Ati nurs100 physical assessment exam
Total Questions : 27
Showing 25 questions, Sign in for moreA nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?
Explanation
Rationale:
A. "Kennet" is not a recognized food or beverage and is not known to cause bladder irritation. The question might include this as a distractor.
B. "Frestat" is also not a known food or beverage associated with bladder irritation and does not play a role in urinary incontinence management.
C. Dairy products generally do not cause bladder irritation. Although some individuals may experience sensitivity to dairy, it is not commonly associated with bladder irritation or incontinence.
D. Caffeinated beverages are known bladder irritants. Caffeine can increase urine production and stimulate bladder activity, leading to increased urgency and frequency, which can exacerbate urinary incontinence.
A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?
Explanation
Rationale:
A. Cold fluids are less effective in stimulating bowel movements compared to warm fluids. Warm fluids tend to promote peristalsis and help relieve constipation, making cold fluids a less appropriate option.
B. A low-fiber diet would worsen constipation. High-fiber foods are more effective in promoting bowel regularity by adding bulk to the stool, facilitating easier passage.
C. Mineral oil is not a first-line treatment for constipation due to the risk of nutrient malabsorption and potential complications like aspiration in bedridden clients. It should be used cautiously.
D. Increasing fluid intake is an essential intervention for constipation, especially for clients on bedrest. Proper hydration softens stools and helps in promoting bowel movements, reducing the risk of constipation.
A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor for pressure ulcer?
Explanation
Rationale:
A. Being male is not a significant risk factor for developing pressure ulcers. Pressure ulcers are more related to factors like immobility, nutritional status, and circulation.
B. Immobility is a major risk factor for pressure ulcer development. Clients who are immobile or confined to bed, especially for prolonged periods, are at higher risk due to continuous pressure on certain body areas, leading to skin breakdown.
C. Adequate hydration helps maintain skin integrity and is not a risk factor for pressure ulcers. Dehydration, rather than adequate hydration, can contribute to skin breakdown.
D. Anemia can impact tissue oxygenation, but immobility is a more direct risk factor for pressure ulcer development. Although anemia can slow healing, immobility leads to constant pressure on the skin, causing tissue breakdown and ulceration.
A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)
Explanation
Rationale:
A. A client with right-sided heart failure and 4+ edema is at risk for pressure ulcers due to fluid accumulation, which can impair circulation and increase the likelihood of skin breakdown.
B. A client who is ambulatory is at a low risk for pressure ulcers because frequent movement reduces the risk of prolonged pressure on any one area.
C. A client with type 1 diabetes mellitus and hyperglycemia is at risk for pressure ulcers because high blood glucose levels can impair wound healing and affect skin integrity.
D. A client with protein-calorie malnutrition is at a significant risk for pressure ulcers due to inadequate nutrition, which weakens the skin and impairs the body’s ability to repair tissue damage.
E. A client with postoperative delirium may have decreased mobility and cognitive awareness, making it harder for them to reposition themselves, thereby increasing their risk of pressure ulcers.
A nurse is teaching a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?
Explanation
Rationale:
A. Using a moisturizer after cleaning helps keep the skin hydrated, preventing dryness and cracking, which can increase the risk of infection.
B. Allowing the skin to air dry can lead to excessive dryness, especially in vulnerable areas, potentially compromising the skin’s integrity.
C. Rubbing the skin firmly can cause irritation, damage, and increased risk of skin breakdown, particularly in individuals with fragile skin.
D. Washing the skin daily with hot water can strip the skin of natural oils, leading to dryness and irritation, which increases the risk of infection. Warm water should be used instead.
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply)
Explanation
Rationale:
A. The opening of the pouch should be cut about 1/8 of an inch larger than the stoma to ensure a proper fit without restricting blood flow or irritating the stoma.
B. Placing a gauze over the stoma during a pouch change helps to absorb any discharge and keep the area clean while preparing the new appliance.
C. Povidone-iodine should not be used to clean around the stoma, as it can irritate the skin. The skin should be cleaned with mild soap and water or a recommended stoma cleanser.
