ATI RN Fundamentals Proctored Exam With Answers Version-1-9-268 Solved Questions

ATI RN FUNDAMENTALS PROCTORED EXAM
VERSION 1
A nurse is reviewing safety precautions w/a group of young adults at a community health fair.
Which of the following recommendations should the nurse include specifically for this age
group? Select all.
A. Install bath rails & grab bars in bathrooms
B. Wear a helmet while skiing
C. Install a carbon monoxide detector
D. Secure firearms in a safe location
E. Remove throw rugs from the home
Answer: B, C, D
Rationale: A is recommended for older adults and E as well for risk of falls
A nurse is reviewing the CDC's immunization recommendations w/a young adult client.
Which of the following recommendations should the nurse include in this discussion? Select
all.
A. Human papillomavirus
B. Measles, mumps, rubella
C. Varicella
D. Haemophilus influenzae type b
E. Polio
Answer: A, B, C
Rationale: D is not for after 18 months of age and polio is also given as a child and not
usually beyond 18 yrs old
A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101
F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the
following are appropriate nursing interventions for this client? Select all.
A. Obtain culture specimens before initiating antimicrobials
B. Restrict the client's oral fluid intake
C. Encourage the client to limit activity & rest
D. Allow the client to shiver to dispel excess heat
E. Assist the client w/oral hygiene frequently

Answer: A, C, E
Rationale: The nurse should prevent shivering & encourage the client to increase fluids. Oral
hygiene helps prevent cracking of dry mucous membranes of the mouth 1
A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The
nurse is aware that health care professionals are required to report communicable &
infectious diseases. Which of the following illustrate the rationale for reporting? Select all.
A. Planning & evaluating control & prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
D. Identifying endemic disease
E. Monitoring for common-source outbreaks
Answer: A, B, C, E
Rationale: Not D because endemic disease is already prevalent within a population, so
reporting is not necessary
A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a
suspected diagnosis of pertussis. Which of the following should the nurse include in the plan
of care? Select all.
A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr
B. Wear a mask when providing care within 3 ft of the client
C. Place a surgical mask on the client if transportation to another dept is unavoidable D. Use
sterile gloves when handling soiled linens
E. Wear a gown when preforming care that may result in contamination from secretions
Answer: B, C, E
Rationale: Private room w/droplet precautions indicated for this client. The nurse should
wear a gown when contamination from body fluids might happen
A nurse is caring for a client who presents w/linear clusters of fluid-containing vesicles
w/some crustings. Which of the following should the nurse suspect?
A. Allergic reaction
B. Ringworm
C. Systemic lupus erythematosus
D. Herpes zoster

D. Herpes zoster
Rationale: pink body rash = allergic reaction, red circles w/white centers = ringworm, red
cheek rash bilaterally = lupus
A nurse is caring for a client who reports severe sore throat, pain when swallowing, &
swollen lymph nodes. The client is experiencing which of the following stages of infection?
A. Prodromal
B. Incubation
C. Convalescence
D. Illness
Answer: D. Illness
Rationale: specific s/s present is the illness stage
A nurse educator is reviewing w/a newly hired nurse the difference in clinical manifestations
of a localized vs. a systemic infection. The nurse indicates understanding when she states that
which of the following are clinical manifestations of a systemic infection? Select all.
A. Fever
B. Malaise
C. Edema
D. Pain or tenderness
E. Increase in pulse & respiratory rate
Answer: A, B, E
Rationale: Edema and pain and tenderness is localized
A nurse is teaching a young adult client about health promotion & illness prevention. Which
of the following statements by the client indicates an understanding of the teaching?
A. "I already had my immunizations as a child, so I'm protected in that area."
B. "It is important to schedule routine health care visits even if I'm feeling well."
C. "If I'm having any discomfort, I'll just got to an urgent care center."
D. "If I am felling stressed, I will remind myself that this is something I should expect."
Answer: B. "It is important to schedule routine health care visits even if I'm feeling well."
Rationale: Routine health screenings are important at any age

A nursing instructor is explaining the various stages of the lifespan to a group of nursing
students. The nurse should offer which of the following behaviors by a young adult as an
example of appropriate psychosocial development?
A. Becoming actively involved in providing guidance to the next generation
B. Adjusting to major changes in roles and relationships due to losses
C. Devoting a great deal of time to establishing an occupation
D. Finding oneself "sandwiched" in between & being responsible for 2 generations
Answer: C. Devoting a great deal of time to establishing an occupation
Rationale: Exploring and establishing career options & establishing oneself is important
developmental task in a young adult
A nurse is counseling a young adult who describes having difficulty dealing w/several issues.
Which of the following problems the client verbalized should the nurse identify as the
priority for further assessment & intervention?
A. "I have my own apartment now, but it's not easy living away from my parents."
B. "It's been so stressful for me to even think about having my own family."
C. "I don't even know who I am yet, & now I'm supposed to know what to do."
D. "My girlfriend is pregnant, & I don't think I have what it takes to be a good father."
Answer: C. "I don't even know who I am yet, & now I'm supposed to know what to do."
Rationale: Applying Erikson stages of development, knowing oneself is done in
adolescence, and this requires the most urgent help & lips.
A nurse is instructing an AP in caring for a client who has a low platelet count as a result of
chemo. Which of the following is the nurse's priority instruction for measuring vital signs for
this client?
A. "Don't measure the client's temp rectally."
B. "Count the client's radial pulse for 30 sec & multiply by 2."
C. "Don't let the client know you are counting her respirations."
D. "Let the client rest for 5 mins before you measure her BP."
Answer: A. "Don't measure the client's temp rectally."
Rationale: The greatest risk to a client w/a low platelet count is injury that results in
bleeding, obtaining a temp this way increases the risk for bleeding.

A nurse is instructing a group of nursing students in measuring a client's RR. Which of the
following guidelines should the nurse include? Select all.
A. Place the client in semi-Fowler's position
B. Have the client rest an arm across the abdomen
C. Observe 1 full respiratory cycle before counting the rate
D. Count the rate for 1 min if it is regular
E. Count & report any signs the client demonstrates
Answer: A, B, C
Rationale: As for D, this is if the rate is irregular after initial count, for E, sighs are expected
& don't need to be reported
A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94
mmHg. The client denies any history of HTN. Which of the following actions should the
nurse take next?
A. Request a prescription for an antihypertensive med
B. Ask the client if she is having pain
C. Request a prescription for an anti-anxiety med
D. Return in 30min to recheck the client's BP
Answer: B. Ask the client if she is having pain
Rationale: Perform a pain assessment would be the appropriate action to take next
A nurse is performing an admission assessment on a client. When measuring her vital signs,
the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse rate is
84/min. What is the client's pulse deficit?
Answer: 16/min
Rationale: The pulse deficit is the difference between the apical & radial pulse rates. 84 - 68
= 16
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of
the following info should the nurse include when explaining the procedure to the client?
A. Eating more protein is optimal prior to testing
B. One stool specimen is sufficient for testing
C. A red color change indicates a positive test
D. The specimen cannot be contaminated

Answer: D. The specimen cannot be contaminated
Rationale: The stool specimens cannot be contaminated with water or urine
A nurse is talking w/a client who reports constipation. When the nurse discusses dietary
changes that can help prevent constipation, which of the following foods should the nurse
recommend?
A. Macaroni & cheese
B. Fresh fruit & whole wheat toast
C. Rice pudding & ripe bananas
D. Roast chicken & white rice
Answer: B. Fresh fruit & whole wheat toast
Rationale: A high-fiber diet promotes normal bowel elimination
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the
client, the nurse should expect which of the following findings? Select all.
A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema
Answer: B, C, D
Rationale: fever = caused by dehydration tachycardia not bradycardia hypotension because
of decreased BP from dehydration fluid overload = peripheral edema
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a
diagnostic procedure. Which of the following are appropriate steps for the nurse to take?
Select all.
A. Warm the enema prior to instillation
B. Position the client on the left side w/the right leg flexed forward
C. Lubricate the rectal tube or nozzle
D. Slowly insert the rectal tube about 2 inches
E. Hang the enema container 24 inches above the client's anus
Answer: A, B, C

Rationale: D is the appropriate length of insertion for a child, 3-4 for an adult. 24 inches is
too high & will cause it to run to fast & possible painful distention of the colon, 18 inches is
the recommended height
While a nurse is administering a cleansing enema, the client reports abdominal cramping.
Which of the following is the appropriate intervention?
A. Have the client hold his breath briefly
B. Discontinue the fluid instillation
C. Remind the client that cramping is common at this time
D. Lower the enema fluid container
Answer: D. Lower the enema fluid container
Rationale: This will slow the rate of instillation & relieve some discomfort
A nurse is caring for a client who has been sitting in a chair for 3 hrs. Which of the following
problems is the client at risk for developing?
A. Stasis of secretions
B. Muscle atrophy
C. Pressure ulcer
D. Fecal impaction
Answer: C
Rationale: Unrelieved pressure over a bony prominence for too long increases the risk of a
pressure ulcer, sitting will help prevent stasis of secretions B and D-these are from prolonged
bed rest
A nurse is caring for a client who is on bed rest. Which of the following interventions should
the nurse implement to maintain the patency of the client's airway?
A. Encourage isometric exercises
B. Suction Q8 hr
C. Give low-dose heparin
D. Promote incentive spirometer use
Answer: D. Promote incentive spirometer use
Rationale: helps keep airways open and prevent atelectasis, this strengthens skeletal muscles
B-this is not indicated, C-helps prevent thrombus formation

A nurse is caring for a client who is postop. Which of the following nursing interventions
reduce the risk of thrombus development? Select all.
A. Instruct the client not to use the Valsalva maneuver
B. Apply elastic stockings
C. Review lab values for total protein level
D. Place pillows under the client's knees & lower extremities
E. Assist the client to change position often
Answer: B, E
Rationale: A nurse is instructing a postop client about the sequential compression device the
provider has prescribed.
Which of the following statements should indicate to the nurse that the client understands the
teaching?
A. "This device will keep me from getting sores on my skin."
B. "This thing will keep the blood pumping through my leg."
C. "With this thing on, my leg muscles won't get weak."
D. "This device is going to keep my joints in good shape."
Answer: B. "This thing will keep the blood pumping through my leg."
Rationale: sequential pressure devices promote venous return in the deep veins of the legs &
thus help prevent thrombus formation.
To promote the safe use of a cane for a client who is recovering from a minor
musculoskeletal injury of the left lower extremity, which of the following instructions should
the nurse provide? Select all that apply.
A. Hold the cane on the right side
B. Keep 2 points of support on the floor
C. Place the cane 15in in front of the feet before advancing
D. After advancing the cane, move the weaker leg forward
E. Advance the stronger leg so that it aligns evenly w/the cane
Answer: A, B, D
Rationale: C-the client should place the cane 6-10 inches in front before advancing not 15 Ethe client should advance the stronger leg past the cane not aligned w/it

A nurse is assessing the pain level of a client who has come to the ER reporting severe abd.
pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is
assessing which of the following?
A. Presence of associated symptoms
B. Location of the pain
C. Pain quality
D. Aggravating & relieving factors
Answer: A. Presence of associated symptoms
Rationale: this is a common symptom people have when experiencing pain
A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can
best assess the intensity of the client's pain by:
A. asking what precipitates the pain
B. questioning the client about the location of the pain
C. offering the client a pain scale to measure his pain
D. using open-ended questions to identify the situation
Answer: C. offering the client a pain scale to measure his pain
Rationale: pain scale can measure the amount and intensity of the pain
A nurse is obtaining history from a client who has pain. The nurse's guiding principle
throughout this process should be that:
A. some clients exaggerate their level of pain
B. pain must have an identifiable source to justify the use of opioids.
C. objective data are essential in assessing pain
D. pain is whatever the client says it is
Answer: D. pain is whatever the client says it is
Rationale: the client is the best source of information in their pain, it is a subjective
experience
A nurse is caring for a client who is receiving morphine via a PCA infusion device after
abdominal surgery. Which of the following statements indicates that the client knows how to
use the device?
A. "I'll wait to use the device until it's absolutely necessary."
B. "I'll be careful about pushing the button so I don't get an overdose."

C. "I should tell the nurse if the pain doesn't stop after I use this device."
D. "I will ask my son to push the dose button when I am sleeping."
Answer: C. "I should tell the nurse if the pain doesn't stop after I use this device."
Rationale: The client should let the nurse know if not receiving adequate pain control, so
they can reevaluate the pain control plan
A nurse is monitoring a client who is receiving opioid analgesia for adv effects of the med.
Which of the following effects should the nurse anticipate? Select all.
A. Urinary incontinence
B. Diarrhea
C. Bradypnea
D. Orthostatic hypotension
E. Nausea
Answer: C, D, E
Rationale: Urinary retention, not incontinence is an adverse effect of these meds as well as
constipation, not diarrhea.
A nurse is assessing a client who takes haloperidol (Haldol) for the tx of schizophrenia.
Which of the following findings should the nurse document as extrapyramidal symptoms
(EPS)? Select all.
A. Orthostatic hypotension
B. Fine motor tremors
C. Acute dystonias
D. Decreased level of consciousness
E. Uncontrollable restlessness
Answer: B, C, E
Rationale: A and D are adverse effects, but not EPS
A nurse is providing teaching about managing anticholinergic effects for a client who has a
new prescription for oxy-butunin (Ditropan XL). Which of the following are appropriate to
include in the teaching? Select all.
A. Take frequent sips of water
B. Wear sunglasses when exposed to sunlight
C. Use a soft toothbrush when brushing teeth

D. Take the medication w/an antacid
E. Urinate prior to taking the med
Answer: A, B, E
Rationale: side effects of this med include: dry mouth, photophobia, and urinary retention
A nurse is reviewing the reported meds of a client who was recently admitted. The meds
include cimetidine (Tagamet) & imipramine hydrochloride (Tofranil). Knowing that
cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify
that this combination is likely to result in which of the following effects?
A. Decreased therapeutic effects of cimetidine
B. Increased risk of imipramine hydrochloride toxicity
C. Decreased risk of adv effects of cimetidine
D. Increased therapeutic effects of imipramine hydrochloride
Answer: B. Increased risk of imipramine hydrochloride toxicity
Rationale: med that decreases the metabolism of a 2nd med increases the serum level of the
2nd med, increasing risk for toxicity
A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant.
The client currently takes a Category D pregnancy risk med for the control of seizures. Which
of the following statements by the nurse is appropriate?
A. "This med is prescribed if necessary but it is known to cause adverse effects to the fetus."
B. "This med has evidence indicating that it is safe to take during pregnancy & will not harm
the fetus."
C. "This med cannot be taken during pregnancy because the risk outweighs the potential
benefits."
D. "This med hasn't been studied in pregnant women but is believed to be safe for the fetus."
Answer: A. "This med is prescribed if necessary but it is known to cause adverse effects to
the fetus."
Rationale: Category D meds are known to cause harm to fetuses, however the use during
pregnancy may be warranted based on potential benefits.
A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The
client has a prescription for preoperative diazepam (Valium). Prior to administering the med,
which of the following actions is the highest priority?

A. Teaching the client about the purpose of the med
B. Administering the med to the client at the prescribed time
C. Identifying the client's med allergies
D. Documenting the client's anxiety level
Answer: C. Identifying the client's med allergies
Rationale: The greatest risk to the client is an allergic reaction to the med
A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV
bolus. The amount available is 40 mg/mL. How many mL should the nurse administer?
(round to nearest tenth)
Answer: 0.3 mL
A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15min. The nurse
should set the infusion pump to deliver how many mL/hr? (round to nearest whole number)
Answer: 400 mL/hr
A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse
over 30min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the
manual IV infusion to deliver how many gtt/min? (round to nearest whole number)
Answer: 83 gtt/min
A nurse is caring for a client who is at high risk for aspiration. Which of the following is an
appropriate nursing intervention?
A. Give the client thin liquids.
B. Instruct the client to tuck her chin when swallowing.
C. Have the client use a straw.
D. Encourage the client to lie down & rest after meals.
Answer: B. Instruct the client to tuck her chin when swallowing.
Rationale: Tucking when swallowing allows food to pass down esophagus more easily.
A nurse is preparing a presentation about basic nutrients for a group of high school athletes.
She should explain that which of the following is the body's priority energy reserve?
A. Fat
B. Protein

C. Glycogen
D. Carbohydrates
Answer: D. Carbohydrates
Rationale: Carbs provide glucose
A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see
which of the following foods on the client's meal tray?
A. Cooked barley
B. Pureed broccoli
C. Vanilla custard
D. Lentil soup
Answer: C. Vanilla custard
Rationale: low-residue diets are low in fiber and easy to digest: dairy products especially
A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate
her BMI & determine whether this client is obese based on her BMI.
Answer: BMI = 30
Rationale: above 30 equals obese so yes.
A nurse in a senior center is counseling a group of older adults about their nutritional needs &
considerations. Which of the following info should the nurse include? Select all.
A. Older adults are more prone to dehydration than younger adults are
B. Older adults need the same amount of most vitamins & minerals as younger adults do
C. Many older men & women need calcium supplementation
D. Older adults need more calories than they did when they were younger
E. Older adults should consume a diet low in carbs
Answer: A, B, C
Rationale: D-they need fewer calories not more E-they need more carbs & fiber
A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The
client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication
administration record, which of the following medications should the nurse administer?
A. Meperidine (Demerol) 75 mg IM
B. Fentanyl 50 mcg/hr transdermal patch

C. Morphine 2 mg IV
D. Oxycodone 10 mg PO
Answer: C. Morphine 2 mg IV
Rationale: IV morphine is the best because the onset is rapid and absorption to the blood is
immediate, which is adequate for a client with a 10 pain severity
A nurse is teaching a client about taking multiple oral meds at home to include time-release
capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by
the client indicates an understanding of the teaching?
A. "I can open the capsule w/the beads in it & sprinkle them on my oatmeal."
B. "If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding."
C. "The pills w/the coating on them can be crushed."
D. "I will eat 2 crackers w/the pain pills."
Answer: D. "I will eat 2 crackers w/the pain pills."
Rationale: this will prevent N&V from the narcotic
A nurse is teaching a client how to administer medication through a jejunostomy tube. Which
of the following instructions should the nurse include in the teaching?
A. "Flush the tube before & after each med."
B. "Administer your meds w/your enteral feeding."
C. "Administer tablets through the tube slowly."
D. "Mix all the crushed meds prior to dissolving in water."
Answer: A. "Flush the tube before & after each med."
Rationale: The client should flush the tube w/15-30 mL of water to prevent clogging of the
tube
A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed
nurses. Which of the following statements by a newly licensed nurse indicates an
understanding of the 1st-pass effect?
A. "Some meds block normal receptor activity regulated by endogenous compounds or
receptor activity caused by other meds."
B. "Some meds may have to be administered by a non-enteral route to avoid inactivation as
they travel through the liver."

