ATI Fundamentals 2

ATI Fundamentals 2 A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. Hold the irrigator 1.25 cm (0.5 in) above the eye B. Direct the irrigation solution upward toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelid open. D. Direct the irrigation from the outer canthus to the inner canthus of the eye - ANSWER C. Exert pressure on the bony prominences. The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye. Other Rationales: The nurse should hold the irrigator 2.5 cm (1 in) above the eye to prevent the irrigator from touching the eye and to prevent the solution from damaging the eye tissue. The nurse should direct the irrigation solution onto the lower conjunctiva sac to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. The nurse should direct the irrigation solution from the inner canthus to the outer canthus of the eye to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube. B. Instill 100 mL of air into the NG tube before removal. C. Pinch the NG tube while removing the tube. D. Instruct the client to breathe in and out during the removal of the NG tube. - ANSWER C. Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents. Other Rationales: The nurse should disconnect the NG tube from the suction apparatus before removal to decrease injury to the gastrointestinal mucosa. The nurse should instill 50 mL of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube. The nurse should instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis and decrease the risk of aspiration of any gastric contents. A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. The lower, medial quadrant of the buttock near the coccyx B. The side hip between the iliac crest and the anterior iliac spine C. The tissue of the posterior upper arm D. The lower, inner thigh 4 finger widths above the patella - ANSWER B. The side hip between the iliac crest and the anterior iliac spine The side hip between the iliac crest and anterior iliac spine forms the boundaries for ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is the preferred site for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (right hand on left hip, for example) with the first two fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. Other Rationales: To administer intramuscular medication using the dorsogluteal site, the nurse should select the upper, lateral quadrant of the buttock. However, the nurse should recognize this site can increase risk of injury to the client because the medication is more likely to be injected into subcutaneous tissue, and there is increased risk of piercing the sciatic nerve. The nurse should select the outer, posterior tissue of the upper arm when preparing to administer a subcutaneous injection. For intramuscular injections of less than 1 mL, the nurse may select the deltoid muscle by placing four fingers on the deltoid