ATI
1. A nurse is caring for a client who is postoperative and is
experiencing nausea and vomiting. The nurse should identify which
of the following finding as indication that the client has fluid volume
deficit?
Ans:
-Orthostatic hypotension indicates fluid volume deficit.
-Flat neck vein indicates fluid volume deficit.
-Cool extremities can indicate fluid volume deficit.
2. Define full bounding pulse.
Ans: A full bounding pulse indicates fluid volume excess. The nurse should
expect a weak peripheral pulse in a client who has fluid volume deficit.
3. What does moist crackles in the lungs indicate?
Ans: Moist crackles in the lungs indicate fluid volume excess. The nurse
should expect clear lungs in a client who has fluid volume deficit.
4. The nurse is providing handoff Report for a client who has a chest
tube in place. Which of the following information should the nurse
include in the report?
Ans: -The amount and characteristics of drainage. For a client who has a
chest tube, the amount and characteristics of the drainage provide important
information about the client's current respiratory and immune status and are
an essential component of change-of-shift report.
5. Define tracheostomy.
Ans: Surgical creation of an opening into the trachea through the neck.
,6. Define Hypoxic.
Ans: Pertaining to a low level of oxygen.
7. Define decannulated tracheostomy tube.
Ans: When using the urgent vs non urgent approach to client care, the
nurse should stay with the client and call immediately for assistance to
replace the old tracheostomy tube or place a new tube down the stoma, if
available. The nurse should monitor and prepare to manually ventilate if the
client becomes hypoxic.
8. Tracheostomy dressing with dark red drainage?
Ans: A moderate amount of dark red drainage on a new tracheostomy
dressing is non urgent because it is an expected finding. Drainage should
subside as healing of the client's stoma occurs.
9. Patient is coughing red tinged mucous during suctioning of
tracheostomy.
Ans: Coughing of red tinged mucous during suctioning is non urgent
because it is an expected finding for a client who has a new tracheostomy.
The nurse should reassure the client and monitor for hypoxia.
10. A nurse in a long-term care facility is serving as a preceptor to a
newly hired nurse. The nurse asks the preceptor. What should i do
for my client who has dyspnea with oxygen saturation of 92%,
Which of the following interventions should the preceptor
recommend?
a. Apply oxygen using a non-rebreather face mask.
b. Encourage the client to cough and deep breathe every 4 hr.
c. Initiate nasotracheal suctioning.
d. Position the client at a 45° angle in bed.
, Ans: d. Position the client at a 45 angle in the bed. The preceptor should
recommend for the nurse to position the client at a 45° angle in bed to
promote greater lung expansion and decrease pressure from the abdomen
onto the diaphragm.
11. a nurse is reinforcing teaching about using crutches with a client
who has a fractured ankle. Which of the following client statements
indicates an understanding of the instructions?
a. "I'll place my weight on the crutch pads at my armpits." The client
should use their arms, not their axillae, to bear their body weight.
Pressure on the axillae can damage the radial nerve and cause
weakness and partial paralysis below the elbows.
b. "I'll wear my leather-sole shoes when I am using my crutches."
The client should wear rubber-sole shoes to reduce the risk for
slipping or skidding.
c. "I'll bend my elbows to about 25 degrees when I walk with my
crutches." The client should have 20° to 30° of flexion at the elbows
when using their crutches. The nurse should verify that the client
understands the correct amount of elbow flexion to have when
using crutches.
d. "When I go downstairs, I will put my crutches and my right leg on
the lower step first." The client should shift their weight to their
right leg and then advance the crutches and their left leg down to
the next step. Then, they should transfer their weight to the
crutches and move their right leg down to the step that their left leg
and the crutches are on.
Ans: c. "I'll bend my elbows to about 25 degrees when I walk with my
crutches."
The client should have 20° to 30° of flexion at the elbows when using their
crutches. The nurse should verify that the client understands the correct
amount of elbow flexion to have when using crutches.
12. A nurse is contributing to the plane of care for a client who has
urinary and fecal incontinence. Which of the following interventions
should the nurse implement to help maintain clients skin integrity?
a. Use soap and hot water to cleanse the skin.