C. "Some meds leave the body more slowly & therefore have a greater risk of accumulation
& toxicity."
D. "Some meds have a wide safety margin, so there is no need for routine serum medication
level monitoring."
Answer: B. "Some meds may have to be administered by a non-enteral route to avoid
inactivation as they travel through the liver."
Rationale: first pass deals with the liver
Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia?
Yes.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients.
Which of the following client's needs may the nurse assign to a assistive personnel (AP)?
A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
B. Reinforcing teaching w/a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
Answer: C. Reapplying a condom catheter for a client who has urinary incontinence
Rationale: The application of a condom catheter is a noninvasive, routine procedure that the
nurse may delegate to the AP
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an
AP. Which of the following information should the nurse share with the AP? Select All.
A. The roommate is up independently.
B. The client ambulates w/his slippers on over his antiembolic stockings
C. The client uses a front-wheeled walker when ambulating
D. The client had pain medication 30 min ago
E. The client is allergic to codeine
F. The client ate 50% of his breakfast this morning
Answer: B, C, D
An RN is making assignments for client care to a LPN at the beginning of the shift. Which of
the following assignments should the LPN question?
A. Assisting a client who is 24hr postop to use an incentive spirometer

B. Collecting a clean-catch urine specimen from a client who was admitted on the previous
shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump
Answer: D. Replacing the cartridge and tubing on a PCA pump
Rationale: The RN is responsible for the PCA pump
A nurse is preparing an in-service program about delegation. Which of the following
elements should she identify when presenting the 5 rights of delegation? Select all.
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances
Answer: B, C, E
Rationale: A and D are rights of medication administration
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift.
A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To
which staff member should the nurse assign to this client?
A. Charge nurse
B. RN
C. LPN
D. AP
Answer: B. RN
Rationale: A client returning from surgery requires assessment and establishment of a plan
of care. RNs are responsible for this, especially if the client is potentially unstable.
A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells
him she will put a diaper on him if he does not use the urinal more carefully next time. Which
of the following torts is the AP committing?
A. Assault
B. Battery
C. False imprisonment

D. Invasion of privacy
Answer: A. Assault
Rationale: By threatening the client, the AP is committing assault.
An adult client who is competent tells the nurse that he is thinking about leaving the hospital
against medical advice. The nurse believes that this is not in the client's best interest, so she
administers a PRN sedative med that the client has not requested along w/his usual meds.
Which of the following tort has the nurse committed?
A. Assault
B. False imprisonment
C. Negligence
D. Breach of confidentiality
Answer: B. False imprisonment
Rationale: The nurse gave the med as a chemical restraint to keep the client from leaving the
facility against medical advice. The client did not consent.
A client who will undergo neurosurgery the following week tells the nurse in the surgeon's
office that he will prepare his advance directives before he goes to the hospital. Which of the
following statements by the client indicates to the nurse that he understands advance
directives?
A. "I'd rather have my brother make decisions for me, but I know it has to be my wife."
B. "I know they won't go ahead w/the surgery unless I prepare these forms."
C. "I plan to write that I don't want them to keep me on a breathing machine."
D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."
Answer: C. "I plan to write that I don't want them to keep me on a breathing machine."
Rationale: The client has the right to decide and specify which medical procedures he wants
when a life-threatening situation arrives
A client is about to undergo an elective surgical procedure. Which of the following actions
are appropriate for the nurse who is providing pre-op care regarding informed consent? Select
all.
A. Make sure the surgeon obtained the client's consent
B. Witness the client's signature on the consent form
C. Explain the risks and benefits of the procedure

D. Describe the consequences of choosing not to have the surgery E. Tell the client about
alternatives to having the surgery
Answer: A, B
Rationale: The rest of the choices are the surgeon's responsibility, not the nurse
A nurse has noticed several occasions in the past week when another nurse on the unit
seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a
chair in the break room when she was not on break. Which of the following actions should
the nurse take?
A. Remind the nurse that safe client care is a priority on the unit
B. Ask others on the team whether they have observed the same behavior
C. Report observations to the nurse manager on the unit
D. Conclude that her coworker's fatigue is not her problem to solve
Answer: C. Report observations to the nurse manager on the unit
Rationale: Any nurse who notices behavior that could possibly jeopardize client care or
indicate a substance abuse problem has a duty to report the situation immediately to the nurse
manager
A nurse is preparing info for a change-of-shift report. Which of the following info should the
nurse include in the report?
A. The client's input & output for the shift
B. The client's BP from the previous day
C. A bone scan that is scheduled for today
D. The med routine from the med administration record
Answer: C. A bone scan that is scheduled for today
Rationale: This is important because the nurse might have to modify the client's care to
accommodate them leaving the unit
A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower,
but I got myself back up & into my chair." How should the nurse document this in the client's
chart?
A. The client fell in the shower.
B. The client states he fell in the shower & was able to get himself back into his chair
C. The nurse should not document this info because she did not witness the fall

D. The client fell in the shower & is now resting comfortably
Answer: B. The nurse should not document this info because she did not witness the fall
Rationale: By writing what the client states, the info is subjective data
A nursing instructor is reviewing documentation w/a group of nursing students. Which of the
following legal guidelines should they follow when documenting a client's record? Select all
that apply
A. Cover errors w/correction fluid, & write in the correct info
B. Put the date & time on all entries
C. Document objective data, leaving out opinions
D. Use as many abbreviations as possible
E. Wait until the end of the shift to document
Answer: B, C
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to
ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when
the client is supine in bed. The nurse telephoned the physical therapist about the difficulties
containing the drainage from the fistula, so the therapist didn't ambulate the client today. The
client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the
food on her tray. The wound care nurse confirmed that she will see the client later today. The
client states she feels frustrated at not having physical therapy, but the nurse thinks the client
welcomed having a day to rest. Which of the following information should the nurse include
in the change-of-shift report? Select all that apply.
A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the client stands.
C. The client seemed to welcome having a "day off" from physical therapy
D. The wound care nurse will see the client later today
E. The client ate all the food on her lunch tray
Answer: A, B, D
A nurse is receiving a provider's prescription by telephone for morphine for a client who is
reporting moderate to severe pain. Which of the following nursing actions are appropriate?
Select all that apply.
A. Repeat the details of the prescription back to the provider

B. Have another nurse listen to the telephone prescription
C. Obtain the prescriber's signature on the prescription within 24hrs
D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone
Answer: A, B, C
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He
states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To
which of the following members of the health care team should the nurse refer him?
A. Registered dietitian
B. Occupational therapist
C. Physical therapist
D. Social worker
Answer: D. social worker
Rationale: A social worker can make arrangements for a meal delivery service to provide
nutritious meals daily, or recommend a congregate meal site near the client's home
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use
adaptive devices. The nurse caring for the client should initiate a referral w/which of the
following members of the inter-professional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist
E. Registered dietitian
Answer: D. Occupational therapist
Rationale: An occupational therapist can assist clients who have physical challenges to use
adaptive devices & strategies to help w/self-care activities
A client who is postop following a knee arthroplasty is concerned about the adverse effects of
the medication he is receiving for pain management. Which of the following members of the
inter-professional care team may assist the client in understanding the medication's effects?
Select all that apply.
A. Provider

B. CNA
C. Pharmacist
D. RN
E. Respiratory therapist
Answer: A, C, D
A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The
nurse caring for the client should initiate a referral w/which of the following members of the
inter-professional care team?
A. Social worker
B. CNA
C. Occupational therapist
D. Speech-language pathologist
Answer: D. Speech-language pathologist
Rationale: A speech-language pathologist can initiate specific therapy for clients who have
difficulty feeding due to swallowing difficulties
A nursing instructor is acquainting a group of nursing students w/the roles of the various
members of the health care team they will encounter on a medical-surgical unit. When she
gives examples of the types of tasks CNAs may perform, which of the following client
activities should she include? Select all.
A. Bathing
B. Ambulating
C. Toileting
D. Determining Pain Level
E. Measuring vital signs
Answer: A, B, C, E
Rationale: Determining pain level requires assessment, which is the job of the licensed
personnel.
A nurse in a provider's office is preparing to assess a young adult male client's
musculoskeletal system as part of a comprehensive physical examination. Which of the
following findings should the nurse expect? Select all.
A. A concave thoracic spine posteriorly

B. An exaggerated lumbar curvature
C. A concave lumbar spine posteriorly
D. An exaggerated thoracic curvature
E. Muscles slightly larger on his dominant side
Answer: C, E
A nurse is evaluating a client's neurosensory system. To evaluate stereo-gnosis, she would ask
the client to close his eyes & identify which of the following items?
A. A word she whispers 30cm from his ear
B. A number she traces on the palm of his hand
C. The vibration of a tuning fork she places on his foot
D. A familiar object she places in his hand
Answer: D. A familiar object she places in his hand
Rationale: Stereognosis is tactile recognition
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of
her right shoulder. Which of the following activities is this problem likely to affect?
A. Mopping her floors
B. Brushing the back of her hair
C. Fastening her bra behind her back
D. Reaching into a cabinet above her sink
Answer: C. Fastening her bra behind her back
Rationale: Fastening a bra from behind requires internal rotation of the shoulder, so this
activity will illicit pain
A nurse is preforming a neurosensory examination for a client. Which of the following tests
should the nurse preform to test the client's balance? Select all.
A. Romberg test
B. Heel-to-toe walk
C. Snellen test
D. Spinal accessory function
E. Rosenbaum test
Answer: A, B

Rationale: C and E test visual acuity, D tests cranial nerve XI is intact by asking the client to
shrug shoulders without complication.
A nurse is collecting data from an older adult client as part of a neurosensory examination.
Which of the following findings should the nurse expect as changes associated w/aging?
Select all.
A. Slower light touch sensation
B. Some vision & hearing decline
C. Slower fine finger movement
D. Some short-term memory decline
E. Slower superficial pain sensation
Answer: B, C, D
A nurse is providing discharge instructions to a client who has a prescription for the use of
oxygen in his home. Which of the following should the nurse teach the client about using
oxygen safely in his home? Select all.
A. Family members who smoke must be at least 10 ft from the client when the oxygen is in
use
B. Nail polish should not be used near a client who is receiving oxygen
C. A "No smoking" sign should be placed on the front door
D. Cotton bedding & clothing should be replaced w/items made from wool
E. A fire extinguisher should be readily available in the home
Answer: B, C, E
Rationale: Family members that smoke should do so outside, and wool creates static
electricity so it should be avoided.
A nurse educator is conducting a parenting class for new parents. Which of the following
statements made by a participant indicates a need for further clarification & instruction?
A. "I will begin swimming lessons as soon as my baby can close her mouth under water."
B. "Once my baby can sit up, he should be safe in the bathtub."
C. "I will test the temp of the water before placing my baby in the bath."
D. "Once my infant starts to push up, I will remove the mobile from over the bed."
Answer: B. "Once my baby can sit up, he should be safe in the bathtub."

Rationale: Although the baby can hold his head above the water by sitting up, this does not
make the baby safe in the tub. Parents should never leave a child unattended in a tub.
A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client.
Which of the following information should the nurse include in her counseling?
A. Carbon monoxide has a distinct odor
B. Water heaters should be inspected every 5 years
C. The lungs are damaged from carbon monoxide inhalation
D. Carbon monoxide binds w/hemoglobin in the body
Answer: D. Carbon monoxide binds w/hemoglobin in the body
Rationale: Carbon monoxide is a very dangerous gas because it binds w/hemoglobin &
ultimately reduces the oxygen supplied to the tissues in the body. Carbon monoxide is
tasteless, has no scent, and cannot be seen. The water heaters, gas-burning furnaces, and
appliances should be inspected annually the lungs are not damaged in the process of
inhalation.
A nurse educator is presenting a module on basic first aid for newly licensed home health
nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse
states the client who has heat stroke will have which of the following?
A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea
Answer: A. Hypotension
Rationale: Tachycardia, hot dry skin, and tachypnea are other manifestations of heat stroke
A home health nurse is discussing the dangers of food poisoning w/a client. Which of the
following info should the nurse include in her counseling? Select all.
A. Most food poisoning is caused by a virus
B. Immunocompromised individuals are at risk for complications from food poisoning
C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk,
yogurt, cheese, or other dairy products
D. Healthy individuals usually recover from the illness in a few weeks

E. Handling raw & fresh food separately to avoid cross contamination may prevent food
poisoning
Answer: B, C, E
Rationale: Most food poisoning is caused by a bacteria such as E. coli. Healthy individuals
usually recover in a few days.
A nurse is teaching an adult client how to administer ear drops. Which of the following
statements by the client indicates understanding of the proper technique?
A. "I will straighten my ear canal by pulling my ear down & back."
B. "I will gently apply pressure w/my finger to the tragus of my ear after putting in the
drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing
the drops in."
D. "After the drops are in, I will place a cotton ball all the way into my ear canal."
Answer: B. "I will gently apply pressure w/my finger to the tragus of my ear after putting in
the drops."
Rationale: The client should apply gentle pressure w/the finger to the tragus of the ear after
administering the drops to help the drops go into the ear canal.
A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports
pain. Prior to administering, the nurse is called to another room to assist another client onto a
bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the
2nd nurse take?
A. Offer to assist the client needing the bedpan.
B. Administer the injection prepared by the other nurse
C. Prepare another syringe & administer the injection
D. Tell the client needing the bedpan she will have to wait for her nurse
Answer: A. Offer to assist the client needing the bedpan.
A nurse is preparing to administer a med to a client. The med was scheduled for
administration at 0900. Which of the following are acceptable administration times for this
med? Select all.
A. 0905
B. 0825
C. 1000

D. 0840 E. 0935
Answer: A, D
Rationale: 30min time frame for meds
A nurse is working w/a newly hired nurse who is administering meds to clients. Which of the
following actions by the newly hired nurse indicates an understanding of med error
prevention?
A. Taking all meds out of the unit-dose wrappers before entering the client's room
B. Checking w/the provider when a single dose requires administration of multiple tablets
C. Administering a med, then looking up the usual dosage range
D. Relying on another nurse to clarify a med prescription
Answer: B. Checking w/the provider when a single dose requires administration of multiple
tablets
Rationale: this could indicate a possible error so it should be checked w/the provider
A nurse educator is teaching a module on safe med administration to newly hired nurses.
Which of the following statements by the newly hired nurse indicate understanding of the
nurse's responsibility when implementing med therapy? Select all.
A. "I will observe for med side effects."
B. "I will monitor for therapeutic effects."
C. "I will prescribe the appropriate dose."
D. "I will change the dose if adverse effects occur."
E. "I will refuse to give a med if I believe it is unsafe."
Answer: A, B, E
A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want to
take that med. I do not want one more pill." Which of the following responses by the nurse is
appropriate in this situation?
A. "Your physician prescribed it for you, so you really should take it."
B. "Well, let's just get it over w/quickly then."
C. "Okay, I'll just give you your other meds."
D. "Tell me your concerns w/taking this med."
Answer: D. "Tell me your concerns w/taking this med."

A nurse is assessing a client who has an acute resp. infection that puts her at risk for
hypoxemia. Which of the following findings are early indications that should alert the nurse
that the client is developing hypoxemia? Select all.
A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Pallor
Answer: A, B, E
Rationale: C and D are late manifestations of hypoxemia.
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is
already receiving oxygen therapy via nasal cannula. Which of the following interventions is
the nurse's priority?
A. Increase the oxygen flow
B. Assist the client to Fowler's position
C. Promote removal of pulmonary secretions
D. Obtain a specimen for arterial blood gases
Answer: B. Assist the client to Fowler's position
Rationale: Fowler's facilitates better breathing
A nurse is preparing to preform endotracheal suctioning for a client. Which of the following
are appropriate guidelines for the nurse to follow? Select all.
A. Apply suction while withdrawing the catheter
B. Perform suctioning on a routine basis, Q2-3 hours
C. Maintain medical asepsis during suctioning
D. Use a new catheter for each suctioning attempt E. Limit suctioning to 2-3 attempts
Answer: A, D, E
Rationale: B-Suctioning is not w/out risk so it should be done as needed, not routinely.
Cendotracheal suctioning requires surgical asepsis
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.

A. Apply the oxygen source loosely if the SPO2 decreases during the procedure B. Use
surgical asepsis to remove & clean the inner cannula
C. Clean the outer surfaces in a circular motion from the stoma site onward
D. Replace the tracheostomy ties w/new ties
E. Cut a slit in gauze squares to place beneath the tube holder.
Answer: A, B, C
Rationale: D-only replace ties if soiled or wet E-use a commercially prepared gauze w/slit
not one nurse makes
A provider is discharging a client with a prescription from home oxygen therapy via nasal
cannula. Client & family teaching by the nurse should include which of the following? Select
all.
A. Apply petroleum jelly around the inside of the nares
B. Remove the nasal cannula during mealtimes
C. Check the position of the cannula often
D. Report any nasal stuffiness, nausea, or fatigue
E. Post "no smoking" signs in a prominent location
Answer: C, D, E
A nurse is delivering an enteral feeding to a client who has an NG tube in place for
intermittent feedings. When the nurse pours water into the syringe after the formula drains
from the syringe, the client asks the nurse why the water is necessary. Which of the following
is an appropriate response by the nurse?
A. "Water helps clear the tube so it doesn't get clogged."
B. "Flushing helps make sure the tube stays in place."
C. "This will help you get enough fluids."
D. "Adding water makes the formula less concentrated."
Answer: A. "Water helps clear the tube so it doesn't get clogged
Rationale: this action clears the excess formula preventing any clumps/clogging
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place.
Which of the following is the nurse's highest assessment priority before performing this
procedure?
A. Check how long the feeding container has been opened

B. Verify the placement of the NG tube
C. Confirm that the client doesn't have diarrhea
D. Make sure the client is alert & oriented
Answer: B. Verify the placement of the NG tube
Rationale: The greatest risk is aspiration so verifying the placement of the tube is most
important
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the
following nursing interventions is the highest priority when the nurse suspects aspiration of
the feeding?
A. Auscultate breath sounds
B. Stop the feeding
C. Obtain a chest xray
D. Initiate oxygen therapy
Answer: B. Stop the feeding
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via
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 temp.
E. Discard any residual gastric contents.
Answer: A, B, C
Rationale: D-the formula should be room temp not body, E-unless the volume of the
contents is more than 250 mL, the nurse should the residual content to the client's stomach
A nurse is preparing to insert an NG tube for a client who requires gastric decompression.
Which of the following actions should the nurse perform prior to beginning the procedure?
Select all.
A. Review a signal the client can use if feeling any distress
B. Lay a towel across the client's chest
C. Administer oral pain meds

D. Obtain a Dobhoff tube for insertion
E. Have a petroleum-based lubricant available
Answer: A, B
An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The
client is tolerating a regular diet. He has ambulated successfully around the unit w/assistance.
He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving
the med. His incision is approximated & free of redness, w/scant serous drainage on the
dressing. Which of the following risk factors for poor wound healing does this client have?
Select all.
A. Extremes in age
B. Impaired circulation
C. Impaired/suppressed immune system
D. Malnutrition
E. Poor wound care
Answer: B, C
A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon
suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to
initiate after collecting wound & blood specimens for culture & sensitivity. Which of the
following assessment findings should the nurse expect? Select all.
A. Increase in incisional pain
B. Fever & chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
E. Decrease in thirst
Answer: A, B, C
A nursing instructor is reviewing the wound healing process w/a group of nursing students.
They should be able to identify which of the following alterations as a wound or injury that
heals by secondary intention? Select all.
A. Stage III pressure ulcer
B. Sutured surgical incision
C. Casted bone fracture

D. Laceration sealed w/adhesive
E. Open burn area
Answer: A, E
Rationale: B and D are healed w/primary intention, C is not a skin wound unless bone has
pierced the skin
A client who had abd. surgery 24 hr ago reports a pulling sensation & pain in his surgical
incision. The nurse checks the client's surgical wound & finds the wound separated w/viscera
protruding. Which of the following interventions is appropriate? Select all.
A. Cover the area w/saline-soaked sterile dressings
B. Apply an abdominal binder snugly around the abd.
C. Use sterile gloves to apply gentle pressure to the exposed tissues
D. Position the client supine w/his hips & knees bent
E. Offer the client a warm beverage, such as herbal tea
Answer: A, D
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.
A. Keep the head of the bed elevated 30 degrees
B. Massage the client's bony prominences often
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 Q 3 hr while in bed
Answer: A, D
Rationale: Not E because it should be at least every 2 hours
The nurse is caring for an older adult with mild dementia with heart failure. What nursing
care will be helpful for this client in reducing potential confusion related to hospitalization
and change in routine? Select all that apply.
A. Reorient frequently to time, place and situation.
B. Put the client in a quiet room furthest from the nursing station.
C. Perform the necessary procedures quickly.
D. Arrange for familiar pictures or special items at bedside.

