ATI final exam

Question 1

Montgomery straps

Answer 1

Used for abdominal drainage

Decreased skin irritation

Question 2

Where to adhere catheter tubing to male?

Answer 2

Lower abdomen

Question 3

Removal of NG tube

Answer 3

Disconnect from suction

Instill 50 mL air into tube

Pinch tubing

Instruct to take deep breath and hold breath on removal

Question 4

How often to change colostomy pouch

Answer 4

3-7 days

Question 5

When to change colostomy bag

Answer 5

Before breakfast

Question 6

NG feeding when to auscultate bowel sounds

Answer 6

Before feeding

Question 7

Elevation of head for NG tube

Answer 7

30-45 degrees

Question 8

How much water to flush NG tube after feeding ?

Answer 8

30 mL

Question 9

Eye irrigation

Answer 9

2.5 cm (1 in) above eye

Lower conjunctiva sac

Hold bony prominences

Direct solution from inner canthus to outer

Question 10

Cleansing enema

Answer 10

Lubricate 5-8cm (2-3 in)

Lie on left side

Insert tip 8cm (3.1 in)

Hold 45 cm (18 in) above rectum

Question 11

Incentive spirometer

Answer 11

Inhale slowly

Homey breath 3-5 sec after reaching max inspiratory volume

Breathe normally between cycle

Repeat every 10-20 breaths while awake

Question 12

Tracheostomy suctioning

Answer 12

Pull suction 1cm (.5 in) when coughing occurs

Allow 1 min between suctioning passes

Hyperventilate 100% oxygen 2 min prior

Max : 3 passes

Question 13

Proliferation stage

Answer 13

Wound healing

Pink, shiny tissue with granular appearance

Question 14

IV local infection

Answer 14

Redness at IV entry site

Question 15

Phlebitis

Answer 15

Palpable cord felt along vein used for infusion

Inflamm of inner vein

Discontinue and start at another location

Question 16

IV infiltration

Answer 16

Taut skin

Skin cool to touch

1. Stop infusion
2. Elevate
3. Apply warm or cold compress

Question 17

Primary intention

Answer 17

Wound healing

Edges are well-approximated

Question 18

Tertiary intention

Answer 18

Wound healing

Wound closed at later date

Skin graft placed over wound bed

Question 19

Secondary intention

Answer 19

Wound healing

Beefy, red tissue called granulation

Left open to drain and heal

5-21 days

Question 20

Cane use

Answer 20

Top of cane parallel to greater trochanter

Client moves can 18 in forward

Client holds cane on stronger side of body

Move weaker leg forward first

Question 21

Manifestations of thrombophlebitis

Answer 21

Calf swelling

Question 22

Cdiff and family

Answer 22

Family must gown and glove

Question 23

Assessing older adult for risk of falls (eyes)

Answer 23

Pupil clarity (cloudy-cataracts)

Visual fields

Visual acuity (distance vision, card for near vision)

*should wear glasses during assessment

Question 24

Anti-embolic stockings

Answer 24

Remove once per shift

Should keep on when sitting in chair

Avoid crossing legs

Question 25

TB nurse priorities

Answer 25

Negative pressure airflow room Wear gloves for oral care Nurse should wear N95 respirator Use antimicrobial sanitizer No need to limit visitors

Question 26

Role ambiguity

Answer 26

Person unclear of expectations

Question 27

Role conflict

Answer 27

Person assume opposite roles with incompatible expectations

Question 28

Priority assessment when admin IV fluid to older adult

Answer 28

Auscultation of lung sounds

Question 29

Narrowed arterial lumen

Answer 29

Arterial bruits blowing sounds Blood flowing through occluded or narrowed arteries

Question 30

Distended jugular veins

Answer 30

Produce no sound

Question 31

Impaired ventricular contraction

Answer 31

Produces extra heart sounds S3 or S4

Question 32

Asynchronous closure of aortic and pulmonic valves

Answer 32

“Splitting” of S2 Two “dub” sounds heard

Question 33

Urine specific gravity during fluid deficit

Answer 33

1.030

Question 34

Fluid volume excess

Answer 34

Neck vein distention

Question 35

Fluid volume deficit

Answer 35

Rapid heart rate Hypotension

Question 36

Chickenpox

Answer 36

Airborne