge ATI Focused Review Questions and Answers 100% correct

Med-Surge ATI Focused Review Questions and Answers 100% correct What are some factors that affect pain experience? age, fatigue, genetic sensitivity, cognitive function, prior experiences, anxiety and fear, coping styles, culture A nurse finds a client on the floor. Which of the following actions should the nurse take first? A) assist the client back to bed B) seek assistance from the charge nurse C) inspect the client for evidence of injury D) Admonished pain medication C) Inspect the client for evidence of injury What are low-flow oxygen delivery systems? Nasal cannula, simple face mask, partial rebreather mask, non-rebreather mask What are high-flow oxygen delivery systems? Venturi mask, aerosol mask What is a nursing consideration when it comes to simple task masks and venturi masks? Assess proper fit to ensure a secure seal over the nose and mouth; Assess for skin breakdown; Ensure that the patient wears a nasal cannula during meals A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A) Increase oxygen flow B) assist the client to fowler's position C) promote removal of pulmonary secretions B) Assis the client to fowler's position What are some actions that a nurse should take when a seizure is occurring? stay with the client and call for help, maintain airway patency and suction PRN, note the duration of the seizure and the sequence and type of movements, after a seizure the nurse should determine mental status and measure vital signs How to use a fire extinguisher using the PASS sequence: P: Pull the pin A: Aim at the base of the fire S: Squeeze the handle S: sweep the extinguisher from side to side, covering the whole area of the fire A nurse observes smoke coming from under the door of the staff;s lounge. Which of the following actions is the nurse's priority? A) Extinguish fire B) activate fire alarm C) Move clients who are nearby D) Close all open doors on the unit C) Move clients who are nearby A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A) Complete a fall-risk assessment B) Educate the client about fall risks C) Eliminate safety hazards from the client's environment D) Make sure the client uses assertive aids in his possession A) Complete a fall-risk assessment Sensory perception is: the ability to receive and interpret sensory impressions through sight , hearing, touch, smell, taste, and movement What are some contributing factors to vision loss? Presbyopia, cataracts, glaucoma, diabetic retinopathy, macular degeneration, infection, inflammation, injury, brain tumor What are some nursing considerations when handling a patient who has vision loss? call clients by name before approaching to avoid startling them, identify yourself, stay within clients visual field if they have partial loss, explain interventions before touching client, etc. What are some nursing considerations when handling a patient with aphasia? Greet the clients and call them by name, do not shout, make sure only one person is speaking at a time, speaks clearly and use short sentences with simple words, pause between statements to allow time for clients to understand, check for comprehension, etc A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A) immediately complete a thorough assessment B) put the client in a room with a client who has hearing loss C) provide a private room and limit stimulation D) speak at a higher volume to the client and encourage ambulation answer is C) provide a private room and limit stimulation What are some examples of reports nurses do? change-of-shift reports, telephone reports, transfer reports, incident reports, etc What is an acronym used for focused charting? D: data A: action R: response A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? A_ Input and output for the shift B) BP from the previous day C) bone scan scheduled for today D) medication routine from the medication administration record Answer is C) bone scan scheduled for today What is the chain of infection? Causative agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host A nurse is caring for a client who reports a severe sore throat, pain when swallowing and swollen lymph nodes. The client is experiencing which of the following stages of infection? A) Prodromal B) incubation C) convalescence D) illness D) illness A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. The nurse should identify the client has manifestations of which of the following conditions? A) allergic reaction B) ringworm C) systemic lupus erythematous D) herpes zoster answer is D) Herpes zoster What are some indictions of nasogastric intubation? decompression, ending, lavage. compression A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A) Auscultate breath sounds B) stop the feeding C) obtain a chest x-ray D) initiate oxygen therapy answer is B) stop the feeding What are some clinical manifestations of fluid overload? distended neck veins, increased blood pressure, tachycardia, shortness of breath, crackles in lungs, edema, etc