E. Limit the client’s visitors.
F. Spend time with the client, establishing a trusting relationship.
Answer: A. Reorient frequently to time, place and situation.
D. Arrange for familiar pictures or special items at bedside.
F. Spend time with the client, establishing a trusting relationship.
Which would be most helpful when coaching a client to stop smoking?
A. Review the negative effects of smoking on the body.
B. Discuss the effects of passive smoking on environmental pollution.
C. Establish the client’s daily smoking pattern.
D. Explain how smoking worsens high blood pressure.
Answer: C. Establish the client’s daily smoking pattern.
A nurse is helping a suspected choking victim. The nurse should perform the Heimlich
maneuver when the victim:
A. Starts to become cyanotic
B. Cannot speak due to airway obstruction
C. Can make only minimal vocal noises
D. Is coughing vigorously
Answer: B. Cannot speak due to airway obstruction
While the nurse is providing preoperative teaching for a client with peripheral vascular
disease who is to have a below-the-knee amputation, the client says. “I hate the idea of being
an invalid after they cut off my leg.” The nurse’s most therapeutic response should be:
A. “Focusing on using your one good leg will make your recovery easier.”
B. “Tell me more about how you are feeling.”
C. “We will talk more about this after your surgery.”
D. “You are fortunate to have a wife who can take care of you.”
Answer: B. “Tell me more about how you are feeling.”
Which indicates that a client has achieved the goal of correctly demonstrating deep breathing
for an upcoming splenectomy? The client:
A. Breathes in through the nose and out through the mouth
B. Breathes in through the mouth and out through the nose

C. Uses diaphraphragmatic breathing in the lying, sitting, and standing positions.
D. Takes a deep breath in through the nose, holds it for seconds, and blows it out through
pursed lips
Answer: D. Takes a deep breath in through the nose, holds it for seconds, and blows it out
through pursed lips
Which nursing action is most important in preventing cross-contamination?
A. Changing gloves immediately after use
B. Standing 2 feet (61cm) from the client
C. Speaking minimally when in the room
D. Wearing protective coverings
Answer: A. Changing gloves immediately after use
The nurse’s best explanation for why the severely neutropenic client is placed in reverse
isolation is that reverse isolation helps prevent the spread of organisms:
A. To the client from sources outside the client’s environment
B. From the client to healthcare personnel, visitors and other clients
C. By using special techniques to handle the client’s linens and personal items
D. By using special techniques to dispose of contaminated materials
Answer: A. To the client from sources outside the client’s environment
Which statement indicated to the nurse that a client has understood the discharge instructions
provided after nasal surgery?
A. “I should not shower until my packing is removed.”
B. “I will take stool softeners and modify my diet to prevent constipation.”
C. “Coughing every 2 hours is important to prevent respiratory complications.”
D. “It is important to blow my nose each day to remove the dried secretions.”
Answer: B. “I will take stool softeners and modify my diet to prevent constipation.”
The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of
time the nurse should suction the client?
A. 10 seconds
B. 20 seconds
C. 25 seconds

D. 30 seconds
Answer: A. 10 seconds
A client with a history of asthma is admitted to the emergency department. The nurse notes
that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of
accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds.
What should the nurse do first?
A. Initiate oxygen therapy as prescribed, and reassess the client in 10 mintues
B. Draw blood for arterial blood gas
C. Encourage the client to relax and breath slowly through the mouth
D. Administer bronchodilators as prescribed
Answer: D. Administer bronchodilators as prescribed
A confused client with carbon monoxide poisoning experiences dizziness when ambulating to
the bathroom. The nurse should:
A. Put all four side rails up on the bed
B. Ask the unlicensed assistive personnel to place restraints on the client’s upper extremities
C. Request that the client’s roommate put the call light on when the client is attempting to get
out of bed
D. Check on the client at regular intervals to ascertain the need to use the bathrooms
Answer: D. Check on the client at regular intervals to ascertain the need to use the bathrooms
The nurse should use which type of precautions for a client being admitted to the hospital
with suspected tuberculosis?
A. Hand hygiene
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
Answer: D. Airborne precautions
The nurse is teaching a client with stomatitis about mouth care. Which instruction is most
appropriate?
A. Drink hot tea at frequent intervals
B. Gargle with antiseptic mouthwash

C. Use an electric toothbrush
D. Eat a soft, bland diet
Answer: D. Eat a soft, bland diet
A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which indicates
the client is ready to try a liquid diet? The client:
A. Is hungry
B. Has not requested pain medication for 8 hours
C. Has frequent bowel sounds
D. Has had a bowel movement
Answer: C. Has frequent bowel sounds
A client has returned from surgery during which the jaws were wired as treatment for a
fractured mandible. The client is in stable condition. The nurse in instructing the unlicensed
assistive personnel (UAP) on how to properly position the client. Which instructions about
positioning would be appropriate for the nurse to give to the UAP?
A. Keep the client in a side-lying position with the head slightly elevated
B. Do not reposition the client without the assistance of a registered nurse
C. The client can assume any position that is comfortable
D. Keep the client’s head elevated on two pillows at all times
Answer: A. Keep the client in a side-lying position with the head slightly elevated
ATI Fundamentals
Version 3
A nurse is teaching a group of older adults about expected changes of aging. Which of the
following statements by a group member indicates that the teaching has been effective?
Answer: "I should expect my heart rate to take longer to return to normal after excessive as I
get older."
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the
following abdominal assessments should the nurse expect?
Answer: Absent bowel sounds with distention

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse
reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min,
a soft contender abdomen, and census overdue by 2 days. Which of the following findings
should be the nurse's priority?
Answer: Temperature
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
Answer: Administer analgesics to the child on a routine schedule throughout the day and
night.
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both
systole and diastole with diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
Answer: Pericardial friction rub
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the
following statements by the AP indicates an understanding of the teaching?
Answer: "There are times I should use soap and water rather than alcohol based hand rub to
clean my hands."
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes
by an electronic blood pressure machine. The nurse notices the machine begins to measure
the blood pressure at varied intervals and the readings are inconsistent. Which of the
following actions should the nurse take?
Answer: Discontinue the machine, and measure the blood pressure manually every 15 min.
A nurse is providing teaching to a client who has heart failure about how to reduce his daily
intake of sodium. Which of the following factors is the most important in determining the
client's ability to learn new dietary habits?
Answer: The involvement of the client in planning the change

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea
and who might have a right ear infection. Which of the following routes should the nurse use
to obtain the temperature?
Answer: Temporal
A nurse is witnessing a client sign an informed consent form for surgery. Which of the
following describes what the nurse is affirming by this action?
Answer: The signature on the preoperative consent form is the client’s
A nurse on a medical-surgical unit is admitting a client. Which of the following information
should the nurse document in the client’s record first?
Answer: Assessment
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing techniques?
Answer: The nurse washes with her hands held higher than her elbows.
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve?
Answer: Second intercostal space to the right of the sternum
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of
the following actions should the nurse take?
Answer: Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
A nurse is caring for an older adult client who becomes agitated when the nurse requests the
client’s dentures be removed prior to surgery. Which of the following responses should the
nurse make?
Answer: “What worries you about being without your teeth?”

A nurse is caring for a client who has a terminal illness. The client asks several questions
about the nurse’s religious beliefs related to death and dying. Which of the following actions
should the nurse take?
Answer: Encourage the client to express his thoughts about death and dying
A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to learning
self-injection of insulin. Which of the following statements should the nurse make?
Answer: “Tell me what I can do to help you overcome your fear of giving yourself
injections.”
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
Answer: Confirm unresponsiveness.
A community health nurse is preparing a campaign about seasonal influenza. Which of the
following plans should the nurse include as a secondary prevention?
Answer: Screening groups of older adults in nursing care facilities for early influenza
manifestations
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
Answer: Perform hand hygiene
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
Answer: Place the bladder of the cuff over the posterior aspect of the thigh
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported
for the procedure, which of the following actions should the nurse take first?
Answer: Identify the client using two identifiers

A nurse in an emergency department is assessing a client who reports diarrhea and decreased
urination for 4 days. Which of the following actions should the nurse take to assess the
client's skin turgor?
Answer: Grasp a skin fold on the chest under the clavicle, release it, and note whether it
springs back
A nurse is providing teaching to an older adult client who has constipation. Which of the
following statements should the nurse include in the teaching?
Answer: "Sit on the toilet 30 minutes after eating a meal."
A nurse on a medical-surgical unit is caring for a client. Which of the following actions
should the nurse take first when using the nursing process?
Answer: Obtain client information
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from
bed to a wheelchair. Which of the following techniques should the nurse use?
Answer: Place the wheelchair at a 45 degree angle to the bed
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the
following actions by the nurse will improve the client's commitment to a long-term goal of
weight loss?
Answer: Attempt to increase the client's self-motivation
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV
lines. The provider prescribes soft wrist restraints. Which of the following actions should the
nurse take while the client is in restraints?
Answer: Remove the restraints one at a time
A nurse is caring for a client who is in terminal stage of cancer. Which of the following
actions should the nurse take when she observes the client crying?
Answer: Sit and hold the client's hand

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
Answer: I keep having nightmares about my upcoming surgery."
A nurse is performing an abdominal assessment for an adult client. Identify the correct
sequence of steps for this assessment.
Answer: Inspect, Auscultate, Percuss, Palpate
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?
Answer: Obtaining cotton balls for the tracheostomy care
A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
Answer: Evaluate pedal pulses
A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating
room when the client states she no longer wants to have surgery. Which of the following
actions should the nurse take?
Answer: Notify the provider about the client's decision
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the
next month that might require a blood transfusion. The client expresses concern about the risk
of acquiring an infection from the blood transfusion. Which of the following statements
should the nurse make to the client?
Answer: Donate autologous blood before the surgery
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who
will have emergency surgery for appendicitis. Which of the following statements indicates a
lack of readiness to learn by the client?
Answer: The client reports severe pain

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a
regular size cuff for a client who is obese. Which of the following explanations should the
nurse give the AP
Answer: "Using a cuff that is too small will result in an inaccurately high reading."
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand.
The client has no documented bloodstream infection. Which of the following actions should
the nurse take?
Answer: Carefully remove the gloves and follow with hand hygiene
A nurse is receiving a client from the PACU who is postoperative following abdominal
surgery. Which of the following actions should the nurse take to transfer the client from
stretcher to the bed?
Answer: Lock the wheels on the bed and stretcher
A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take?
Answer: Raise the level of the bed
ATI Fundamental 1
Version 4
A nurse is caring for a client who has a terminal illness. The client asks several questions
about the nurse's religious beliefs related to death and dying. Which of the following actions
should the nurse take?
A. Change the topic because the client is trying to divert attention from the illness to the
nurse.
B. Encourage the client to express his thoughts about death and dying?
C. Tell the client that religious beliefs are a personal matter.
D. Offer to contact the client's minister or the facility's chaplain.
Answer: B. Encourage the client to express his thoughts about death and dying?
A nurse should recognize the client's need to talk about impending death, and encourage the
client to discuss his thoughts on the subject. This is therapeutic technique of reflecting.

Depending on the situation, the nurse can also share some thoughts on this topic. Selfdisclosure is a communication skill that can help open lines of communication when
appropriate. If the nurse does not want to share personal beliefs, the communication skills of
offering self and listening to the client's thoughts are appropriate.
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
A. Open all sterile supplies and solutions.
B. Stabilize the tracheostomy tube.
C. Don sterile gloves.
D. Perform hand hygiene
Answer: D. Perform hand hygiene
According to evidence-based practice, the nurse should first perform hand hygiene before
touching the client or performing any skills, such as tracheostomy care. This is vital because
contamination of the nurse's hands is a primary source of infection.
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of
the following actions should the nurse take?
A. Measure the pulse using a Doppler ultrasound stethoscope.
B. Check the client's pedal pulses.
C. Count the apical pulse rate for a full minute and describe the rhythm in the chart.
D. Take the pulse at each peripheral site and count the rate for 30 seconds.
Answer: C. Count the apical pulse rate for a full minute and describe the rhythm in the chart.
If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 1 minute to
obtain an accurate rate. The nurse should document irregularity in the client's medical record.
A nurse on a med-surg unit is caring for a client. Which of the following actions should the
nurse take first when using the nursing process?
A. Identify goals for client care.
B. Obtain client information
C. Document nursing care needs
D. Evaluate the effectiveness of care
Answer: B. Obtain client information

The nursing process is based on scientific process. The first step in the scientific process is
the collection of data. Therefore, the first step is assessing and obtaining information about
the client.
A nurse is receiving a client from the PACU (post-anesthetic care unit) who is postoperative
following abdominal surgery. Which of the following actions should the nurse take to transfer
the client from stretcher to the bed?
A. Lock the wheels on the bed and stretcher
B. Instruct the client to raise his arms above his head
C. Elevate the stretch 2.5 cm (1 inch) above the height of the bed
D. Log roll the client
Answer: A. Lock the wheels on the bed and stretcher
Locking the wheels prevents the client from falling to the floor by not allowing the cart of
bed to move apart or away from the client.
A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
A. Evaluate pedal pulses
B. Obtain medical history
C. Measure vital signs
D. Assess for leg pain
Answer: A. Evaluate pedal pulses
For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in
order to determine adequate blood supply to the foot. The nurse should apply the safety and
risk reduction priority-setting framework. This framework assigns priority to the factor
posing the greatest safety risk to the client. When there are several risks to client safety, the
one posing the greatest threat is the highest priority. The nurse should use Maslow's
Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify
which risk poses the greatest threat to the client.
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the
following abdominal assessments should the nurse expect?
A. Frequent bowel sounds with flatus
B. Absent bowel sounds with distention

C. Hyperactive bowel sounds with diarrhea
D. Normal bowel sounds with increased peristalsis
Answer: B. Absent bowel sounds with distention
Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the
abdomen is distended
A nurse is providing teaching to an older adult client who has constipation. Which of the
following statements should the nurse include in the teaching?
A. "Drink a minimum of 1,000 ml of fluid daily"
B. "Increase your intake of refined-fiber foods"
C. "Sit on the toilet 30 mins after eating a meal"
D. "Take a laxative everyday to maintain regularity"
Answer: C. "Sit on the toilet 30 mins after eating a meal"
Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after
eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel
retraining to treat constipation
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. the nurse auscultates a high-pitched scratching sound during both
systole and diastole with diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
A. Audible click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
Answer: D. Pericardial friction rub
A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound
heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial
friction rub is a manifestation of pericardial inflammation and can be heard with infective
pericarditis with myocardial infarction, following a cardiac surgery or trauma, and with some
autoimmune problems, such as rheumatic fever. The client who develops pericarditis
typically has chest pain which becomes worse with inspiration or coughing and which may be
relieved by sitting up and leaning forward.