D. A stoma that turns purple-blue is a sign of impaired blood flow and requires immediate medical attention. A healthy stoma should appear pink or red and moist.
E. The ostomy pouch should be emptied when it is about one-third full to prevent leakage, odor, and unnecessary pressure on the stoma.
A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?
Explanation
Rationale:
A. Although the adolescent in a halo brace has some immobility, the greatest risk factors for skin breakdown involve areas where prolonged pressure is applied, and older adults are more vulnerable due to age-related skin changes.
B. A fractured radius and arm cast do not pose a significant risk for skin breakdown because the client can still mobilize and reposition themselves, reducing prolonged pressure.
C. An older adult with a hip fracture in Buck's traction is at greatest risk for skin breakdown due to immobility, pressure from the traction setup, and the reduced skin elasticity and healing capacity that come with age.
D. While skeletal balanced suspension traction poses some risk, a young adult typically has better skin integrity and mobility than an older adult, reducing the risk for skin breakdown.
The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?
Explanation
Rationale:
A. Adequate nutrition actually promotes wound healing. Poor nutrition, especially a lack of protein and vitamins, delays healing and increases the risk of infection.
B. Chronic wounds heal better in a moist environment rather than a dry one. Moist wound healing promotes cell migration and prevents scab formation, improving healing.
C. Fat tissue does not heal more rapidly. In fact, it heals more slowly due to decreased vascularization, which impairs oxygen delivery and nutrient supply to the tissue.
D. Long-term steroid use diminishes the body’s inflammatory response, reducing the body's ability to initiate the healing process. This delay in inflammation can lead to slower wound healing and a higher risk of infection.
A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
Explanation
Rationale:
A. Clients receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP) often feel a constant urge to void due to the presence of the catheter and the irrigation fluid in the bladder. The nurse should reassure the client that this sensation is expected.
B. Weighing the client is not necessary for immediate postoperative care following TURP. Fluid balance is managed by monitoring urine output rather than daily weight.
C. Urine output should be monitored more frequently than every 6 hours in the immediate postoperative period, especially with continuous bladder irrigation, to ensure there are no blockages or complications.
D. Fluid restriction is not recommended after TURP. In fact, encouraging oral fluid intake helps maintain hydration and prevents blood clots in the bladder irrigation system.
A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
Explanation
Rationale:
A. A significant drop in blood pressure from 138/86 mm Hg to 90/60 mm Hg indicates potential hypovolemia or hemorrhage, which requires immediate intervention to prevent shock or other complications. This is the most critical finding among the clients.
B. A client with stable blood glucose levels between 110 mg/dL and 100 mg/dL is not a priority, as these readings are within a normal range and do not indicate immediate danger.
C. The transition of wound drainage from sanguineous to serosanguineous is a normal part of the healing process and is not an urgent concern.
D. A mild increase in pain from 1 to 3 on a 1 to 10 scale is also not an immediate priority, as it remains within a low pain range and can be managed with routine pain control measures.
A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?
Explanation
Rationale:
A. A guaiac test does not check for parasites. Tests for parasites typically involve microscopic examination of the stool or other specialized tests.
B. Steatorrhea refers to fat in the stool, and this is detected through tests that measure fat content in the stool, not a guaiac test.
C. A guaiac test is specifically used to detect occult (hidden) blood in the stool, which can indicate gastrointestinal bleeding, polyps, or colorectal cancer.
D. Bacteria in the stool is detected through stool cultures, not a guaiac test.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?
Explanation
Rationale:
A. Placing the client supine with knees bent helps reduce abdominal pressure, but it is not the first action. Protecting the exposed organs from infection or drying out takes priority.
B. Assessing for manifestations of shock is important, but the immediate concern is to prevent further injury or infection to the exposed tissues.
C. The priority action when a wound eviscerates is to cover the area with a sterile dressing moistened with 0.9% sodium chloride solution to keep the organs moist and prevent infection until surgical repair can be done.
D. Raising the head of the bed slightly may help reduce pressure, but it is not the most immediate action compared to covering the exposed organs to prevent drying or infection.
