ATI: BOARD VITALS

ATI: BOARD VITALS

ScienceMedicineNursing m_c_e_1 Save Board Vitals/ATI - NEED to KNOW 20 terms sia_simonePreview ATI comprehensive predictor STUDY...198 terms h_trtPreview BoardVitals NCLEX Prep RN 40 terms Chelsea_Brown361 Preview Adapti 111 terms ann a nurse is collecting data from a patient who had PAD and is scheduled for RLE amputation. Which of the following findings should the nurse expect in the affected limb. SATA

• Skin cool to touch from calf to toes
• Develop rubor when extremity is dependent position
• palpable pedal pulse
• excess hair growth on lower extremity
• Blackened areas on several toes
• Skin cool to touch from calf to toes
• Develop rubor when extremity is dependent position
• Blackened areas on several toes

A nurse is providing teaching to a female client who has frequent UTI's. Which of the following information should nurse include the teaching?

SATA

• clean perineal area prior to intercourse
• wipe perineal area back to front following elimination
• empty the bladder when there is urge to urinate
• where synthetic fabric underwear
• Avoid vaginal douching
• clean perineal area prior to intercourse
• empty the bladder when there is urge to urinate
• Avoid vaginal douching

RN and LPN caring for a patient admitted for control of patient due to metastatic cancer. The RN administers prescribed dose of hydromorphone 2.0mg IVP stat. patient calls for the nurse in 2 hours states his patient is 8 on a 0-10 scale and requests pain medication. which of the following is the priority action by the RN?

• reposition the client
• assess the client and notify the PCP
• give a second dose of hydromorphone
• ask the LPN to take vital signs and administer the medication if vitals are with in normal limits.
• assess the client and notify the PCP

Rationale; A Stat order prescribes immediate one-time dose of a prescribed medication, therefore pcp must be contacted for the medication to be repeated.When caring for a client with hypoxemia and right sided pneumonia the nurse knows to place the client in which of the following positions to improve O2 saturation?

• left side down
• right side down
• semi-fowlers
• high-fowlers
• left side down

Rationale; if client is placed with the affected side downward gravity will promote blood flow to the area with diminished perfusion, increasing ventilation- perfusion mismatch.A RN is assessing a client in the ED who presented with epigastric pain, nausea. the client has bluish disoloration around the umbilicus. which ofthe following is the most appropriate initial nursing action?

• complete a head to toe assessment
• place ng tube
• notify pcp
• establish IV acess
• notify pcp

Rationale; this is Cullen's sign reflects pancreatic necrosis or internal bleeding pcp should be notified after receiving morning lab results the nurse will need to intervene for which of the following clients?

• client with end stage liver disease and elevated ammonia level
• client receiving warfarin with an INR of 2.0
• client with HF who had Digoxin level of 2.4ng/ml
• client with MI and elevated CK-MB
• client with HF who had Digoxin level of 2.4ng/ml

Rationale; therapeutic levels are 0.8-2 ng/L toxic levels are greater than 2ng/L

A patient with leukemia is scheduled for bone marrow transplantation. the health care team was instructed about the schedule. the RN needs to check which of the following tests and procedures were done before the transplantation? SATA

• crossmatching of patient serum against the donor lymphocytes
• administration of acylovir
• administration of granciclovir
• deep cough and breathing exercises
• give instruction prior to surgery
• cross-matching of patient serum against the donor lymphocytes
• administration of acyclovir
• administration of ganciclovir

RN is caring for an obese client postoperatively who has an abdominal incision that is healing poorly. After the client complains of coughing forcefully, the nurse notes protrusion of the intestine through the surgical wound. Which of the following is the priority action?

• take the clients vitals
• cover wound with dry sterile towel
• using a sterile towel press the organs back into the body cavity
• place the patient in low fowler's position
• place the patient in low fowler's position

rationale:

This prevents tension on the abdominal would and is a medical emergency. incision should be covered with sterile towel moistened with normal saline to keep the organ moist.RN is preparing to insert an indewlling urinary catheter for a female patient. As the catheter is inserted which of the following instructions should the nurse give the patient?

• contract pelvic muscles
• take a sip of water
• breathe out slowly through the mouth
• bear down
• bear down

Rationale:

Bearing down gently as if to void relaxes the external sphincter and to allow ease of urinary catheter insertion, and aid in visualization of the urinary meatus.A patient is admitted to the hospital with iron-deficiency anemia and blood-streaked emesis. Which question is the most important to help determine the extent of the client's activity intolerance.

• what daily activities were you able to do 6 mo ago?
• How long have you had this problem?
• have you been able to keep up with all your usual activities?
• are you more tired now than you used to be?
• what daily activities were you able to do 6 mo ago?

rationale:

RN can best assess activates from 6 mo to the present.

Which of the following is a benefit associated with electoronic medication administration records? SATA

• improves access to information
• Eliminates the need for the nurse to verify client id
• eliminates the need for the nurse to verify dosage calculation
• Reduces the risk of medication errors
• allow easy medication substitutions by the RN
• improves access to information
• Reduces the risk of medication errors

Rn in the peds unit is caring for serval infants and toddlers with severe physical's developmental problems resulting in immobility and subsequent inactivity. Which physical nursing diagnosis is a priority for these infants?

• lack of maternal bonding r/t immobilization
• impaired cognitive development r/t immobilization
• impaired musculoskeletal development r/t

immobility

• impaired nutritional status r/t immobilization
• impaired musculoskeletal development r/t

immobility

rationale:

A nurse at a long term care facility is preparing to adminster a medication to a patient. WHich of the following client identifiers should the nurse use to identify the patient?

• patient date of birth
• patient room number
• printed name on the MAR
• phone number of the patient room
• patient date of birth

rationale:

RN should use 2 id's before giving meds acceptable id's name date of birth medical record number personal telephone number photo id RN is caring for a patient providing informed consent for a procedure.The RN is aware that which of the following are components of informed consent? SATA

• patient must have the capacity to make decisions
• the medical provider must disclose info about procedure, including risks and benefits
• pcp must discuss alternative tx.
• family members must be included and understand tx options.
• patient must voluntarily grant consent.
• patient must have the capacity to make decisions
• the medical provider must disclose info about procedure, including risks and benefits
• PCP must discuss alternative tx.
• patient must voluntarily grant consent.