ATI MED SURG RN ENDOCRINE DYSFUNCTION
ASSESSMENT. WITH QUESTIONS AND
ANSWERS GRADED A+
A nurse is caring for a client who has an NG tube and
... [Show More] is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?
A. Rinse the feeding bag with water between feedings.
B. Tell the client to keep the head of the bed elevated at least 30 degrees
C. Make sure the enteral formula is at room temperature.
D. Wipe the top of the formula can with alcohol. - ANS-B. Tell the client to keep the head of the bed elevated at least 30 degrees
Rationale: The first action the nurse should take when using the ABC approach to client care is to prevent aspiration of the enteral formula; therefor, the priority intervention is to keep the head of the bed elevated at least 30 degrees to prevent reflux of the formula backward into the esophagus
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously.
Determine the correct order of steps for this procedure.
A. Inject 5 units of air into the bottle of regular insulin
B. Withdraw the correct does of NPH insulin from the bottle
C. Inject 10 units of air into the bottle of NPH insulin
D. Withdraw the correct does of regular insulin from the bottle - ANS-1. Inject 10 units of air into the bottle of NPH insulin
2. Inject 5 units of air into the bottle of regular insulin
3. Withdraw the correct does of regular insulin from the bottle
4. Withdraw the correct does of NPH insulin from the bottle
Rationale: The nurse should first inject air into the vial of NPH (cloudy) without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin, and then withdraw the correct amount of the regular (clear) insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with the NPH insulin.
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? - ANS-Auscultate the lungs
Rationale: The priority assessment the nurse should make when using the ABC approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and SOB.
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
A. The top of the cane is parallel to the client's waist.
B. When walking, the client moves the cane 46 cm (18 inch) forward
C. The client hold the cane on the stronger side of her body
D. The client movers her stronger limb forward with the cane - ANS-C. The client holds the cane on the stronger side of her body
Rationale: The client should hold the cane on the stronger side of her body to increase support and maintain alignment
A nurse is caring for a client receiving a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as [Show Less]