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who
will have emergency surgery for appendicitis. Which of the following statements indicates a
lack of readiness to learn by the client?
A. The client asks the nurse to repeat the instructions before attempting the exercises.
B. The client reports severe pain
C. The client asks the nurse how often deep breathing should be done after surgery.
D. The client tells the nurse that this exercise will probably be painful after surgery.
Answer: B. The client reports severe pain
A client who is experiencing severe pain is not able to concentrate and therefore, is not ready
to learn a new activity
A nurse is teaching a group of older adults about expected changes of aging. Which of the
following statements by a group member indicates that the teaching has been effective?
A. "I should expect my heart rate to take longer to return to normal after exercise as I get
older"
B. "Urinary incontinence is something I will have to live with as I grow older"
C. "I can expect to have less ear was as I get older"
D. "My stomach will empty more quickly after meals as I grow older"
Answer: A. "I should expect my heart rate to take longer to return to normal after exercise as
I get older"
Older adults experience decreased CO, which causes increased pulse rate during exercise.
The pulse rate also takes longer to return to normal after exercise.
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning selfinjection of insulin. Which of the following statements should the nurse make?
A. "Tell me what I can do to help you overcome your fear of giving yourself injections"
B. "I am sure your provider will not be pleased that you refuse to give yourself insulin
injections"
C. "It's okay. I'm sure your partner will be able to learn how to give you the insulin
injections"
D. "You won't be able to go home unless you learn to give yourself insulin injections"
Answer: A. "Tell me what I can do to help you overcome your fear of giving yourself
injections"

The response illustrates the therapeutic communication technique of clarifying and offering
of self. It is important for the nurse to allow the client to express feelings and fears and to
support the client in learning how to give the injections.
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the
next month that might require a blood transfusion. The client expresses concern about the risk
of acquiring an infection from the blood transfusion. Which of the following statements
should the nurse make to the client?
A. "Ask your provider to prescribe epoetin before the surgery"
B. "You should ask your provider about taking iron supplements prior to the surgery"
C. "Request a family member to donate blood for you"
D. “Donate autologous blood before the surgery”
Answer: D. “Donate autologous blood before the surgery”
Autologous blood transfusion is the collection and reinfusion of the client's blood. With
preoperative autologous blood donation, the blood is drawn from the client 3-5 week before
an elective surgical procedure and stored for transfusion at the time of the surgery.
Autologous blood is the safest form of blood transfusion because exclusive use of a client's
own blood eliminates exposure to transfusion-transmitted infection.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?
A. Obtaining hydrogen peroxide for the tracheostomy care
B. Obtaining cotton balls for the tracheostomy care
C. Obtaining sterile gloves for the tracheostomy care
D. Obtaining a sterile brush for the tracheostomy care
Answer: B. Obtaining cotton balls for the tracheostomy care
Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a
tracheal abscess. The charge nurse should intervene for this action
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a
regular size cuff for a client who is obese. Which of the following explanations should the
nurse give the AP?
A. "The reading will be inaudible if the cuff is too small for the client"
B. "The width of the cuff bladder should be 75% of the circumference of the client's arm"

C. "As long as the cuff will circle the arm the reading will be accurate"
D. "Using a cuff that is too small will result in an inaccurately high reading"
Answer: D. "Using a cuff that is too small will result in an inaccurately high reading"
Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a
reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for
the client.
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported
for the procedure, which of the following actions should the nurse take first?
A. Explain the x-ray procedure to the client
B. Help the client into a wheelchair before the transporter arrives
C. Ask if the client has any questions
D. Identify the client using two identifiers
Answer: D. Identify the client using two identifiers
The nurse should apply the safety and risk reduction priority-setting framework. This
framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the
highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting
framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
Once the client's identity is determined, the nurse can then proceed with the other options.
This action is the priority action because it provides for the safety of the client. It is a nursing
responsibility to be certain that each client receives only what has been prescribed. The nurse
must assure that the correct client is being transported for the chest x-ray.
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
A. Auscultate for the BP at the dorsalis pedis artery
B. Measure the BP with the client sitting on the side of the bed
C. Place the cuff 7.6 cm (3 inches) above the popliteal artery
D. Place the bladder of the cuff over the posterior aspect of the thigh
Answer: D. Place the bladder of the cuff over the posterior aspect of the thigh
This is the correct position for the nurse to place the bladder of the cuff when measuring a
lower extremity BP

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
A. Encourage the child to cough frequently to clear congestion from anesthesia
B. Place a heating pad at the child's neck for comfort
C. Administer analgesics to the child on a routine schedule throughout the day and night
D. Provide the child with icecream when oral intake is initiated
Answer: C. Administer analgesics to the child on a routine schedule throughout the day and
night
To sooth the client's throat following a tonsillectiomy, the nurse should administer pain
medication routinely around the clock. The nurse can provide the medication rectally or
intravenously to avoid the oral route.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV
lines. The provider prescribes soft wrist restraints. Which of the following actions should the
nurse take while the client is in restraints?
A. Tie restraints to the side rails
B. Perform ROM exercises to the wrists every 3hr
C. Remove restraints one at a time
D. Obtain a PRN prescription for the restraints
Answer: C. Remove restraints one at a time
The nurse should remove one restraint at a time for a client who is violent or noncompliant
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
A. Call for assistance
B. Begin chest compressions
C. Confirm unresponsiveness
D. Give rescue breaths
Answer: C. Confirm unresponsiveness
The nurse should apply the nursing process priority-setting framework. The nurse can use the
nursing process to plan client care and prioritize nursing actions. Each step of the nursing
process builds on the previous step, beginning with the assessment or data collection. Before
the nurse can formulate a plan of action, implement a nursing intervention or notify a

provider of a change in the client's status, she must first collect adequate data from the client.
Assessing or collecting additional data will provide the nurse with knowledge to make an
appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a
client is unresponsive, the nurse should activate the emergency response team.
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea
and who might have a right ear infection. Which of the following routes should the nurse use
to obtain the temperature?
A. Rectal
B. Tympanic
C. Oral
D. Temporal
Answer: D. Temporal
The temporal artery route, while not as accurate as the rectal route for obtaining a precise
body temperature, is noninvasive and can be used to obtain a temperature in a toddler who
might have an ear infection and who is having diarrhea. The nurse should place the probe
behind the ear if the client is diaphoretic, but should avoid placing it over an area covered
with hair.
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve?
A. 5th intercostal space just medial to the midclavicular line
B. 2nd intercostal space to the left of the sternum
C. 5th intercostal space to the left of the sternum
D. 2nd intercostal space to the right of the sternum
Answer: D. 2nd intercostal space to the right of the sternum
The aortic valve is located at the second intercostal space to the right of the sternum. Aortic
stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area
with the client leaning forward.

ATI FUNDAMENTALS EXAM
VRESION 5
1. CHAPTER 1: HEALTH CARE DELIVERY SYSTEMS
A. Components of Health care systems
a.

Participants
1. Consumers- clients
2. Providers
a. Licensed providers: registered nurses, license practical (or vocational) nurses
(LPN), advanced practice nurses (APN), medical doctors, pharmacists, dentists,
dietitians, physical/respiratory/occupational therapists, etc
b. Unlicensed providers: assistive personal

b.

Settings
1. Hospitals, homes, skilled nursing, assisted living, schools, etc

c.

Regulatory Agencies
1. US department of Health and Human Services
2. US Food and Drug Administration (FDA)
3. State and local public health agencies
4. State licensing boards
a. Determines laws/regulations that govern nursing in their state
b.

ensure health care providers and agencies comply with state regulations

c. Issue/revoke nursing license
i.

Nurses need a license in every state they practice in

5. Joint Commission (JCAHO)
a. Set quality standards for accreditation of health care facilities
6. Professional Standards Review Organizations- monitor health care services provided
d.

Healthcare financing Mechanisms
1. Public federally funded programs
a. Affordable Care Act (Obamacare)
i.

Increases access to healthcare for all individuals

ii.

Decreasing healthcare costs

iii.

Providing opportunities for uninsured to become insured at an
affordable cost

b. States Children’s Health Insurance
i.

Covers uninsured children up to 19 years old at a low cost to p arents

Don’t stop until you are proud
c.
MEDICARE

MEDICAID

Eligibility: >65 years old OR on
disability for more than 2 years OR
have ALS OR on dialysis

Eligibility: low socioeconomic status, no
insurance

Part A: inpatient hospital, limited
skilled
nursing care, home
health care

Individual states determine eligibility
requirements

Federally and state funded

(hospital insurance)
Part B: outpatient care, diagnostic
services, OT/PT (medical insurance)
Part C: combination of parts A and
B, optional private insurance
(Medicare advantage plan)
Part D: prescription drugs
(medications)

e.

Levels of Health Care
Preventative

Focuses on educating and equipping clients to reduce or control
risk factors for disease

Primary

Emphasizes health promotion and includes prenatal, well-baby
care, family planning, nutrition counseling, disease control

Secondary

Diagnosis and treatment of acute illness and injury

Tertiary

Provision of specialized and highly technical care

Restorative

Intermediate follow-up care for restoring health and promoting
self-care

Continuing

Addresses long-term or chronic health care needs over a period
of time

2. CHAPTER 2: THE INTERPROFESSIONAL TEAM
A. Interprofessional Personnel (non-nursing)
Spiritual Support Staff

Provides spiritual care (pastors, rabbis, priests)

Registered Dietitian

Assess/plans for/educates regarding nutrition needs

Laboratory technician

Obtains specimens of body fluids, and performs diagnostic tests

Occupational therapist

Focuses on patient’s independence and regain activities of daily
living (ADL) skills

Pharmacist

Provides and monitors meds

Physical Therapist

Focuses on increasing musculoskeletal function (especially lower
extremities), to maintain mobility

Provider

Assess/diagnose/treat diseases or injury, includes doctors, APNs,
physician’s assistant

Radiologic
technologist

Positions client and performs x rays and other imaging
procedures for providers to review for diagnosis of disorders of
various body parts

Evaluates respiratory status and provides respiratory treatments
Stay Positive,
work hard, make it happen
including oxygen including oxygen therapy, chest physiotherapy,

Respiratory therapist

inhalation therapy, and mechanical ventilation
Social worker

Works with clients and families by coordinating inpatient and
community resources to meet psychosocial and environmental
needs that are necessary for recovery and discharge

Speech-language
pathologist

Evaluates and makes recommendations regarding the impact of
disorders or injuries on speech, languages, and swallowing
Ex: patient with dysphagia→ call speech pathologist for consult

3. CHAPTER 3: ETHICAL RESPONSIBILITIES
A. Ethical Decision Making In Nursing
a.

Basic principles of ethics
1. Advocacy- support of client’s health, wellness, safety, privacy, and personal rights

2. Responsibility- willingness to respect obligations and follow through on promises
3. Accountability- ability to answer for one’s own actions
4. Confidentiality- protection of privacy without diminishing access to high-quality care
b.

c.

Ethical Principles for client care
Autonomy

The right to make one’s own personal decisions, even when those
decisions might not be in that person’s best interest (ex: Jehovah’s
witness- blood transfusion)

Beneficence

Action that promotes good for others, without any self interest

Fidelity

Fulfillment of promises

Justice

Fairness in care delivery and use of resources

Nonmaleficence

A commitment to do no harm

Veracity

Commitment to tell the truth

Ethical Dilemma
1. Problems that involve more than one choice and stem from differences in values and
beliefs of the decision maker
a. A problem is an ethical dilemma when:
i.

There is not enough scientific data to solve it

ii.

It conflicts between 2 moral imperatives

iii.

Answer will have a profound effect on the situation and the client

2. When making an ethical decision:
a. Identify if the issue is an ethical dilemma, gather as much relevant info as
possible, reflect on own values, list and analyze all possible options, select
correct option, apply it to situation

Don’t stress. Do your best. Forget the
rest.
4. LEGAL RESPONSIBILITIES
A. Sources of Law
a.

Federal regulations

1. Health Insurance Portability and Accountability Act (HIPPA)
2. Americans with Disabilities Act (ADA)
3. Mental Health Parity Act (MHPA)
4. Patient Self-Determination Act (PSDA)
b.

Criminal and civil laws
1. Criminal law- relates to the relationship between an individual and the government
2. Civil law- protect individual rights (ex: tort law)

c.

State laws

d.

Licensure

B. Types of Torts
a.

Unintentional torts
1. Negligence
a. nurse fails to implements safety measured for a client at risk for falls (ex: bed
alarm)
b. 5 elements necessary to prove negligence
i.

Duty to provide care as defined by a standard

ii.

Breach of duty by failure to meet standard

iii.

Foreseeability of harm

iv.

Breach of duty has potential to cause harm

v.

Harm occurs

2. malpractice
a. nurse admins a large dose of meds due to a calculation error and client gets hurt
b.

Intentional torts
1. Assault- threat
2. Battery- acting on the threat
3. False imprisonment
a. A person is confined or restrained against his will; inappropriate use of
restraints and sedatives

C. Informed consent
a.

Legal process by which a client or the client legally appointed designee has given written
permission for a procedure or treatment

b.

Provide should explain (needs to be in clients primary language- interpreter may be needed):
1. Reason the patient needs procedure or treatment
2. How the procedure/treatment will benefit the client
3. The risks involved if the client receives the procedure/treatment

4. Other options to treat the problem
c.

Nurses role:
1. Witness patient’s informed consent signature
2. Notify provider if they have more questions

d.

Individuals may grant consent for another person if they are:
1. Parent of a minor
2. legal guardian
3. court specified representative
4.

e.

individual has durable power of attorney authority for health care

Refusal of treatment
1. Notify provider, patient signs a document indicating understanding of risks

D. Advanced Directives
a.

Living will- legal document that expresses client’s wishes regarding medical treatment in the
event the client becomes incapacitated and is facing end of life issues

b.

Durable power of attorney for health care- document in which clients designates health care
proxy to make health care decisions for them if they are unable to do so

c.

Providers orders- unless there is DNR or AND in the clients medical record, the nurse will
initiate CPR

E. Mandatory reporting
a.

Abuse- nurses must report any suspicion of abuse (child, elderly, or domestic abuse)

b.

Communicable disease

c.

Impaired coworker (drinking, drugs)
1. Do not talk directly to them
2. Do not gather more information
3. Report the suspicion

5. INFORMATION TECHNOLOGY
A. Documentation
a.

Elements of documentation
1. Subjective data- direct quotes or summarize information as the client’s statement
2. Objective data- what the nurse sees, hears, feels, and smells; NO OPINIONS

b.

Legal guidelines
1. Begin with date and time; write legibly, do not leave blank spaces; do not use
correction fluid, erase, scratch out or blacken out errors, sign all documents with
name and title

B. Reporting formats
a.

Change of shift report

b.

Telephone reports
1. Try to have another RN there to listen in on phone call
2. Read back order to the provider
3. Provider signs order off within 24 hours

c.

Transfer (hand off) reports

d.

Incident reports
1. Document facts without judgement or opinion
2. Do not refer to an incident report in a client’s medical record

C. Information security
a.

HIPPA (health insurance portability and accountability act of 1996
1. Only health care team members directly responsible for a client’s care may access
that client’s record
2. Clients have a right to read and obtain a copy of their medical record
3. Staff must keep medical records in a secure area to prevent inappropriate access to
the info
4. Electronic records are password-protected
5. Nurses must not disclose unauthorized individuals or family members
6. Nurses must not disclose client’s info to unauthorized individuals or family members
a. Many hospitals use a code system

6. DELEGATION AND SUPERVISION
A. Delegation
a.

RN cannot delegate
1. Patient education
2.

task that needs nursing judgement

3. Nursing assessment
RN to LPN
Monitoring findings
Reinforce patient teaching
Tracheostomy care
Suctioning
Checking NG tube patency

RN to CNA
Activities of Daily Living (ADLs)
-

Bathing, grooming, dressing,
toileting, ambulating, feeding
(without swallowing
precautions), positioning
Routine tasks

Administering enteral feedings

-

Inserting a urinary catheter
Administering medication

b.

Bed making, specimen
collection, intake and output,
vital signs (for stable clients)

5 rights of delegation
1. Right task
a. Right task is repetitive, requires little supervision, and is noninvasive for the
client
2. Right circumstance
a. Determine the health status and complexity of care the client requires
3. Right person
a. Task is within the delegatee’s scope of practice
4. Right direction and communication
a. Provide a method and timeline for reporting
b. Communicate specific tasks and detail expected results. Timeline, and
expectations for follow-up communication
5. Right supervision and evaluation
a. Provide supervision and provide feedback

7. NURSING PROCESS
A. Assessment/Data collection
a.

Subjective data (symptoms)- during nursing history
1. client’s feelings, perceptions, and descriptions of health status

b.

Objective data (signs)- during physical examination
1. Feel, see, hear, and smell objective data through observation or physical assessment
of the client

c.

Sources of data collection
1. Primary sources
a. Subjective: what the client tells the nurse
b. Objective: data the nurse obtains through observation and examination
2. Secondary sources
a. Subjective: what others tell the nurse (family, friends)
b. Objective: data the nurse collects from their sources

B. Analysis/Data collection
a.

Requires nurses to look at the data and
1. Recognize patterns or trends
2. Compare the data with expected standards or reference ranges

C. Planning
a.

Prioritize outcomes of care they can readily measure and evaluate

D. Implementation
a.

Nurses base the care they provide on assessment data, analyses and then

E. Evaluation
a.

Nurses evaluate the client’s responses to nursing interventions and form a clinical judgement
about the extent to which clients have met the goals and outcomes

8. CRITICAL THINKING
A. Don’t know specifics and know how to use critical thinking skills

9. ADMISSIONS, TRANSFERS, AND DISCHARGE
A. Admission process
a.

Document client’s advance directive status (DNR, full code, etc), Base line data (vital signs,
height, weight, allergies), Health history, swallowing problems (get evaluation from speech
pathologist), spiritual health/quality of life concerns, safety assessments (risk for falls)

b.

Discharge planning starts at admission

c.

Inventory personal items
1. Assistive items: glasses, hearing aids, dentures
2. Medications
3. Discourage keeping valuables at the bedside

B. Transfer
a.

Best thing to use:
1. Situation
2. Background
3. Assessment
4. Recommendation

C. Discharge Education
a.

Review symptoms of potential complications and when to contact provider

b.

Provide names and numbers of community resources

c.

Step by step instructions for continuing treatments (dressing changes, etc)

d.

Dietary restrictions and guidelines

e.

Directions how to take medications

f.

Follow up appointments

10.

MEDICAL AND SURGICAL ASEPSIS
A. Hand Hygiene
a.

Hand wash with antimicrobial or alcohol-based products
1. Antimicrobial: wash for 15 seconds, dry hands with clean paper towel before turning
off faucet
a. Use antimicrobial soap over alcohol based when:
i.

Hands are visibly soiled

ii.

Before eating a meal

iii.

After using the bathroom

iv.

After contact with any bodily fluids

2. Alcohol based: use 3-5 mL, continue to rub until both hands are completely dry
B. Physical environment
a.

Cover mouth and nose when coughing or sneezing, using and disposing of facial tissues
1. Ensure 3 spatial separation of 3 ft from a cough

b.

Keep nails short, clean, and no artificial nails; remove jewelry from hands and wrists

c.

Do not put items on flood, do not shake linens

C. Sterile Field
a.

Do not cough, sneeze, talk over the sterile field

b.

Outer 1 inch wrapping of package is not sterile

c.

Objects below waist/above chest contaminated

d.

Do not reach across/above sterile field, turn back on sterile field
1. To add item drop form 6 inches above the field

e.

11.

Any sterile, nonwaterproofed wrapper that encounters moisture becomes nonsterile

INFECTION CONTROL
A.

Immune Defenses
a.

Nonspecific innate- barriers respond immediately to all antigens

1. Ex: skin, mucus membrane, stomach acid
b.

Specific adaptive immunity – allows the body to make antibodies in response to a foreign
organism (antigen)
1. Involves B ant T lymphocytes; takes more time

c.

Types of immunity
1. Active natural immunity- body produces antibodies in response to exposure to a live
pathogen
2. Active artificial immunity- body produces antibodies in response to a vaccine
3. Passive natural immunity- antibodies passed down form a mom to a baby through
breastmilk or the placenta
4. Passive artificial immunity- patient’s immunoglobins administered to them after
exposure to pathogen

B. Infection Processes
a.

Chain of infection
1. Causative agent (bacteria, virus, fungus, prion, parasites)
2. Reservoir- where it lives (human, animal, food, organic matter on inanimate
surfaces, water, soil, insects)
3. Portal of exit- where it leaves the host (respiratory tract, gastrointestinal trac, etc)
4. Mode of transmission
a. Contact- direct physical contact (person to person)
b. Droplet- sneezing, coughing, and talking
c. Airborne- sneezing and coughing
5. Portal of entry- how it enters the host (may be the same as the portal of exit)
6. Susceptible host- compromised defense mechanisms (immunocompromised, breaks
in skin) leave the host more susceptible to infections

b.

Stages of infection
1. Incubation- pathogen enters the body to first symptom
2. Prodromal stage- onset of general symptoms to more distinct symptoms
3. Illness stage- specific symptoms to infection occur
4. Convalescence- acute symptoms disappear to total recovery

c.

Virulence- ability of pathogen to produce disease

C. Assessment/Data collection
a.

Risk factors:
1. Inadequate hand hygiene, compromised health/defense, chronic or acute disease,
poor personal hygiene, crowded environment, use of IV drugs, unprotected sex, poor
sanitation

b.

Inflammation
1. Body’s local response to injury or infection
2. First stage: redness, edema, pain
3. Second stage: fluid containing dead tissue cells and WBCs accumulates and exudate
appears at the site
a. Types of exudate
i.

