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Ati ns 117 fundamentals exam
Total Questions : 47
Showing 10 questions, Sign in for moreA nurse is reinforcing teaching with a client who has a prescription for amoxicillin 5 mL PO. How many teaspoons (tsp) should the nurse instruct the client to take?
A nurse is assisting with teaching a newly licensed nurse about wearing medical masks. Which of the following statements should the nurse include?
A nurse is planning to perform perineal care for a female client. Which of the following actions should the nurse plan to take?
Day 1
- Temperature 38 °C (100.4oF)
- BP 118/72 mm Hg
- Heart rate 90/min
- Respiratory rate 18/min
- Oxygen saturation 95% on room air
Day 2:
- Temperature 38.5°C (101.3 oF)
- BP 108/74 mm Hg
- Heart rate 92/min
- Respiratory rate 18/min
- Oxygen saturation 88% on room air
- Mucous membranes pink, skin warm and dry.
- Coughing and clearing throat when eating.
- Voice hoarse after swallowing.
- Bilateral breath sounds with wheezing heard in upper lobes.
A nurse is assisting with the care of a client who had a stroke.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
- Mucous membranes pink, skin warm and dry.
- Coughing and clearing throat when eating.
- Voice hoarse after swallowing.
- Temperature 38 °C (100.4 °F)
- Bilateral breath sounds with wheezing heard in upper lobes.
- Oxygen saturation 88% on room air
Explanation
- Mucous membranes pink, skin warm and dry.
- Coughing and clearing throat when eating.
- Voice hoarse after swallowing.
- Temperature 38 °C (100.4 °F)
- Bilateral breath sounds with wheezing heard in upper lobes.
- Oxygen saturation 88% on room air
Rationale
Coughing and clearing throat when eating: This indicates potential dysphagia (difficulty swallowing), which increases the risk of aspiration pneumonia—a serious complication post-stroke.
Voice hoarse after swallowing: Hoarseness or voice changes can also signal impaired swallowing or aspiration risk, necessitating evaluation by a speech therapist or further swallowing studies.
Temperature 38.5°C (101.3°F): An elevated temperature may suggest infection (e.g., aspiration pneumonia or another complication) and warrants further investigation, particularly in a post-stroke client.
Bilateral breath sounds with wheezing heard in upper lobes: Wheezing could indicate an airway obstruction, aspiration, or developing respiratory compromise, which is critical in this population.
Oxygen saturation 88% on room air: Hypoxemia is a critical finding requiring immediate intervention, such as supplemental oxygen and investigation into the underlying cause (e.g., aspiration, infection, or pulmonary embolism).
Mucous membranes pink, skin warm and dry: These findings are within normal limits and do not indicate a pressing issue.
A charge nurse is assisting in providing an in-service to a group of nurses about benefits of an interprofessional team. Which of the following information should the nurse include?
A nurse is assisting with teaching a class about alternative medicine. The nurse should include that which of the following practices uses diluted substances to stimulate the body to heal itself?
A nurse is preparing a presentation about hospice care services. Which of the following statements should the nurse plan to make during the presentation?
Day 1:
- Abdomen soft, nondistended.
- Ileostomy present. Stoma is red.
- Stoma draining brown liquid stool.
- Client will not look at stoma
- Client states they are not interested in learning about stoma care.
Day 2:
- Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.
A nurse is assisting in the care of a light-skinned client who has an ileostomy
The nurse is reviewing the client's medical record.
Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.
Day 1:
Abdomen soft, nondistended.
Ileostomy present. Stoma is red.
Stoma draining brown liquid stool.
Client will not look at stoma
Client states they are not interested in learning about stoma care.
Day 2:
Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.
Stoma with small amount of bleeding noted during cleaning.
Explanation
ANSWERED:
Day 1:
- Abdomen soft, nondistended.
- Ileostomy present. Stoma is red.
- Stoma draining brown liquid stool.
- Client will not look at stoma
- Client states they are not interested in learning about stoma care.
Day 2:
- Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.
- Stoma with small amount of bleeding noted during cleaning.
Rationale:
Findings requiring intervention
Client will not look at stoma: This indicates potential emotional distress, denial, or difficulty adjusting to the ileostomy. The nurse should address these concerns by providing emotional support and encouraging gradual acceptance of the stoma through education and therapeutic communication.
Client states they are not interested in learning about stoma care: A lack of interest in learning stoma care poses a barrier to self-care and independence. The nurse should explore the client’s feelings, provide gentle encouragement, and offer step-by-step guidance to build their confidence.
Skin surrounding stoma reddened and has small open areas: Redness and open areas suggest irritation or breakdown of peristomal skin, likely due to improper pouch application or leakage. The nurse should assess the fit of the ileostomy pouch, recommend barrier creams, and consult a wound care specialist if needed.
Findings not requiring intervention
Abdomen soft, nondistended: This finding is normal and does not indicate any issues requiring intervention.
Stoma is red: A healthy stoma is typically moist, red, and similar in appearance to the inside of the mouth. This finding is expected.
Stoma draining brown liquid stool: Brown liquid stool is a normal output for an ileostomy and does not require intervention.
Stoma with small amount of bleeding noted during cleaning: Minimal bleeding from the stoma is common during cleaning or manipulation, especially early postoperatively. This is generally not a concern unless the bleeding is excessive or persistent.
A nurse is preparing to clean a client's dentures. Which of the following actions should the nurse plan to take?
A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?
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