1. A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the
... [Show More] laboratory test. Which of the following is an appropriate response by the nurse?
a. "This test will indicate if you are at risk for developing blood clots
b. "This test will determine if your heart is performing properly"
c. "This test will provide information about the function of your liver"
d. "This test is used to check how your kidneys are working" - c. "This test will provide information about the function of your liver"
2. A nurse is caring for a client who has a prescription for morphine 5mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first?
a. Notify the client's provider.
b. Report the incident to the pharmacy.
c. Complete an incident report.
d. Measure the client's respiratory rate. - d. Measure the client's respiratory rate.
Morphine can cause respiratory depression if given too much. Also you should ALWAYS ASSESS the patient first when a med error is performed to make sure med error doesn't put the client's health in risk.
3. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?
a. Label the pump with a defective equipment sticker.
b. Unplug the pump.
c. Obtain a replacement pump.
d. Notified the biomedical department to fix the pump. - b. Unplug the pump.
Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire.
4. A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing?
a. Serum albumin 3 g/dL
b. Total lymphocyte count 2400 mm3
c. HCT 42%
d. HGB 16g/dL - a. Serum albumin 3 g/dL
Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client at risk for poor wound healing.
The other lab values are within normal limits
5. A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?
a. Apply the cuff above the clients antecubital fossa.
b. Use a cuff with a width that is about 60% of the client's arm circumference.
c. Have the clients sit with his arm resting above the level of his heart.
d. Release the pressure on the client's arm 5 to 6 mm per second.- - a. Apply the cuff above the clients antecubital fossa.
Rationale: width of the cuff should be 40% of the arm circumference; arms should rest that the level of the heart; release the pressure no faster than 2-3 mmHg per second; apply cuff 2.5cm (1in) above the antecubital space with the brachial artery in line with the marking on the cuff.
6. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take?
a. Hold the suction catheter with the clean non-dominant hand.
b. Apply suctioning for 20 to 30 seconds.
c. Place the catheter in a location that is clean and dry for later use new line.
d. Use surgical asepsis when performing the procedure. - d. Use surgical asepsis when performing the procedure.
Rationale: suction should be no more than 10-15 seconds to avoid hypoxemia; catheter should never be re-used; use surgical asepsis for all types of suctioning
7. A nurse is documenting client care. Which of the following abbreviations should the nurse use?
a. "SS" for sliding scale
b. "BRP" for bathroom privileges
c. "OJ" for orange juice
d. "SQ" for subcutaneous - b. "BRP" for bathroom privileges
8. A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage?
a. Supine and low-Fowler's position
b. Right lateral in Trendelenburg position
c. Side lying with the right side of the chest elevated
d. Prone with pillows under the extremities - b. Right lateral in Trendelenburg position
9. A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?
a. Dietitian consult
b. Speech therapy referral
c. Oral suction at the bedside
d. Clear liquids - d. Clear liquids
food levels for dysphagia include pureed, mechanically altered, advanced/mechanically soft, and regular. Liquids must be THICK.. Clear liquids can cause aspiration
10. A nurse is administering a large volume enema to a client. Identify the sequence of steps the nurse should follow after preparation and lubricating the enema set.(ati funds video enema)
1. Administer the enema solution.
2. Remove the enema tube from the clients rectum.
3. Wrap the end of the enema tube with a disposable tissue.
4. Insert the enema tube into the client's rectum.
5. Clamp the enema tube. - 4, 1, 5, 2, 3 [Show Less]