Serious (clear), sanguineous (blood), serosanguineous (pinkish tint),
Purulent (leukocytes and bacteria)

4. Third stage: scar tissue
D. Laboratory tests
a.

Leukocytosis- WBC level greater than 10,000/uL indicates infection
1. Normal range: 5,000-10,000/uL
2. Left shift: increase in neutrophils

b.

Elevated erythrocyte sedimentation rate (ESR)- over 20 mm/hr indicates infection

c.

Presence of micro-organisms on culture of the specific fluid/area

d.

Diagnostic procedures
1. Gallium scan, radioactive gallium citrate
2. X rays, CT scan, MRI

E. Isolation Guidelines
a.

Standard precautions- for everyone
1. Hand hygiene- use alcohol based waterless product when hands are not visibly
soiled
2. Masks, eye protection, face shields when splashing or spraying of bodily fluids may
occur
3. Clean gloves

b.

Airborne precautions
1. Used for measles, varicella, pulmonary, or laryngeal tuberculosis
2. Private room
3. N95 masks for visitors and caregivers
4. Negative air flow in the room

c.

Droplet Precautions
1. Used for pneumonia, influenza, rubella, mumps, sepsis
2. Private room or room with someone with the same thing
3. Masks for providers and visitors

d.

Contact Precautions
1. Used for respiratory syncytial virus (RSV), shigella, wound infections, scabies

2. Private room or room with other patient that has the same infection
3. Gloves and gowns worn by caregivers
F. Herpes Zoster (shingles)
a.

Chickenpox→ shingles

b.

Risk factors
1. Concurrent illness, stress, compromise immune system, fatigue, poor nutritional
status

c.

Symptoms: paresthesia, unilateral rash, low grade fever
1. Rash is erythematous, vesicular, pustular, or crusting

d.

Nursing care
1. Isolate the client until the vesicles have crusted
2. Avoid exposing to infants, pregnant women, and those who not had the chicken pox

e.

Medications:
1.

analgesics- enhance client comfort

2. Antiviral agents- acyclovir
f.

Complications
1. Postherpetic neuralgia- pain more than 1 month after shingles is gone

g.

12.

Prevention: Zoster vaccine and chicken pox vaccine

CLIENT SAFETY
A. Preventing falls
a.

Patient with orthostatic hypotension should avoid getting up too quickly
1. Sit on side of bed for few seconds, stand up for a few seconds, then walk

b.

Provide regular toileting

c.

Place clients at risk for falls close to nurses’ station

d.

Provide hourly rounding

e.

Keep bed in low position and lock breaks

f.

Avoid using all side rails

g.

Provide nonskid footwear

h.

Use gait belts

B. Seizures
a.

Sudden surge of electrical activity in the brain

b.

Do not restrain

c.

Lower them to the floor→ put them on their side→ don’t put anything in their mouth

C.

Fire Safety
Fire Extinguishers
P- pull the pin
A-aim at base of fire
S- squeeze the handle
S- sweep the extinguisher side to
side
Fire Response
R-rescue by moving people to a
safer location
A-alarm- activate facility’s alarm
system
C-contain- close doors/windows,
turn off sources of oxygen
E- extinguish the fire

13.

HOME SAFETY
A. Infants and Toddlers
a.

Do not feed the infant ad hard foods that could be choking hazard

b.

Always place infants on their back to rest

c.

Keep plastic bags to reach

d.

Make sure crib slats are no more than 2 3/8 inches apart

e.

Do not place anything in the crib with the infant

f.

Place toddlers in rear facing car seat in the back seat until 2 years old

g.

Use car seat with 5-point harness for infants and children

h.

Place pots on back burner and turn handle away from front of stove

B. Preschool age children
a.

Place locked fences around pools and provide supervision around pools or water

b.

Use booster seats for children who are less than 4 feet 9 in tall and weigh less than 40 lbs

c.

If passenger seat has an air bag, place children under 12 years in the back seat

d.

Use of protective equipment in sports

e.

Keep firearms unloaded, locked up, and out of reach
1. Store bullets in different location

f.

Reduce setting on water heater to no higher than 120 degrees F

C. Adolescents
a.

Educate on the hazards of smoking, alcohol, legal, and illegal drugs, and unprotected sex

b.

Educate on the hazards of driving while distracted

c.

Be alert ot signs of depression, anxiety, or other behavioral changes

D. Older adults
a.

Remove items that could cause the client to trip, such as throw rugs and loose carpets

b.

Place electrical cords and extension cords against a wall behind furniture

c.

Place grab bars near the toilet and in the tub or shower, and install a stool riser

d.

Use nonskid mat in the tub or shower

e.

Place shower chair in the shower

E. Fire Safety
a.

use and store oxygen equipment according to the manufacturer’s recommendation

b.

place a no smoking sign near front of the door

c.

ensure that electrical equipment is in a good repair and well grounded

d.

replace bedding that can generate static electricity (wool, nylon, synthetics) with items made
from cotton.

e.

Keep flammable materials such as heating oil and nail polish remover away from the client
when oxygen is in use

F. Carbon Monoxide
a.

Very dangerous gas because it binds with hemoglobin and reduces the oxygen supplied to
the tissues in the body

b.

Carbon monoxide cannot be seen, smelled, or tasted

c.

Symptoms: nausea, vomiting, headache, weakness, unconsciousness

d.

Gas burning furnaces, water heaters, and appliances should be inspected annually

e.

Carbon monoxide detectors should be installed and inspected regularly

G. Food Poisoning
a.

Young, old, immunocompromised, and pregnant women are at risk complications

b.

Perform hand hygiene

c.

Ensure meet and fish are cooked at correct temperature

d.

Handling raw and fresh food separately to avoid cross contamination, refrigerated perishable
items

H. ABCDE principle
a.

Airway/cervical spine- need patent airway, stabilize cervical spine

b.

Breathing

1. Exception: COPD patients- O2 saturation is low 90s—expected
a. NOT PRIORITY
c.

Circulation- assess BP, HR, capillary refill

d.

Disability- determine level of consciousness

e.

Exposure

I.

First Aid
a.

Bleeding
1. Direct pressure to wound site
2. Do not remove impaling objects- instead stabilize them

b.

Fractures
1. Apply a splint
2. Reassess neurovascular status below the injury

c.

Sprains
1. RICE
a. Rest, ice, compression, elevate

d.

Frostbite
1. Warm the affected area to 37-42 degrees C (98.6-108 F) water bath
2. Admin tetanus vaccine

e.

Burns
1. Remove burning agent
2. Elevate clients extremity
3. Admin fluids and tetanus toxoid

14.

ERGONOMIC PRINCIPLES
A. Body Mechanics
a.

Spread feet apart to lower center of gravity and broaden base of support
1. Results in greater balance

b.

Use the major muscle groups to prevent back strain

c.

Distribute weight between the large muscles of arms and legs

d.

Hold object as close as possible

e.

Have a staff member help with positioning clients

f.

Use smooth movements

g.

Gurnee→ bed
1. Bed should be slightly lower

2. Patient’s arms crossed, chin tilted in
3. Put board against feet to prevent foot drop
B. Client positions
a.

Semi-Fowlers- head of the bed elevated 15-45 degrees
1. Prevents regurgitation and aspiration
2. Promotes lung expansion and ventilation

b.

Fowlers- head of bed elevated 45-60 degrees
1. Useful during nasogastric tube insertion and suctioning
2. Promotes lung expansion and ventilation

c.

High Fowlers- head of bed elevated 60-90 degrees
1. Promotes lung expansion and ventilation
2. Relieves severe dyspnea
3. Prevents aspiration during meals

d.

Supine- client lies on back

e.

Prone- client lies on abdomen
1. Helps prevent hip flexion contractures after a lower extremity amputation

f.

Sims- client lays on left side and both legs in flexion
1. comfortable sleeping position for many clients
2. used for enema or rectal exams

g.

Orthopneic- sits at the side of bed with arms on bedside table
1. Promotes lung expansion and ventilation
2. Beneficial for COPD patients

h.

Trendelenburg- head of bed lower than the foot of the bed

i.

Reverse Trendelenburg- foot of the bed lower than the head of the bed
1. Promotes gastric emptying for GERD

j.

Modified Trendelenburg- flat with legs about the level of the heart
1. Prevent and treat hypovolemia or hypovolemic shock

15.

SECURITY AND DISASTER PLANS
A. Triage
a.

Class 1: Emergent category (red tag)
1. Highest priority- life threatening injuries

b.

Class 2: Urgent Category (Yellow tag)
1. Second highest priority- major injuries (ex: bone fracture)

c.

Class 3: Nonurgent Category (Green tag)
1. Minor injuries (ex: sprain, cut)

d.

Class 4: Expectant category (black tag)
1. Not expected to live and allowed to die naturally (ex: chest is crushed)

B. Tornado
a.

Close drapes, lower bed to lowest position and move away from windows, place blanket over
clients who are confined to bed

C. Chemical Incident
a.

Undress the client

b.

Irrigate skin with running water
1. Except dry chemicals- then brush the agent off clothes and skin

D. Hazardous material
a.

Identify hazardous material

b.

Use water

E. Bomb threat
a.

Extend conversation for as long as possible

b.

Listen for distinguishing background noises to help police

16.

HEALTH PROMOTION AND DISEASE PREVENTION
A. Tests
a.

Colorectal screening
1. Every year beginning at age 50 for fecal occult blood testing
2. sigmoidoscopy every 5 years
3.

b.

colonoscopy ever 10 years

Pap Smear (Papanicolaou test)
1. Every 3 years starting at age 21

c.

Mammogram
1. Every year starting at age 40

d.

Testicular Examination
1. Starting at age 20

e.

Prostate exam
1. Starting at age 50

B. Prevention
a.

Primary Prevention

1. Helps prevent initial occurrence of disease
a. Ex: immunization programs, client teaching
b.

Secondary Prevention
1. Early detection of illness, limiting severity
a. Ex: screening

c.

Tertiary Prevention
1. Maximizing recovery after illness
a. Ex: support groups, rehab

17.

CLIENT EDUCATION
A. Domains of Learning
a.

Cognitive Learning
1. Thinking, knowledge, comprehension

b.

Affective learning
1. Feelings, beliefs, values

c.

Psychomotor learning
1.

mental and physical activity

B. Assessment
a.

Assess learning needs

b.

identifying learning style (auditory, visual, kinesthetic)

c.

identify available resources

C. Planning
a.

Identify mutually agreeable outcomes

D. Implementation
a.

No medical jargon

b.

6th grade level or lower

E. Evaluation
a.

Observe demonstrations

18.

SKIP

19.

SKIP

20.

SKIP

21.

SKIP

22.

SKIP

23.

SKIP

24.

SKIP

25.

SKIP

26.

DATA COLLECTION AND GENERAL SURVEY
A. Therapeutic communication
a.

Don’t do one long assessment try to break it up

b.

Allow more time for responses for older adults

c.

Make sure client is comfortable

d.

Reduce environmental noises
1. Ex: tv, visitors

B. Assessments
a.

Normal order: Inspection, palpation, percussion, auscultation
1. *Exception is abdomen: inspection, auscultation, percussion, palpation

b.

Inspection
1. Size, shape, color, symmetry, position

c.

Palpation
1. Size, consistency, texture, temperature, location, tenderness
a. Palpate tender areas last
2. Dorsal surface: most sensitive to temperature
3. Palmar surface: sensitive to vibration

d.

Percussion
1. Size, location, tenderness, density

e.

Auscultation
1. Amplitude/intensity, pitch/frequency, duration, quality
2. Used for heart sounds, bowel sounds, lung sounds

C. General Survey
a.

Physical Appearance
1. Age, gender race, level of consciousness, signs of distress, signs of substance abuse

b.

Body structure
1. Height and weight, Nutritional status, posture, abnormalities (amputation, skin
lesions)

c.

Mobility
1. Gait, movements, range of motion

d.

Behavior
1. Mood, speech

e.

Vital signs
1. Temperature, pulse, respiration, blood pressure, oxygen saturation

27.

VITAL SIGNS
A. Temperature
a.

Ways to take temp
1. Oral: 36-38 C or 96.8 to 100.4 F
2. Rectal: 0.5 C or 0.9 F higher than oral
a. 36.5-38.5 or 97.7- 101.1 F
b. Patient in sim’s position, lubricate thermometer, place in about 1 -1.5 in for adult
3. Axillary: 0.5 C or 0.9 F lower than oral
a. 35.5-37.5 C or 95.9-99.3 F
4. Temporal: 0.5 C or 0.9 F higher than oral
a. 36.5-38.5 or 97.7- 101.1 F
b. Move gently from forehead over the temporal artery and then to skin behind
earlobe
5. Tympanic
a. Adult: pull ear up and back
b. Child younger than 3: pull down and back

b.

Considerations
1. Newborns: 36.5-37.5 C or 97.7 and 99.5 F
2. Older adults: average temp: 36 C (96.8 F)

3. Hormonal Changes- temp rises with ovulation, menses, and menopause
4. Exercise, activity, and dehydration: development of hyperthermia
5. Recent food, drink, or smoking: wait 20-30 min to take temp
c.

Complications
1. Hyperthermia- greater than 39 C
a. Obtain specimens
b. Admin antibiotics
c. Provide fluids
d. Provide antipyretics
e. Prevent shivering- offer blankets
2. Hypothermia- less than 35 C
a. Provide warm environmental temperature
i.

Warming blanket, warmed IV fluids

b. Keep head covered
B. Pulse
a.

Rate
1. Normal adult: 60-100 bpm
2. Normal infant: 120-160 bpm

b.

Rhythm- regularity

c.

Strength (amplitude)
1. 0= absent
2. 1+= diminished
3. 2+= normal, expected
4. 3+= increased, strong
5. 4+= bounding

d.

Locate radial pulse
1. If pulse is regular: count rate for 30 sec and multiply by 2
2. If pulse is irregular: count for full min and compare to apical pulse

e.

Locate apical pulse
1. Fifth intercostal space, left midclavicular line

f.

Tachycardia- greater than 100 bpm

g.

Bradycardia- less than 60 bpm

C. Respirations
a.

Physiological responses
1. Chemoreceptors in carotid arteries and the aorta monitor CO2 levels of the blood

a. Rising CO2 levels trigger respiratory centers of the brain to increase respiratory
rate
b.

Process of respiration
1. Ventilation- exchange of CO2 between environment and lungs
2. Diffusion- exchange of O2 and CO2 between alveoli and RBC
3. Perfusion- flow of RBC to and from pulmonary capillaries (tissues)

c.

Assessment
1. Rate
a. Normal rate:
i.

adults= 12-20/min

ii.

infants= 35-40/min

iii.

school age kids= 20-30

2. Depth- deep or shallow
3. Rhythm
d.

Pulse Oximetry
1. Normal 95-100%
2. COPD normal: 91-100%

e.

Considerations
1. Increased respiratory rate
a. Anxiety, smoking, illnesses, anemia, high altitude
2. Decreased respiratory rate
a. Opioids, sedative meds, increasing old age

D. Blood Pressure
a.

hypertension
Systolic BP

Diastolic BP

normal

100

b.

Hypotension- Systolic is less than 90 mmHg

c.

Pulse pressure=systolic- diastolic
1. Increase pulse pressure can indicate cardiovascular disease

d.

Orthostatic hypertension- blood pressure that decreases when a client changes position from
lying to sitting/standing

1. Take clients BP and HR while lying in supine
2. Then have them sit, wait 1-3 min, take BP again
3. The client has orthostatic hypotension if the Systolic decreases more than 20 mmHg
and/or Diastolic decreases more than 10 mmHg with a 10-20% increase in HR
e.

Auscultatory method
1. Width of a cuff should be 40% of arm circumference
2. The inside of the cuff should surround 80% of the arm circumference
a. Too large of cuff: falsely low readings
b. Too small of cuff: falsely high readings

f.

Nursing implications
1. Don’t measure BP:
a. in an arm with IV infusion in progress
b. side where the client has had a mastectomy

28.

HEAD AND NECK
A. Cranial Nerves
Number

Name

Function

1

Olfactory

Sensory: Smell

2

Optic

Sensory: vision

How to test
Snellen chart

3

Oculomotor

Motor: pupil constriction, eye
movements

4

Trochlear

Motor: eye movements (up/down)

5

Trigeminal

Sensory + motor: face, chewing

6

Abducens

Motor: eye movement laterally

7

Facial

Sensory + Motor: Facial muscles,
taste (ant), parotid/lacrimal glands

8

Vestibulocochlear

Sensory: hearing and balance

9

Glossopharyngeal

Sensory + Motor: parotid gland,
gag reflex, taste (posterior)

10

Vagus

Sensory + Motor: voice,
pharyngeal/laryngeal muscles,
thoracic/abdominal sense

11

Accessory

Motor: sternocleidomastoid and
trapezius muscle

12

Hypoglossal

Motor: tongue

Follow the finger,
penlight
Close eyes- touch
face- pt explains
what they feel
Smile/Frown

Gag reflex

Shrug, turning head

B. Assess
a.

Thyroid glands
1. Take sip of water and feeling the thyroid gland as it moves up the trachea
a. Sizes, masses, and smoothness

b.

Eyes
1. 20/30 vision means a client can read a line from 20 ft away that a person who has
unimpaired vision can read from 30 ft away
2. Tests:
a. Snellen chart- used to screen myopia (nearsightedness)
b. Rosenbaum eye chart- used to screen for presbyopia (farsightedness)
c. Ishihara Test- color vision
d. Corneal light reflex
e. Uncover/cover test- Strabismus (misalignment)
f.

6 cardinal positions of gaze- wide H pattern

3. PERRLA
a. P- pupils clear
b. E- equal and between 3-7 mm
c. R- round

d. RL- reactive to light
e. A- accommodation of pupils
4. 2 arteries for every 3 veins
c.

Ears
1. Check alignment
2. Pull auricle
a. Adults: Up and back
b. Young children: down and back
3. Insert otoscope 1-1.5 cm bur do not touch ear canal
a. Expect to see: pearly gray and intact tympanic membranes
i.

Light reflex is visible

ii.

Normal amount of cerumen

4. Tests:
a. Whisper test
b. Rinne test
c. Weber test
i.

Negative is normal

C. Changes with aging
a.

Eyes: decreased visual acuity, glare/darkness, yellowing of the lens

b.

Ears: hearing loss, thickening of the tympanic membrane

c.

Mouth: decreased sense of taste, tooth loss, pale gums, gum disease, decreased salivation

d.

Voice: rise in pitch

e.

Nose: decreased sense of smell

29.

THORAX, HEART, AND ABDOMEN
A. Breasts
a.

Monthly self-exams after menstruation

B. Lungs
a.

Percussion
1. Dullness: indicates pneumonia
2. Hyperresonance: pneumothorax, emphysema

b.

Auscultation
1. Expected: bronchial, bronchovesicular, vesicular
2. Unexpected: crackles (fluid), wheezes, rhonchi, pleural friction rub

C. Heart
a.

S1 sound: mitral and tricuspid close

b.

S2 sound; aortic and pulmonic close

c.

Thrills: vibration→ murmurs

d.

Bruits: swishing sound→ obstructed blood flow

e.

