ATI
proctored
final
exam
-
✅✅
-
4
techniques
to
improve
the
chances
of
good
IV
access
-
✅✅
-1.
Trim
hair
around
the
area
2.
Gently
stroke
the
area
from
the
distal
to
proximal
end
3.
Place
a
warm
blanket
over
the
extremity
4.
Palpate
gently
A
____
bath
can
be
helpful
in
soaking
a
client's
pelvic
area
in
warm
water
to
decrease
inflammation.
-
✅✅
-sitz
A
70
y.
male
develops
new
diarrhea
and
a
high
WBC
while
in
the
hospital
recovering
from
MV
Replacement
surgery
which
was
complicated
by
a
CVA.
He
is
bed
bound
and
incontinent
of
stool.
What
do
you
suspect
is
the
cause
for
his
diarrhea?
-
✅✅
-A
bacterial,
nosocomial
infection
A
nurse
has
prepared
a
sterile
field.
Which
of
the
following
events
should
the
nurse
recognize
as
contaminating
the
sterile
field?
(Select
all
that
apply.)
A.
The
provider
drops
a
sterile
instrument
onto
the
near
side
of
the
sterile
field.
B.
The
nurse
moistens
a
cotton
ball
with
sterile
normal
saline
and
places
it
on
the
sterile
field.
C.
The
procedure
is
delayed
1
hr
because
the
provider
receives
an
emergency
call.
D.
The
nurse
turns
to
speak
to
someone
who
enters
through
the
door
behind
the
nurse.
E.
The
client's
hand
brushes
against
the
outer
edge
of
the
sterile
field.
-
✅✅
-B,
C,
D
A
nurse
is
assessing
a
client
who
reports
losing
control
of
urine
whenever
she
coughs,
laughs,
or
sneezes.
Which
of
the
following
interventions
are
appropriate
for
helping
to
control
or
eliminate
the
client's
incontinence?
(Select
all
that
apply.)
A.
Limit
total
daily
fluid
intake. B.
Decrease
or
avoid
caffeine.
C.
Increase
the
intake
of
calcium
supplements.
D.
Avoid
the
intake
of
alcohol.
E.
Use
Credé
maneuver.
-
✅✅
-A.
INCORRECT:
Because
stress
incontinence
results
from
weak
pelvic
muscles
and
other
structures,
limiting
fluids
will
not
resolve
the
problem.
B.
CORRECT:
Caffeine
is
a
bladder
irritant
and
can
worsen
stress
incontinence.
C.
INCORRECT:
Calcium
has
no
effect
on
stress
incontinence.
D.
CORRECT:
Alcohol
is
a
bladder
irritant
and
can
worsen
stress
incontinence.
E.
INCORRECT:
The
Credé
maneuver
helps
manage
reflex
incontinence,
not
stress
incontinence.
A
nurse
is
caring
for
a
client
in
a
long-term
care
facility
who
is
receiving
enteral
feedings
via
an
NG
tube.
Which
of
the
following
is
an
appropriate
nursing
action
prior
to
administering
the
tube
feeding?
(Select
all
that
apply.)
A.
Auscultate
bowel
sounds.
B.
Assist
the
client
to
an
upright
position.
C.
Test
the
pH
of
gastric
aspirate.
D.
Warm
the
formula
to
body
temperature.
E.
Discard
any
residual
gastric
contents.
-
✅✅
-A,
B,
C
A
nurse
is
caring
for
a
client
receiving
dextrose
5%
in
0.9%
sodium
chloride
IV
at
120
mL/hr.
Which
of
the
following
statements
by
the
client
should
alert
the
nurse
to
suspect
fluid
overload?
(Select
all
that
apply.)
A.
"I
feel
lightheaded."
B.
"I
feel
as
though
my
heart
is
racing."
C.
"I
feel
a
little
short
of
breath."
D.
"The
nurse's
aide
told
me
that
my
blood
pressure
was
150/90."
E.
"I
think
my
ankles
are
less
swollen."
-
✅✅
-3.
A.
INCORRECT:
A
clinical
manifestation
of
fluid
overload
is
hypertension.
Lightheadness
is
a
clinical
manifestation
of
hypotension. B.
CORRECT:
A
clinical
manifestation
of
fluid
overload
is
tachycardia
due
to
the
increased
blood
volume,
which
causes
the
heart
rate
to
increase.
C.
CORRECT:
A
clinical
manifestation
of
fluid
overload
is
shortness
of
breath
or
dyspnea
due
to
the
increased
amount
of
fluid
entering
the
air
spaces
in
the
lungs,
which
reduces
the
amount
of
circulating
oxygen.
D.
CORRECT:
A
clinical
manifestation
of
fluid
overload
is
hypertension
due
to
the
increased
blood
volume,
which
causes
the
blood
pressure
to
increase.
E.
INCORRECT:
A
clinical
manifestation
of
fluid
overload
is
edema.
If
the
client's
ankles
are
less
swollen,
this
is
an
indication
that
the
edema
is
decreasing.
A
nurse
is
caring
for
a
client
who
has
a
tracheostomy.
Which
of
the
following
actions
should
the
nurse
take
each
time
he
provides
tracheostomy
care?
(Select
all
that
apply.)
A.
Apply
the
oxygen
source
loosely
if
the
SpO2
decreases
during
the
procedure.
B.
Use
surgical
asepsis
to
remove
and
clean
the
inner
cannula.
C.
Clean
the
outer
surfaces
in
a
circular
motion
from
the
stoma
site
outward.
D.
Replace
the
tracheostomy
ties
with
new
ties.
E.
Cut
a
slit
in
gauze
squares
to
place
beneath
the
tube
holder.
-
✅✅
-A,
B,
C
A
nurse
is
caring
for
an
older
adult
client
who
is
at
risk
for
developing
pressure
ulcers.
Which
of
the
following
interventions
should
the
nurse
use
to
help
maintain
the
integrity
of
the
client's
skin?
(Select
all
that
apply.)
A.
Keep
the
head
of
the
bed
elevated
30
degrees.
B.
Massage
the
client's
bony
prominences
frequently.
C.
Apply
cornstarch
liberally
to
the
skin
after
bathing.
D.
Have
the
client
sit
on
a
gel
cushion
when
in
a
chair.
E.
Reposition
the
client
at
least
every
3
hr
while
in
bed.
-
✅✅
-A,
D
A
nurse
is
teaching
a
new
nurse
on
inserting
an
IV.
Which
of
the
following
statements
indicates
understanding?
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