1. A nurse is caring for a client who is postoperative and is
experiencing nausea and vomiting. The nurse should identify which
of the following finding as indication that the client has fluid volume
deficit?
Ans:
-Orthostatic hypotension indicates fluid volume deficit.
-Flat neck vein indicates fluid volume deficit.
-Cool extremities can indicate fluid volume deficit.
2. Define full bounding pulse.
Ans: A full bounding pulse indicates fluid volume excess. The nurse should
expect a weak peripheral pulse in a client who has fluid volume deficit.
3. What does moist crackles in the lungs indicate?
Ans: Moist crackles in the lungs indicate fluid volume excess. The nurse
should expect clear lungs in a client who has fluid volume deficit.
4. The nurse is providing handoff Report for a client who has a chest
tube in place. Which of the following information should the nurse
include in the report?
Ans: -The amount and characteristics of drainage. For a client who has a
chest tube, the amount and characteristics of the drainage provide important
information about the client's current respiratory and immune status and are
an essential component of change-of-shift report.
5. Define tracheostomy.
Ans: Surgical creation of an opening into the trachea through the neck.
,6. Define Hypoxic.
Ans: Pertaining to a low level of oxygen.
7. Define decannulated tracheostomy tube.
Ans: When using the urgent vs non urgent approach to client care, the
nurse should stay with the client and call immediately for assistance to
replace the old tracheostomy tube or place a new tube down the stoma, if
available. The nurse should monitor and prepare to manually ventilate if the
client becomes hypoxic.
8. Tracheostomy dressing with dark red drainage?
Ans: A moderate amount of dark red drainage on a new tracheostomy
dressing is non urgent because it is an expected finding. Drainage should
subside as healing of the client's stoma occurs.
9. Patient is coughing red tinged mucous during suctioning of
tracheostomy.
Ans: Coughing of red tinged mucous during suctioning is non urgent
because it is an expected finding for a client who has a new tracheostomy.
The nurse should reassure the client and monitor for hypoxia.
10. A nurse in a long-term care facility is serving as a preceptor to a
newly hired nurse. The nurse asks the preceptor. What should i do
for my client who has dyspnea with oxygen saturation of 92%,
Which of the following interventions should the preceptor
recommend?
a. Apply oxygen using a non-rebreather face mask.
b. Encourage the client to cough and deep breathe every 4 hr.
c. Initiate nasotracheal suctioning.
d. Position the client at a 45° angle in bed.
, Ans: d. Position the client at a 45 angle in the bed. The preceptor should
recommend for the nurse to position the client at a 45° angle in bed to
promote greater lung expansion and decrease pressure from the abdomen
onto the diaphragm.
11. a nurse is reinforcing teaching about using crutches with a client
who has a fractured ankle. Which of the following client statements
indicates an understanding of the instructions?
a. "I'll place my weight on the crutch pads at my armpits." The client
should use their arms, not their axillae, to bear their body weight.
Pressure on the axillae can damage the radial nerve and cause
weakness and partial paralysis below the elbows.
b. "I'll wear my leather-sole shoes when I am using my crutches."
The client should wear rubber-sole shoes to reduce the risk for
slipping or skidding.
c. "I'll bend my elbows to about 25 degrees when I walk with my
crutches." The client should have 20° to 30° of flexion at the elbows
when using their crutches. The nurse should verify that the client
understands the correct amount of elbow flexion to have when
using crutches.
d. "When I go downstairs, I will put my crutches and my right leg on
the lower step first." The client should shift their weight to their
right leg and then advance the crutches and their left leg down to
the next step. Then, they should transfer their weight to the
crutches and move their right leg down to the step that their left leg
and the crutches are on.
Ans: c. "I'll bend my elbows to about 25 degrees when I walk with my
crutches."
The client should have 20° to 30° of flexion at the elbows when using their
crutches. The nurse should verify that the client understands the correct
amount of elbow flexion to have when using crutches.
12. A nurse is contributing to the plane of care for a client who has
urinary and fecal incontinence. Which of the following interventions
should the nurse implement to help maintain clients skin integrity?
a. Use soap and hot water to cleanse the skin.