Auscultatory sites:
1. Aortic, Pulmonic, Erbs’ point, Tricuspid, Apical

D. Abdomen
a.

Bowel sounds
1. Expected: high pitched clicks and gurgles
2. Unexpected: loud, growling sounds

b.

Percussion
1. Expect to hear tympany
2. Expect dullness over liver
a. Liver size: 6-12 cm

c.

Palpate tender areas last

E. Expected Changes with Aging
a.

Breasts
1. Nipples can invert

b.

Lungs
1. AP diameter similar to transverse diameter (barrel chest)
2. Alveoli dwindle
3. Kyphosis becomes presen

c.

Cardiovascular
1. Systolic hypertension
2. Blood vessels thicken
3. Increase pulse pressure

d.

Abdomen
1. More adipose tissue
2. Decrease saliva, gastric secretions, pancreatic enzymes
3. Decrease motility

30.

INTEGUMENTARY AND PERIPHERAL VASCULAR SYSTEMS
A. Skin

a.

Pallor- loss of color
1. Indicates: anemia, shock, or lack of blood flow

b.

Cyanosis- turning blue
1. Indicates: hypoxia

c.

Jaundice- yellow tint
1. Indicates: liver dysfunction, RBC destruction

d.

Erythema – redness
1. Indicates: inflammation, sun exposure, rash

e.

Brown pigmentation indicates venous insufficiency

f.

Skin turgor can indicate dehydration or aging

B. Nails
a.

Capillary refill- normal return of color within 3 seconds

C. Edema
a.

Evaluate pitting by compressing the skin for at least 5 seconds over a bony prominence
1. + trace, 2 mm, rapid skin response
2. + mild, 4 mm, 10-15 seconds skin response
3. + moderate, 6 mm, prolonged, skin response
4. + severe, 8 mm, prolonged skin response

D. Lesions
Primary Lesions
Macule

Flat, skin color change, < 1 cm
Ex: freckle, petechiae

Papule

Solid elevation of skin, < 1 cm
Ex: mole

Nodule

Deep, firm, 1-2 cm
Ex: wart

Vesicle

Serous fluid- filled, 2 cm
Ex: epithelioma, neoplasm

Wheal

Palpable, irregular borders, edematous
Ex: insect bite

Primary Lesions
Erosion

Loss of epidermis, moist, no bleeding
Ex: popped blister, ruptured vesicle

Crust

Dried blood, serum, pus (elevated)
Ex: scab

E. Expected changes with aging
a.

Dry, flaky skin

b.

Loss of elasticity

c.

Thinning of hair

d.

Less moisture and sweat

e.

Uneven pigmentation

f.

Slow wound healing

g.

Little subcutaneous tissue over bony prominences

31.

Scale

Flakes of skin
Ex: dandruff, psoriasis, eczema

Fissure

Linear crack
Ex: tinea pedis

Ulcer

Loss of epidermis and dermis, scarring
Ex: pressure ulcer

MUSCULOSKELETAL AND NEUROSENSORY SYSTEMS
A. Expected range of motion of joint movement
Flexion

Decreases the angle between 2 adjacent bones

Extension

Increases the angle between 2 adjacent bones

Supination

Ventral (front) surface faces up

Pronation

Ventral (front) surfaces faces down

Abduction

Moving extremity away from midline

Adduction

Moving extremity towards the midline

Dorsiflexion

Foot and toes upward

Plantar flexion

Foot and toes downward

Eversion

Turning body part away from midline

Inversion

Turning body part toward the midline

External Rotation

Rotating a joint outward

Internal Rotation

Rotating a joint inward

B. Curvatures of the Spine
a.

Expected: concave cervical spine, convex thoracic spine, concave lumbar spine, convex sacral
spine

b.

Unexpected:
1. Kyphosis- hunchback (in older adults)
2. Lordosis- exaggerated curvature of lumbar spine (toddler years and pregnancy)
3. Scoliosis- S shape

C. Mental Status
a.

Alert

1. Client is responsive and can open eyes and respond spontaneously and appropriately
b.

Lethargic
1. Client can open eyes but falls asleep readily

c.

Obtunded
1. Responds to light shaking and can be confused and slow to respond

d.

Stuporous
1. Requires painful stimuli (rubbing the sternum)

e.

Comatose- no response
1. Decorticate rigidity- flexion and internal rotation of upper extremity joints and
legs(arms-chin)
2. Decerebrate rigidity- neck and elbow extension, with wrists and fingers flexed (arms
extended)
a. Worse than decorticate

D. Glasgow Coma Scale- baseline of level of consciousness
a.

Looks at eye, verbal, and motor
1. Highest value possible is 15
2. <8 indicates severe head injury
3. 8-12 indicates mild head injury

E. Motor Function
a.

Assessing balance
1. Romberg’s Test
a. Ask the client to stand with feet together, his arms at his sides and his eyes
closed
i.

Expected findings: client stands with minimal swaying for at least 5
seconds

2. Heel-to-toe walk: heel to tow and walk in straight line
F. Sensory Function
a.

Stereognosis- place familiar object in the client’s hand and ask them to identify it

b.

Graphesthesia- trace number on clients hand

G. Grade DTR Response
a.

4+ very brisk with clonus

b.

3+ brisker than average

c.

2+ expected

d.

1+ diminished

e.

0 no response

H. Expected changes with aging
a.

Musculoskeletal system
1. Reduced muscle mass
2. Osteoporosis, loss of bone mass
3. Degenerative alterations in joints
4. Limited range of motion

b.

Neurological system
1. Short term memory decline
2. Diminished, slowed reflex
3. Altered hearing, vision, smell, and deep pain

32.

THERAPEUTIC COMMUNICATION
What to do:

Do not

- Use open ended questions
(“tell me more”)

-ask why
-offer opinion
-false reassurance

-offer personal information
but quickly return focus onto
the patient

-closed ended question(yes/no)
-change subject
-minimize patient’s feelings
- say “I know how you feel”

33.

COPING
A. General Adaptation Syndrome
a.

Alarm Reaction- heightened response to stressors
1. Increased blood pressure and heart rate
2. Cortisol released

b.

Resistance Stage- body functions normalize while responding to the stressor
1. Body returns to homeostasis

c.

Exhaustion Stage- body functions are no longer able to maintain a response to the stressor
1. Can result in fatigue, depression

34.

SELF CONCEPT AND SEXUALITY
A. Impaired body image
a.

Due to amputation, mastectomy, hysterectomy

b.

loss of body function due to arthritis, spinal cord injury, or stroke

35.

CULTURAL AND SPIRITUAL NURSING CARE
A. Spirituality
a.

Christianity
1. may fast during lent

b.

Islam
1. Women must be cared for by female providers
2. May pray 5 times a day
3. Avoid alcohol and pork
4. Fast during Ramadan

c.

Jehovah’s Witness
1. Might night accept blood transfusions

d.

Judaism
1. Some practice a kosher diet
a. No shellfish, pork, or meat with dairy

e.

Mormonism
1. Avoid alcohol, tobacco and caffeine

B. Ethnocentrism
a.

Belief one’s own culture is superior to all other cultures
1. Nurses should avoid this

C. Interpreter
a.

Use facility approved medical interpreter
1. Do not use family/ friends of patient or non-designated employee to interpret

36.

b.

Only ask one question at a time

c.

Direct the questions to the client

d.

Use lay terminology

GRIEF, LOSS, AND PALLIATIVE CARE
A. Types of Loss

a.

Maturational loss
1. Loss that is expected, it is associated with normal life transitions
a. Ex: child leaving home for college

b.

Situational Loss
1. Unanticipated loss caused by an external event
a. Ex: car accident

B. Stages of Grief
a.

Denial- patient has difficulty believing a terminal diagnosis or loss

b.

Anger- client lashes out at other people or things

c.

Bargaining- client negotiates for more time or a cure

d.

Depression- client is overwhelmingly sad

e.

Acceptance- client moves forward

C. Types of grief
a.

Anticipatory grief- grief before having a loss (ex: terminal illness)

b.

Complicated grief- prolonged, severe grief
1. No acceptance of the loss after 6 months

D. Palliative Care vs hospice care
a.

Palliative care- symptom relief and cure

b.

Hospice care- includes palliative care but down not look for cure
1. Patients are not expected to live longer than 6 months]

E. Manifestations of approaching death
a.

Decreased level of consciousness, labored breathing, mottling (cyanosis), slow/weak pulse,
dropping blood pressure, decreased urine output

b.

Hearing is not diminished

F. Preparing the body for viewing
a.

Remove all tubes and personal belongings and excess supplies

b.

Lay the body supine with pillow under the bed

c.

Apply fresh linens, put dentures in, dim the lights

37.

HYGIENE
A. Foot care
a.

Important for diabetic patients
1. May experience decreased sensations

a. Variations in temperature
b. Can’t tell if something is in shoe (Ex: nail in foot)
2. Inspect feet daily, cut nails straight across, check shoes for objects, wear cotton
socks
3. Test water temperature for bath
4. Dry feet thoroughly- especially in between toes
5. Apply moisturizer on feet (not in between toes)
6. Do not use over the counter products- go to podiatrist
7. Do not use heating pad on feet
B. Oral Care for unconscious patient
a.

Have suction apparatus ready- prevent aspiration

b.

Position client on his side with his head turned toward you to allow oral secretions to collect

c.

Denture care:
1. Top denture: pull down and out
2. Bottom denture: pull up and out
3. Store dentures in denture cup

38.

REST AND SLEEP
A. Sleep Cycle

NREM Stage 1

NREM Stage 2

NREM Stage 3

NREM Stage 4

REM

Very light sleep

-Deeper sleep

-deepest sleep

- vivid dreaming

Only a few
minutes long

-10-20 min long

-initial stages
of deep sleep

-15-30 min long

-15-20 min long

-vital signs low

-longer with each
sleep cycle

-difficult to
awaken

- very difficult to
awaken

-average length 20
min

- physiologic rest
and restoration

-varying vital signs

Vital signs and
metabolism
beginning to
decrease

-Vital signs and
metabolism
beginning to
decrease

-sleep walking,
sleep talking

-very difficult to
awaken
-cognitive
restoration

B. Sleep Apnea
a.

More than 5 breathing cessations lasting longer than 10 seconds per hour during sleep

b.

CPAP mask

C. Factors that interfere with sleep

a.

Caffeine consumption, heavy meals before bedtime

b.

Exercise promotes sleep if at least 2 hours before bedtime

39.

NUTRITION AND ORAL HYDRATION
A. Basic Nutrients the body requires
a.

Carbohydrates
1. Provide most of the body’s energy
2. Each gram produces 4 kcal

b.

Fats
1. Provides energy and vitamins
2. No more than 35% of caloric intake should be from fat
3. Each gram produces 9 kcal

c.

Proteins
1. Repairs body tissues
2. Each gram produces 4 kcal
3. Important for wound healing

d.

Vitamins
1. Fat soluble vitamins A, D, E, K
2. Water soluble vitamins C and B complex

B. Age
a.

Newborn
1. Breast milk and formula used during the first full year of life
2. Solid food starting at 4-6 months
a. No cows milk or honey for the first year

b.

Older adults
1. Slower metabolic rate requires fewer calories
2. Thirst sensations diminish
3. Calcium is important for both men and women

C. BMI
a.

Weight (kg) divided by height (m2)

b.

Scale:
1. = obese
D. Diets
a.

Clear liquid- water, tea, coffee, broth, clear juices, gelatin, ginger ale

b.

Full liquid- milk, pudding, fruit, ice cream, juice

c.

Pureed- pureed meats, fruits, scrambled eggs
1. used if jaw is wired shut or after oral surgery

d.

Mechanical soft- diced or ground foods
1. Used if patient does not have teeth

e.

Low residue- low in fiver and easy to digest
1. Used for IBS or other GI disorders

E. Dysphagia
a.

See Speech pathologist

b.

Semi fowlers position

c.

Thickened liquids

d.

Check for food pockets

e.

Tuck chin to chest when swallowing

f.

Monitor patient during meals

g.

Suction equipment ready

h.

Avoid straws

40.

MOBILITY AND IMMOBILITY
A. Respiratory
a.

Nursing interventions
1. Reposition every 1-2 hours
2. Instruct clients to turn, cough, and breathe deeply every 1-2 hours while awake
3. Instruct clients to use an incentive spirometer while awake
4. Instruct clients to consume at least 2000 mL fluid per day, unless intake is restricted

B. Instructions
a.

Cane
1. maintain 2 points of support on the ground at all times
2. Keep the cane on the stronger side of the body
3. Support body weight on both legs move cane forward 6-10 in
4. Move weaker leg forward, then move stronger leg past the cane

b.

Crutches

1. Do not alter crutches after fitting
a. 3 finger widths between axilla and the top of the crutch
2. Support body weight at the hand grips with elbows flexed (20-30 degrees)
3. Stairs- hold rail with one hand and crutches in the other
C. DVT
a.

Symptoms: pain, edema, warmth, and erythema

b.

Nursing actions
1. Notify provider immediately
2. Position client with leg elevated, give anticoagulants

c.

Anti-embolic stockings
1. Remove the stockings every 8 hours to assess redness, warmth, or tenderness

D. Pulmonary Embolism
a.

Symptoms: shortness of breath, chest pain, decreased BP, increase HR

b.

Nursing actions
1. Give anticoagulants
2. Position client in high fowlers
3. Obtain pulse ox and monitor vital signs
4. Admin oxygen and prepare blood gas analysis

41.

PAIN MANAGEMENT
A. Pain Categories
a.

Acute Pain
1. Protective, temporary, and resolves with tissue healing
2. Tachycardia, hypertension, anxiety, diaphoresis

b.

Chronic pain
1. Lasts longer than 6 months
2. Do not usually alter vital signs—but can have depression, fatigue
3. Idiopathic pain- chronic pain without a known cause (ex: depression)

c.

Nociceptive pain
1. Inflammation of tissue
2. Throbbing, aching, localized
3. Responds to opioids and nonopioid medications
4. 3 types:
a. Somatic- bones, joints, muscles, skin, connective tissues

b. Visceral- internal organs
c. Cutaneous- skin or subcutaneous tissue
d.

Neuropathic pain
1. Damaged pain nerves
2. Includes phantom limb pain, diabetic neuropathy
3. Shooting, burning, pins and needles
4. Responds to antidepressants, muscle relaxers

B. Symptom analysis
a.

Location- superficial, radiating

b.

How the pain feels- shooting, burning, pins and needles….

c.

Intensity- scale 0-10

d.

Timing- onset, duration, frequency

e.

Setting- how it affects ADLs

f.

Associated findings- fatigue, depression, nausea

g.

Aggravating/relieving factors-

C. Pain care
a.

Nonopioid analgesics
1. Mild to moderate pain
2. No more than 4 g/day
3. Monitor for salicylism (tinnitus, vertigo)
4. Prevent gastric upset by admin with food
5. Long term use- monitor for bleeding

b.

Opioid analgesics
1. Moderate-severe pain
2. Around the clock administration
3. Sedation, respiratory depression, orthostatic hypotension, urinary retention,
nausea/vomiting, constipation
4. Nolocsone- antidote for opioids

42.

COMPLEMENTARY AND ALTERNATIVE THERAPIES
A. Types of CAM
a.

Acupuncture- needles or pressure along meridians to alter body function or produce
analgesia

b.

Chiropractic medicine- spinal manipulation for healing

c.

Massage therapy- stretching and loosening muscles and connective tissue for relaxation and
circulation

d.

Biofeedback- using tech to increase awareness of various neurological body responses to
minimize extremes

e.

Therapeutic touch – using hands to help bring energy fields into balance

B. Natural products and Herbal Remedies
a.

Garlic, ginger, ginseng increase bleeding

C. Therapies
a.

Guided imagery- encourage healing and relaxation of the body by having the mind focus on
images

b.

Relaxation techniques- promotes relaxation using breathing techniques while thinking
peaceful thoughts or while tensing and relaxing specific muscle groups

43.

BOWEL ELIMINATION
A. Constipation
a.

Help constipation
1. Increase fluid intake
2. Increase fiber intake (25-30 g/day)
3. Decrease laxatives
4. Increase activity

b.

Fecal Occult Blood test
1. Collect stool 3 times from 3 different defecations
2. Blue color indicates the stool is positive for blood

B. Enema
a.

Warm the enema solution

b.

Position the client on the left side with the right leg flexed forward

c.

Lubricate the rectal tube or nozzle

d.

Insert the rectal tube 7.5-10 cm (3-4 in)

e.

Bag level with the client’s hip, open the clamp

f.

Raise the bag 30-45 cm (12-18 in) above the anus

g.

Slow the flow by lowering the container if the client reports cramping

C. Ostomy Care
a.

Remove the pouch

b.

Inspect the stoma- should appear moist and pink, peristomal area should be intact

c.

Use mild soap and water to cleanse the skin and dry it gently and completely
1. NO MOISTURIZING SOAPS

d.

Cut the opening 0.15-0.3 cm (1/18 to 1/8 in) larger

e.

Fold the bottom of the pouch and clamp it

D. Diarrhea
a.

Fluid and electrolyte disturbances: metabolic acidosis
1. Monitor for dehydration
a. Weak/rapid pulse, hypotension, poor skin turgor, elevated body temperature

b.

44.

Skin breakdown around the anal area—zinc oxide

URINARY ELIMINATION
A. Input and Output
a.

Input should be about the same as the output

b.

Output less than 30 mL/hr for more than 2 hours is a cause for concern

B. Timed Urine Specimens
a.

Collect for 24 hours

b.

Discard the first voiding and then collect all other urine
1. Refrigerate, label, and transport specimen

C. Catheter Care
a.

Use soap and water at the insertion site

b.

Cleanse the catheter at least 3 times a day

c.

Check for kinks in the tubing

d.

Make sure collection bag is below the bladder level to avoid reflux

D. Urinary Tract Infections
a.

Risk factors
1. Urethral meatus close to the anus, Frequent sexual intercourse, menopausedecreasing estrogen levels, uncircumcised males, use of indwelling catheters

b.

Nursing considerations
1. Female: cleanse from front to back
2. Male: cleanse beneath foreskin
3. Provide catheter care regularly
4. Drink cranberry juice- treat/prevents UTI

E. Urinary Incontinence
a.

Types

1. Stress- loss of small amounts of urine form increased abdominal pressure while
laughing, sneezing, or lifting
2. Urge- inability to stop urine flow long enough to reach the bathroom
b.

Nursing care
1. Establish a toileting schedule
2. Perform kegel exercises
3. Avoid caffeine and alcohol consumption
4. Vaginal cone therapy

45.

SENSORY PERCEPTION
A. Clients with hearing loss
a.

Sit and face the client

b.

Avoid covering your mouth while speaking

c.

Speak slowly and clearly

d.

Do not shout, try lowering vocal pitch

e.

Ask for a sign language interpreter if necessary

B. Clients with Aphasia
a.

Only one person speaking at a time

b.

Speak clearly and slowly using short sentences and simple words

c.

Allow time for clients to understand

d.

Allow plenty of time for clients to respond

C. Hearing loss
a.

Conductive hearing loss
1. Alteration in middle ear that blocks sounds waves before they reach the inner ear
2. Risk factors: history of middle ear infections, older age
3. Expected findings
a. Rinne test- air conduction of sound less than bone conduction
b. Weber test- lateralizes the affected ear

b.

Sensorineural hearing loss
1. Alteration in the inner ear and auditory nerve
2. Risk factors: prolonged exposure to loud noises, ototoxic medications, older age
3. Expected findings
a. Rinne test- air conduction of sound greater than bone conduction
b. Weber test- lateralizing unaffected ear

D. Hearing aids
a.

Client education
1. Use the lowest setting that allows hearing without feedback
2. When not in use: turn it off and remove battery, avoid corrosion of the hearing aid

46.

PHARMACOKINETICS AND ROUTES OF ADMINISTRATION
A. Absorption
a.

Oral
1. Must pass through the GI tract
2. Absorption varies greatly due to
a. Stability and solubility of the meds
b. Gastrointestinal pH
c. Presence of food in the stomach
d. Forms of meds

B. Distribution
a.

Circulation- inhibit of blood flow or perfusion such as peripheral vascular or cardiac disease

b.

Permeability of the cell membrane

c.

Plasma protein binding- medication to bind to a protein can affect how much of the
medication will leave and travel to target tissues

C. Metabolism
a.

Factors influencing medication metabolism rate
1. Age- older adults require smaller doses of medication
2. First -pass effect
a. Liver inactivates some medications on their pass through the liver
i.

Require non-enteral route

3. Similar metabolic pathways
a. Same pathway metabolize two medications, can alter the metabolism of one or
both
4. Nutritional status
a. Malnourished can be deficient in the factors that are necessary
D. Excretion
a.

Elimination of medications from the body, primarily through the kidneys
1. Other areas: liver, lungs, intestines

E. Therapeutic Index (TI)

a.

Meds with high TI have a wide safety margin

b.

Meds with low TI need to be closely monitored

F. Half Life
a.

The time for the medication in the body to drop by 50%

b.

Short half-life- meds leave the body quickly, 4-8 hours

c.

Long half-life1. meds leave the body more slowly:
a. over more than 24 hours
2. with a greater risk for meds accumulation and toxicity

G. Pharmacodynamics (mechanism of action)
a.

Agonist- medication that can mimic the receptors activity
1. Morphine is an agonist because it activates the receptors that produce analgesia,
sedation, and constipation

b.

Antagonist- medication that can block the usual receptors activity

H. Routes and Administration
a.

Oral
1. Vomiting, decreased GI motility, absence of a gag reflex, difficulty swallowing, and
decreased level of consciousness
2. Have clients sit upright at a 90 degrees angle
3. Do not mix with large amounts of food or beverages
4. Clients Swallow enteric coated or time released meds whole

b.

Sublingual
1. Sublingual: under the tongue
2. Buccal: between the cheek and the gum
3. Clients should not eat or drink while the tablet is in place or until it has completely
dissolved

c.

Transdermal
1. Wash the skin with soap and water, and dry it thoroughly
2. Place the patch on a hairless area and rotate sites

d.

Instillation
1. Rest your dominant hand on the client’s forehead, hold the dropper above the
conjunctival sac
2. If instilling more than one medication in the same eye, wait at least 5 minutes
between them
3. Ears

a. Clients lie on their side
b. Pulling the auricle upward and outward for adults or down and back for children
c. Dropper 1 cm above the ear canal, instill the medication, and then gently apply
pressure with your finger to the tragus
d. 2-3 min after installation of ear drops
e.

Inhalation
1. Metered-dose inhalers (MDI)
a. Shake inhaler
2. Dry powdered inhalers (DPI)- do not shake

f.

Nasogastric and gastrostomy tubes
1. Verify proper tube placement
2. Do not mix meds with enteral feedings
3. Completely dissolve crushed tablets and capsule contents in 15-30 mL water
4. Flush the tubing before and after each med with 15-30 mL water

g.

Intradermal
1. 0.01-0.1 mL in a 26-27 gauge
2. Bevel up, small bleb should appear

h.

Subcutaneous
1. 3/8-5/8 in, 25-27 gauge or 28-31-gauge insulin syringe
a. Inject no more than 1.5 mL of solution
2. 45-90 angle; use a 90 degree and

i.

Intramuscular
1. Common sites: ventrogluteal, deltoid and vastus lateralis (pediatric)
2. 18-27 gauge, 1-1.5 in long
3. Use Z track method

47.

SAFE MEDICATION AND ADMINISTRATION AND ERROR REDUCTION
A. Pregnancy risk categories
a.

A, B, C, D, E, X

B. Types of medication prescriptions
a.

Routine/ standard prescriptions
1. Regular schedule

b.

Single- or one-time prescriptions
1. Administration once at a specific time or as soon as possible

c.

Stat prescriptions
1. One and immediately

d.

Now prescriptions
1. Only admin. Once, but up to 90 min from when the nurse received the prescription

e.

PRN prescriptions
1. Specifies what dosage, what frequency, and under what conditions a nurse may
administer the medication

f.

Standing prescriptions
1. For specific circumstances or for specific units

C. Components of a medication prescription
a.

The clients full name

b.

Date and time

c.

Name of the medication

d.

strength and dosage

e.

route of admin

f.

time and frequency

g.

number of refills

h.

signature of the prescribing provider

D. Rights of safe medication administration
a.

Right client

b.

Right medication

c.

Right dose

d.

Right time

e.

Right route

f.

Right documentation

g.

Right client education

h.

Right to refuse

i.

Right assessment right evaluation

E. Common medication errors
a.

Administration of a medication to which the client is allergic

b.

Omission of a dose or extra dose

F. Error-prone abbreviation list
Do not use
MS, MSO4

Use
Morphine

MgSO4

Magnesium sulfate

Decimal point without a
leading zero (0.5 mg)

Small units (500 mcg) or a
leading zero (0.5 mg)

Trailing zero (1.0 mg,100.0 g)

Without a trailing zero ( 1
mg, 100 g)

U, U, IU

units

q.d, qd, Q.D., QD, q1d, i/d

daily

q.o.d., QOD

Every other day

SC, SQ, sub q

Subcutaneously

G. Implementation
a.

Prepare medications for one client at a time

b.

Doses are usually one to 2 tablets or one single-dose vial

c.

Only give meds that you have prepared

d.

Do not leave medication at the bedside

48.

DOSAGE CALCULATION
A. Standard conversion factors
1 mg = 1000 mcg
1 g = 1000 mg
1 kg = 1000 g
1 oz= 30 mL
1 tsp= 5 mL
1 tbsp = 15 mL
1 tbsp = 3 tsp
1 kg = 2.2 lbs
1 gr = 60 mg

49.

INTRAVENOUS THERAPY
A. Intraprocedural
a.

Apply a clean tourniquet or blood pressure cuff (especially for older adults) 10-15 cm (4-6 in)
above the insertion site to compress only venous blow flow

b.

Distal veins first on the nondominant hand

c.

Avoid the following
1. Varicose veins
2. Flexion areas
3. Near valves
4. 10-30-degree angle

B. Post procedure
a.

Maintaining the patency of IV access
1. Flush intermittent IV catheters
2. Every 8-12 hours

b.

Discontinue IV therapy
1. Elevate the extremity and apply pressure
2. Apply tape over the gauze
3. Check the catheter for intactness

C. Complications
a.

Infiltration
1. Local swelling at the site, decreased skin temp around the site, damp dressing,
slowed rate of infusion
2. Elevate the extremity and apply a warm or cold compress

b.

Phlebitis
1. Edema, throbbing, burning, or pain at the site, erythema, red line up the arm
2. Discontinue the infusion
3. Elevate the extremity
4. Apply warm compresses
5. Obtain a specimen for culture

c.

Fluid overload
1. Distended neck veins, increased blood pressure, tachycardia, , shortness of breath,
crackles in the lungs, edema
2. Treatment
a. Stop the infusion, raise the head of the bed, measure vital signs and oxygen
saturation, adjust the rate after correcting fluid overload, admin diuretics

d.

Cellulitis
1. Pain, warmth, edema, induration, red streaking, fever, chills malaise
2. Treatment
a. Discontinue the infusion and remove the catheter

b. Elevate the extremity
c. Apply warm compresses 3-4 times/days
d. Obtain a specimen for culture
e. Admin the following
i.
e.

Antibiotics, analgesics, antipyretics

Catheter embolus
1. Missing catheter tip on removal, severe pain at the site with migration
2. Treatment
a. Place a tourniquet high on the extremity
b. Prepare for removal under x ray or via surgery

50.

ADVERSE EFFECTS INTERACTIONS, AND CONTRAINDICATIONS
A. Extrapyramidal symptoms
a.

Tremors, restlessness, acute dystonia (spastic movements)

B. Anticholinergic effects
a.

Dry mouth, urinary retention, constipation

b.

Wear sunglasses, increase dietary fiber and fluids

c.

Can’t see, can’t pee, cant spit, cant poop

C. Medication- food interactions
a.

Tyramine
1. Avocados, cheese, smoked meats
2. MAOIs can lead to hypertensive crisis

b.

Vitamin K
1. Can decrease effects of vitamin K

c.

Dairy
1. Don’t take Tetracycline within 2 hours of consuming any dairy products

d.

51.

Grapefruit juice

INDIVIDUAL CONSIDERATION OF MEDICATION ADMINISTRATION
A. Pharmacology and older adults (65+ years)
a.

Increased gastric pH

b.

Decreased gastrointestinal motility and gastric emptying time

c.

Decreased blood flow

d.

Decreased kidney function

e.

Decreased protein binding sites, resulting in lower serum albumin levels

f.

Decreased body water, increased body fat, and decreased lean body mass

52.

SPECIMEN COLLECTION FOR GLUCOSE MONITORING
A. Intra procedure
a.

Wrap the site in a warm, moist towel to enhance circulation

b.

Cleanse the site with warm water and soap or an antiseptic swab and allow it to dry

c.

Put finger in dependent position

d.

Pierce the skin using a sterile lancet and holding it perpendicular to the skin

e.

Wipe away the first drop of blood with a cotton ball

f.

Do not touch the site directly to stimulate bleeding

g.

Hold the test strip next to the blood on the finger tip
1. Do not smear blood onto the strip because this can cause an inaccurate reading

B. Interpretation of findings
a.

Greater than 200 mg/dL indicates hyperglycemia

b.

Less than 70 mg/dL indicates hypoglycemia

C. Indications
a.

Perform urine glucose testing

b.

Greater than 240 mg/dL to identify the presence of ketones

53.

AIRWAY MANAGEMENT
A. Interpretations of findings
a.

Expected reference range: 95-100%
1. Hypoxemia: less than 90%

b.

COPD norm: 89-100%

B. Oxygen Therapy

Hypoxemia

Hypoxia

C. Low- flow oxygen delivery systems
a.

Nasal Cannula
1. tubing with 2 small prongs for insertion into the nares
2. 1-6 L/min
3. Provide humidification for flow rates of 4 L/min and greater

b.

Simple face mask
1. 5-8 L/min

c.

Partial rebreather mask
1. 6-10 L/min
2. Keep reservoir bag 1/3 to ½ full on respiration

d.

Nonrebreather mask
1. 10-15 L/min to keep the reservoir bad 2/3 full
2. Hourly assessments of the valve and the flap

D. High-Flow oxygen delivery systems
a.

Venturi mask
1. 4-12 L/min
2. Most precise oxygen concentration

b.

Aerosol mask
1. Face tent: fits loosely around the face and neck
2. High humidification with oxygen delivery

E. Complications
a.

Oxygen toxicity
1. Nonproductive cough, substernal pain, nasal stiffness, nausea, vomiting, fatigue,
headache, sore throat, and hypoventilation

b.

Combustion
1. Post “no smoking” or “oxygen in use” signs to alert others to the fire hazard
2. Have client wear cotton gown
3. Ensure electrical devices are working well
4. Make sure all electric machinery is grounded
5. Do not use volatile, flammable materials (alcohol, acetone, nail polish) near clients
receiving oxygen

F. Chest physiotherapy
a.

Use set of techniques that loosen respiratory secretions and move them into central airways
where coughing or suctioning can remove them

b.

Percussion- use of cupped hands to clap rhythmically on the chest to break up secretions

c.

Vibration- use of shaking movements during exhalation to help remove secretions

d.

Postural drainage- use of various positions to allow secretions to drain by gravity

G. Considerations
a.

Schedule treatments 1 hr before or 2 hr after meals to decrease the likelihood of vomiting

b.

Admin bronchodilator medication or nebulizer treatment 30 min to 1 hr prior to postural
drainage

H. Suctioning
a.

Put client in high fowler’s positions

b.

For nasopharyngeal and nasotracheal suctioning lubricate the to distal 6-8 cm with water
soluble lubricant

c.

The catheter should not exceed one half of the internal diameter of the endotracheal tube

d.

Use suction pressure no higher than 120-150 mmHg

e.

Additional guidelines for nasopharyngeal and nasotracheal suctioning
1. Insert the catheter into the naris during inhalation
2. Apply suction intermittently by covering and releasing the suction port with the
thumb for 10-15 while rotating thumb and forefinger
3. Do not perform more than 2 passes with the catheter. Allow at least 1 min

f.

Additional guidelines for endotracheal suctioning
1. Advance the catheter until resistance is met- should reach the level of the carina
2. Pull the catheter back 1 cm
3. Apply suction intermittently by covering and releasing the suction port with the
thumb for 10-15 seconds and rotate it with the thumb and forefinger

54.

NASOGASTRIC INTUBATION AND ENTERAL FEEDINGS

A. Nasogastric feedings
a.

Intra procedure
1. High fowlers position
2. Check placement by testing pH
3. Confirm placement with an X ray

B. Enteral Feedings
a.

Fowlers position

b.

Auscultate for bowel sounds

c.

Monitor tube placements
1. Contents for pH (between 0-4)

d.

55.

Check placement every 4-6 hour and check tube placement again

PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT
A. Stages of wound healing
a.

Inflammatory stage
1. Lasts 3-6 days
2. Vasoconstriction, clot formation, hemostasis, phagocytosis of microorganisms

b.

Proliferative stage
1. 3-24 days
2. Replacing lost tissue or granulated tissue
3. Contracting with wound’s edges
4. Resurfacing of new epithelial cells

c.

Maturation or remodeling stage
1. After day 21
2. It can take more than 1 year to complete

B. Healing processes
a.

Primary intention
1. Edges approximated as with a surgical incision
2. Heals rapidly
3. Minimal scarring

b.

Secondary intention
1. Loss of tissue
2. Wound edges widely separated longer healing time
3. Increase for risk of infection

4. Scarring
c.

Tertiary intention
1. Spontaneous opening of a previously closed wound
2. Closure of wound occurs when free of infection

C. Factors affecting wound healing
a.

Increased age delays healing

b.

Impaired immune system function

D. Assessment/data collection
a.

Red- healthy regeneration of tissue

b.

Yellow- presence of purulent drainage and slough

c.

Black- presence of eschar that hinders healing and requires removal

d.

Types of drainage
1. Serous drainage: Watery and clear
2. Sanguineous drainage: serum and red blood cells
3. Serosanguineous drainage- both serum and blood
4. Purulent drainage- result of infection

e.

Perform wound cleansing
1. Cleanse from the least contaminated toward the most contaminated
2. If irrigating
a. Apply 5-8 psi
3. Use a 30-60 mL syringe

E. Dehiscence vs evisceration

F. Pressure ulcers
a.

Stages

1. Stage 1- non-blanchable erythema- intact skin
2. Stage 2- partial thickness- affects epidermis and dermis
3. Stage 3- full thickness skin loss- cannot see muscle and bone
4. Stage 4- full thickness skin loss- can see muscle and bone
5. Unstageable- depth unknown
b.

Prevention
1. Reposition the client in bed at least every 2 hours and every 1 hour in a chair
2. Keep the head of the bed at or below 30 degrees
3. Encourage proper nutrition

56.

SKIP- WENT OVER ALREADY

57.

FLUID IMBALANCES
A. Fluid Volume deficiency
a.

Expected findings
1. Tachycardia, hypotension, orthostatic hypotension, decreased central venous
pressure, tachypnea, dry mucus membranes, oliguria, diminished capillary refill,
diaphoresis, flattened neck veins, decreased skin turgor

b.

Lab tests
1. Hct- increased
2. Serum osmolarilty- increase
3. Urine specific gravity- increase

c.

Nursing Care
1. Monitor I&O – less than 30 mL/hr
2. Observe level of gait stability

B. Fluid Volume excess
a.

Expected findings
1. Tachycardia, bounding pulse, hypertension, tachypnea, weight gain, dyspnea,
crackles, edema, distended

b.

Lab tests
1. Hct- decreased
2. Serum osmolarity- decreased
3. Decreased electrolytes, BUN, and creatinine
4. Urine specific gravity decreased

58.

ELECTROLYTE IMBALANCES
Hyponatremia

Hypernatremia

Less than 136 mEq/L

Greater than 145 mEq/L

risk factors:

risk factors:

-

GI losses, diuretics, skin losses,
edematous, hyperglycemia
expected findings:
-

tachycardia, hypotension, confusion,
fatigue, nausea, vomiting

-

water deprivation, excessive sodium
intake, kidney failure, Cushing’s
syndrome
Expected findings
-

Tachycardia, muscle twitches, muscle
weaknesses, edema

Hypokalemia

Hyperkalemia

Less than 3.5 mEq/L

Greater than 5.0 mEq/L

Risk factors

Risk factors

-

GI losses, diuretics, skin losses,
metabolic alkalosis
Expected findings
-

Hypotension, muscle weakness,
muscle cramping, dysrhythmias

-

Diabetic ketoacidosis, uncontrolled
diabetes mellitus, kidney failure, salt
substitutes
Expected findings:
-

dysrhythmias

Hypocalcemia

Hypercalcemia

Less than 9 mg/dL

More than 10.5 mg/dL

Risk factors:

Risk factors:

-

diarrhea, vitamin D deficiency,
hypoparathyroidism
expected findings:
-

numbness and tingling, muscle
spasms, positive Chvostek’s sign,
positive trousseau’s sign

-

hyperparathyroidism, bone cancer,
long term glucocorticoid use
expected findings
-

decreased reflexes. Constipation,
lethargy

Practice Quizzes Fundamentals 1 - 40 preguntas Fundamentals 1
Version 6
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. the nurse auscultates a high-pitched scratching sound during both
systole and diastole with diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
Answer: Pericardial friction rub
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
Answer: Place the bladder of the cuff over the posterior aspect of the thigh
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
Answer: Confirm unresponsiveness
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported
for the procedure, which of the following actions should the nurse take first?
Answer: Identify the client using two identifiers
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
Answer: Administer analgesics to the child on a routine schedule throughout the day and
night.
A nurse is providing teaching to a client who has heart failure about how to reduce his daily
intake of sodium. Which of the following factors is the most important in determining the
client's ability to learn new dietary habits?
Answer: The involvement of the client in planning the change
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?

Answer: Obtaining cotton balls for the tracheostomy care
A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take?
Answer: Raise the level of the bed
A nurse is witnessing a client sign an informed consent form for surgery. Which of the
following describes what the nurse is affirming by this action?
Answer: The signature on the preoperative consent form is the client's
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
Answer: Perform hand hygiene
A nurse is caring for an older adult client who becomes agitated when the nurse requests that
the client's dentures be removed prior to surgery. Which of the following responses should the
nurse make?
Answer: "What worries you about being without your teeth?"
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
Answer: "I keep having nightmares about my upcoming surgery."
A nurse on a medical-surgical unit is caring for a client. Which of the following actions
should the nurse take first when using the nursing process?
Answer: Obtain client information
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV
lines. The provider prescribes soft wrist restraints. Which of the following actions should the
nurse take while the client is in restraints?
Answer: Remove the restraints one at a time

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse
reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min,
a soft contender abdomen, and census overdue by 2 days. Which of the following findings
should be the nurse's priority?
Answer: Temperature
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand.
The client has no documented bloodstream infection. Which of the following actions should
the nurse take?
Answer: Carefully remove the gloves and follow with hand hygiene
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the
following abdominal assessments should the nurse expect?
Answer: Absent bowel sounds with distention
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning selfinjection of insulin. Which of the following statements should the nurse make?
Answer: "Tell me what I can do to help you overcome your fear of giving yourself
injections."
A nurse is receiving a client from the PACU who is postoperative following abdominal
surgery. Which of the following actions should the nurse take to transfer the client from
stretcher to the bed?
Answer: Lock the wheels on the bed and stretcher
A nurse is caring for a client who is in terminal stage of cancer. Which of the following
actions should the nurse take when she observes the client crying?
Answer: Sit and hold the client's hand
A nurse in an emergency department is assessing a client who reports diarrhea and decreased
urination for 4 days. Which of the following actions should the nurse take to assess the
client's skin turgor?
Answer: Grasp a skin fold on the chest under the clavicle, release it, and note whether it
springs back

A nurse is caring for a client who has a terminal illness. The client asks several questions
about the nurse's religious beliefs related to death and dying. Which of the following actions
should the nurse take?
Answer: Encourage the client to express his thoughts about death and dying
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes
by an electronic blood pressure machine. The nurse notices the machine begins to measure
the blood pressure at varied intervals and the readings are inconsistent. Which of the
following actions should the nurse take?
Answer: Discontinue the machine, and measure the blood pressure manually every 15 min.
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from
bed to a wheelchair. Which of the following techniques should the nurse use?
Answer: Place the wheelchair at a 45-degree angle to the bed
A nurse is performing an abdominal assessment for an adult client. Identify the correct
sequence of steps for this assessment.
Answer: Inspect, Auscultate, Percuss, Palpate
A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating
room when the client states she no longer wants to have surgery. Which of the following
actions should the nurse take?
Answer: Notify the provider about the client's decision
A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical
handwashing technique?
Answer: The nurse washes with her hands held higher than her elbows
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the
next month that might require a blood transfusion. The client expresses concern about the risk
of acquiring an infection from the blood transfusion. Which of the following statements
should the nurse make to the client?

Answer: Donate autologous blood before the surgery
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the
following statements by the AP indicates an understanding of the teaching?
Answer: "There are times I should use soap and water rather than alcohol-based hand rub to
clean my hands."
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of
the following actions should the nurse take?
Answer: Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a
regular size cuff for a client who is obese. Which of the following explanations should the
nurse give the AP?
Answer: "Using a cuff that is too small will result in an inaccurately high reading."
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who
will have emergency surgery for appendicitis. Which of the following statements indicates a
lack of readiness to learn by the client?
Answer: The client reports severe pain
A nurse is providing teaching to an older adult client who has constipation. Which of the
following statements should the nurse include in the teaching?
Answer: "Sit on the toilet 30 minutes after eating a meal."
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea
and who might have a right ear infection. Which of the following routes should the nurse use
to obtain the temperature?
Answer: Temporal
A community health nurse is preparing a campaign about seasonal influenza. Which of the
following plans should the nurse include as a secondary prevention?
Answer: Screening groups of older adults in nursing care facilities for early influenza
manifestations

A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
Answer: Evaluate pedal pulses
A nurse on a medical-surgical unit is admitting a client. Which of the following information
should the nurse document in the client's record first?
Answer: Assessment
A nurse is teaching a group of older adults about expected changes of aging. Which of the
following statements by a group member indicates that the teaching has been effective?
Answer: "I should expect my heart rate to take longer to return to normal after excessive as I
get older."
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the
following actions by the nurse will improve the client's commitment to a long-term goal of
weight loss?
Answer: Attempt to increase the client's self-motivation
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve?
Answer: Second intercostal space to the right of the sternum

ATI Fundamental Proctored Study Guide
Version 8
Redness at coccyx and patient is immobile
Answer: Assess for blanching
Patient has IV catheter for right mastectomy, which veins do you select?
Answer: Cephalic vein left distal forearm
Colorectal cancer prevention guidelines for patient teaching
Answer: Reduce intake of red meat
Applying catheter to a patient who is uncircumsized
Answer: • Roll the foreskin down, apply condom and then and roll back up afterwards
• Place adhesive tape directly on the top If patient have an Artificial eye
• Teach patient to apply pressure below the eye to apply traction to retreat upper and lower
lids to insert the artificial eye
If patient is on restraint
Answer: Remove one restraint at a time
PPE for C-Diff
Answer: Gloves, glown, wash hands with soap and water
POINT GAIT
Answer: • Bear weight on both legs
• Elbows should be 30% flexed
• Client should move each leg alternatively with opposite crutch
How to walk with it?
Answer: the type of order
If you enter a client room and after securing the patient, you want to?
Answer: • Pull the alarm

• Race
IF SOMEONE PUT IN EYE DROP
Answer: Make sure they press in corner of the eye
A nurse is assessing a client who is immobile and notices a red area over the client’s coccyx.
Which of the following actions should the nurse take?
Answer: • Change the clients position every 4 hours
• Apply petroleum base ointment in the red area
• Assess the red area for blanching
• Use friction when cleansing the client’s skin
A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which
of the following veins should the nurse select when initiating an IV therapy?
Answer: • The radial vein on the left wrist
• The cephalic vein in the left distal forearm
• The basilic vein in the right antecubital fossa
• The cephalic vein on the back of the right hand
A nurse is teaching a client who had an enucleation about care of an artificial eye. Which of
the following information should the include in the teaching? (select all that apply)
Answer: • Store the artificial eye in the label container filled with 0.9% sodium chloride
irrigation remove
• from the artificial eye by retracting the upper eyelid
• Apply pressure just below artificial eye to break the suction
• Clear the artificial eye with hydrogen peroxide before storing
• Retract the upper and lower lids to reinsert the artificial eye
A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin.
Which of the following actions should the nurse take?
Answer: • Stabilize the vein by applying traction above the insertion site
• Engorge the vein by placing the arm in the dependent position
• Use friction at the insertion site to increase venous distention
• Leave the tourniquet on for 30 to 60 seconds after initial insertion

HEALTH CARE FINANCING MECHANISMS
Answer: • Medicare: For clients greater than 65 years of age or those with permanent
disabilities
• Medicaid: For clients who have low incomes
LEGAL RESPONSIBILITIES
Answer: • Advanced Directives purpose is to communicate a client’s wishes regarding end of
life care should the client be unable to do so
• Living will is a legal document that expresses the client’s wishes regarding med treatment
• Durable power of attorney: in which client designate a healthcare proxy to make healthcare
decisions for them if they are unable to do so
DELEGATIONS
Answer: • 5 Rights: Task, circumstance, person, direction and communication, supervision • Remember that LVN/CNA/UAP can’t EAT(Evaluate, assess and teach)
TYPES OF PREVENTION
Answer: • Primary: Administering vaccine, help those who are healthy to prevent from
getting sick
• Secondary: Screening for disease
• Tertiary: Prevent a disease from getting worst or to help make patient get better
HAND HYGIENE
Answer: • Wash hands with soap and water or antimicrobial soap
• If hands are visibly soiled 2 min
• Scrub hands for at least 15 seconds and dry hand with towel before you turn faucet off
• If using alcohol product, use 3-5 mL and rub hands until dry
• Cover mouth nose when sneezing and encourage patient to do so
• Hold hand above elbow when washing
• Stand at least 3 feet away from those thats coughing
• Keep nails short, no gel polished or artificial nails
• Remove jewelry from hands
• Never shake linen

• Clean lease soiled area first and then move to dirtier area
• Never place items on floor
SETTING/MAINTAINING UP A STERILE FIELD
Answer: • Open flap away from body first
• Open right flap with right and left flap with left
• Hold bottle so label is against the palm
• Do not cough/sneeze or talk over sterile field
• Do not turn your back on a sterile field or reach across
• Outer 1 Inch is not sterile
• Object below waist or above chest should be considered contaminated
TYPES OF PRECAUTION
Answer: Standard
- Use for all patients regardless of infection or isolation
- Make sure to wash hands before going in and out of patient room
- Preferably alcohol unless hands are soiled, then use water+soap - Wear gloves
Contact
- Used for impetigo, scabies, MRSA, VER, c diff, RSV, enteric infection/wound infection
- Private room
- Gowns/glove
- Dispose of linen
Droplet
- Used for influenza, pertussis, mumps, pneumonia, rubella and meningitis
- Private room
- Mask
Airborne
- Used for Measles, varicella, TB
- Negative airflow
- N95 Mask
BREAST EXAMINATIONS
Answer: - As women get older

- Older patient tend to have more Barrel chest and decreased alveolar along with
kyphosis(increased curvature of the thoracic spine)
- Chest reflex, excursion or expansion will diminish
- Nipples no longer have erectile ability and can invert
PHYSICAL ASSESSMENT ON ABDOMEN
Answer: - Inspect, Auscultate, percuss, Palpate
- Left lower quadrant→ left Upper quadrant→ Right upper quadrant→ Right lower quadrant
Hypoactive/Hyperactive bowel Sound:
Answer: Expected sound: High pitched click and gurgles 5-35 times/minute
- To determine absent bowel sound, you must hear no sounds after listening for a full 5 min
- Tympany sound when percussing
Unexpected Sound: Loud, growling sounds(borborygmi) or no bowel sounds
*Make sure to Palpate tender area last
*Paralytic ileus: No bowel movement
*Flatulence: gas accumulation
PRESSURE ULCER STAGES/WOUND CARE
Answer: Stage 1: Non-blanchable erythema;
Stage 2: Partial thickness skin loss with bruising; used hydrocolloid
Stage 3: Full thickness skin loss with undermining/tunneling;
Stage 4: Full thickness skin loss with exposed bone/tissue; use Calcium alginate Unstageable:
Use proteolytic enzyme
NURSING PRINCIPLES
Answer: - Fidelity: Promise with a client
- Autonomy: ensuring that the client has the right to make decisions
- Nonmaleficence: Doing no harm
- Justice: Treating everyone fairly
- Battery = Actually hurting someone
- Assault = Threatening
- Respite care: For caregiver who needs time to rest

WHEN ASSISTING A PATIENT DURING MEAL TIME
Answer: - Have patient sit in an upright position
- Have patient lean forward when eating
- Have patient tilt head forward
- Advise patient to tuck chin downward
CANE
Answer: - Client should keep 2 points of support on ground at all times
- Client should hold cane on stronger side/unaffected side
- Client should advance the cane first then the unaffected/stronger leg
CRUTCHES
Answer: - Place left foot on first step and transfer weight to left foot then the right
- Stance should be 15 cm in front and back
- Client should have his arms bear the weight of their body
- Keep the rubber crutch tips in place
- Make sure client slightly flexed elbow when ambulating
HEALTH CARE ROLES
Answer: - Speech pathologist: Examine/help with swallowing and dysphagia
- Social Worker: Assist with community services such as financial and meal delivery
- Physical therapist: Evaluate the strength/weakness and mobility
- Occupational therapist: Help with ADL or patient who have disabilities
WHEN INSERTING A URINARY CATHETER
Answer: - Have patient bear down
- Encourage patient to take slow, deep breaths
- Encourage patient to relax
- Place urinary catheter below the level of the bladder
- Tape the catheter to the inner thigh
- Use soap and water to clean the perineal area
- For male: Tape urinary catheter to the lower abdomen

WHEN COLLECTING A URINE SPECIMEN FOR PATIENT WITH AN INDWELLING
URINARY CATHETER
Answer: - Clamp the tubing below the collection port
- Place specimen in a sterile specimen cup
ADMINISTERING ENEMA
Answer: - Put patient in sims position
- Lubricate 2-3 inches of the tip of the rectal tube
- Hold enema 18 inches above the rectum
- Insert the tip of tubing 8 cm
WHEN CARING FOR PATIENT WITH DRESSING CHANGES
Answer: - Clean incision from top to bottom
- Apply sterile gloves after opening dressing package
- Pull the tape toward the wound
- Clean the drain from the center to outer
CRANIAL NERVE
Answer: - Cranial Nerve X(Vagus) ask client to vocalize
- Cranial Nerve XII(Hypoglossal) Ask client to stick tongue out
- Cranial Nerve VIII(Vestibulo Ocular) Ask client if they can hear whisper - Cranial Nerve
V(Trigeminal) Ask client to clench their teeth
WHEN DISCHARGING A PATIENT WITH A NASAL CANNULA HOME FOR OXYGEN
Answer: - Make sure equipment have no frayed wires
- Avoid use of oil
- Make sure all electronics are off the floor
- Wear Cotton clothes
TYPES OF POSITIONS
Answer: - Sims is used for rectal procedures
- Supine is used for assessment such as thoracic and abdominal examinations
- Sitting is used for Costovertebral angle tenderness
- Lateral is used for auscultating heart/murmur

Braden Scale
Answer: - Measures the nutrition, Sensory perception, moisture, activity, mobility and
friction
WHEN A NURSE IS ASSISTING A PT. DURING MEALTIME AND SEES THEM
SUDDENLY GRAB THEIR NECK WITH BOTH HANDS AND APPEARS
FRIGHTENED, A NURSE SHOULD FIRST
Answer: - Determine whether the client is able to breathe
- Remember that you need to Assess first
MANIFESTATION OF HYPERCALCEMIA
Answer: - Depressed deep tendon reflexes
- Nausea
- Vomiting - Bone pain - Lethargy
- Weakness
REMOVING PPE
Answer: - Gloves → goggles/face shield → Gown → Mask / respirator
*pH should be between 0 to 4 for gastric secretion
*When examining a patient’s thyroid gland, have them tilt head back and swallow
*Romberg test examines the patient’s balance
*Weber test examines patient’s hearing
*Signs of infiltration for IV include edema and feeling of coolness
*Signs of phlebitis or infection for IV include Redness and warmth
*Patient with a chvostek’s sign will have HYPOcalcemia
*When administering eye drop to client following surgery: Drop the eye medication in the
outer third of the lower conjunctival sac
*Ventrogluteal site is the safest injection site for adults
- Be aware that Ventrogluteal Site can also be described as: “ side hip between the iliac crest
and anterior iliac spine”
TRACH CARE
Answer: - Pull suction catheter back 1 cm if client start coughing

- Allow 1 minute rest between each suction
- Hyperoxygenate 100%
- Perform maximum of 3 suction with the suction catheter
NG TUBE INSERTION
Answer: - Coat tip with lub
- Ask client to swallow water while tube enters the throat
- Tell client to tilt head backward as insertion begins
*Unintentionally torts/delegation (Refer to Into to prof nursing)
*Study chapter 1-6 fundamental
CRANIAL NERVES
Answer: 1. I Olfactory (Smell)
2. II Optic (Sight)
3. III Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye)
4. IV Trochlear (Moves eyeballs)
5. V Trigeminal (Facial muscles incl. chewing; Facial sensations)
6. VI Abducens (Moves eyeballs)
7. VII Facial (Taste, tears, saliva, facial expressions)
8. VIII Vestibulocochlear (Auditory)
9. IX Glossopharyngeal (Swallowing, saliva, taste)
10. X Vagus (Control of PNS e.g. smooth muscles of GI tract)
11. XI Accessory (Moving head & shoulders, swallowing)
12. XII Hypoglossal (Tongue muscles - speech & swallowing)
Cranial Nerve Names Mnemonic
Answer: Only Oranges On Tilting Towers Are Fun And Give Very Awkward Holes
Cranial Nerve Function Mnemonic:
Answer: **S = Sensory M = Motor B = Both
Some Say Marry Money But My Brother Says Big Brains Matter More
Breast Examination- must be performed yearly to check for cancer.
*Use the techniques of inspection and palpation to examine breast.

*Instruct clients who do not currently perform monthly BSE to inspect their breast in front of
a mirror and palpate them during a shower.
*Feel for lumps using the finger pads of your three middle fingers.
*Compress the nipples carefully between your thumb and index finger to check for discharge.
UNEXPECTED FINDING:
Answer: Fibrocystic breast disease: tender cyst often more prominent during menstruation. 3
techniques: circular pattern, wedge pattern, vertical strip pattern.
Version 9
ATI FUNDEMENTALS PROCTOR EXAMS
The following are some of the questions and answers on ATI Fundemental Proctor Exams.
An acute illness is;
A. Less than two weeks
B. Less than one month
C. Less than three months
D. Less than six months
Answer: A. Less than two weeks
Who defines health as “A state of complete physical, mental and social well-being, and not
merely the absence of disease of infirmiy ”
A. W.H.O
B. A.N.A.
Answer: A. W.H.O
Which of the following is a complete wellness diagnoses?
A. Readiness for spiritual well-being
B. Readiness for enhanced family coping
C. Possible social isolation
D. Risk for powerless
Answer: B. Readiness for enhanced family coping
This is a diagnosis that is associated with a cluster of other diagnoses

A. Actual diagnosis
B. Possible nursing diagnosis
C. Risk nursing diagnosis
D. Syndrome diagnosis
Answer: D. Syndrome diagnosis
Which of the following is a correct PES formatted diagnostic statement?
A. Noncompliance (Diabetic Diet) related to unresolved anger about diagnosis as manifested
by weight gain of 5 kg
B. Noncompliance (Diabetic Diet) related to denial of having disease
C. Noncompliance (Diabetic Diet) due to unresolved anger about diagnosis as manifested by
weight gain of 5 kg
D. Situational low self esteem r/t feelings of rejection by husband
Answer: A. Noncompliance (Diabetic Diet) related to unresolved anger about diagnosis as
manifested by weight gain of 5 kg
Which diagnostic statement(s) consist of a NANDA label only?
A. Possible nursing diagnosis
B. Syndrome diagnosis
C. Risk nursing diagnosis
D. Wellness diagnosis
Answer: D. Wellness diagnosis
Which of the following is correct nursing diagnosis?
A. Risk for impaired skin Integrity related to decreased peripheral circulation secondary to
diabetes
B. Impaired skin integrity related to improper position
C. Impaired skin integrity related to ulceration of sacral area
D. Risk for ineffective airway clearance related to emphysema
E. Impaired oral mucous membrane related to decreased salivation secondary to radiation of
neck
Answer: C. Impaired skin integrity related to ulceration of sacral area