You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury: (Select All that Apply.)
Explanation
Rationale:
A. A quadriplegic client is at high risk for pressure injuries due to immobility and lack of sensation, which can lead to prolonged pressure on skin and tissues.
B. A Braden Scale score of 7 indicates severe risk for pressure injuries. The lower the Braden score, the higher the risk, with scores less than 9 signifying very high risk.
C. A client with controlled diabetes who is ambulating frequently is not at high risk for pressure injuries because mobility reduces the risk of sustained pressure.
D. A BMI of 13.6 indicates severe underweight status, and incontinence of stool increases moisture, both of which elevate the risk of pressure injuries. Additionally, the splint on the leg may create pressure points.
A nurse is providing teaching to a client who has a new colostomy, and had a bowel preparation before surgery. Which of the following information should the nurse include in the teaching?
Explanation
Rationale:
A. After a bowel preparation, it typically takes a few days for fecal output to occur from the new colostomy due to the emptying of the bowel before surgery.
B. Increasing raw vegetables immediately after surgery is not recommended, as they can cause gas and irritation to the bowel. Clients are usually advised to start with low-fiber foods and gradually introduce more fiber.
C. A healthy stoma should be pink to red in color. A purplish color may indicate compromised blood flow and should be reported to the healthcare provider.
D. A small amount of bleeding around the stoma is normal, especially when cleaning the area or changing the appliance, as the tissue is delicate and highly vascular.
A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?
Explanation
Rationale:
A. Serous drainage is clear and watery, which is typical during the early stages of healing and indicates normal wound healing.
B. Purulent drainage is thick and may appear yellow, green, or brown, indicating infection.
C. Serosanguineous drainage is a mix of serous fluid and small amounts of blood, typically pink in color, and is seen in wounds that are healing.
D. Sanguineous drainage is primarily blood, indicating fresh bleeding from a wound.
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?
Explanation
Rationale:
A. Cleansing the wound with 0.9% sodium chloride saline irrigation helps remove debris and bacteria from the wound surface, ensuring that the specimen collected for culture reflects the infection present in the wound rather than contaminants.
B. Including intact skin at the wound edges in the culture is not advisable, as it may introduce flora that do not represent the infection. The focus should be on obtaining a specimen from the wound itself.
C. Swabbing an area of skin away from the wound to identify normal flora is not relevant when assessing an infection. The culture should target the actual infected area to determine the causative organisms.
D. Irrigating the wound with an antiseptic prior to obtaining the specimen can alter the bacterial load present and lead to inaccurate culture results, as it may kill or wash away organisms that need to be identified.
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
Explanation
Rationale:
A. Applying cornstarch can absorb moisture; however, it may not be the most effective method to maintain skin integrity and can cause friction when applying.
B. A diet high in protein is essential for skin health and repair, as it supports tissue regeneration and helps prevent skin breakdown in vulnerable clients.
C. Massaging bony prominences is not recommended, as it may cause further tissue damage or disrupt circulation. Instead, padding and reducing pressure on these areas is more beneficial.
D. Repositioning the client every 3 hours may not be frequent enough for someone at high risk for skin breakdown; generally, repositioning should occur at least every 2 hours to alleviate pressure.
Mr. Jones injured his left shin 4 days ago. Upon removal of the dressing, the wound is noted to be red, no slough or drainage. Surrounding tissue is swollen and is painful to the touch. The wound measures 3cm by 5 cm. What phase of healing is the wound in?
Explanation
Rationale:
A. Stating that the phase cannot be determined is incorrect because the wound presents clear signs indicative of a healing phase.
B. The inflammatory phase of healing typically lasts for 3 to 5 days post-injury and is characterized by redness, swelling, warmth, and pain due to the body’s response to injury. The lack of slough or drainage, along with surrounding tissue swelling and pain, aligns with the inflammatory phase.
C. The proliferative phase follows the inflammatory phase and involves the formation of new tissue and the development of granulation tissue, which is not yet apparent in Mr. Jones's wound.
D. The maturation phase occurs after the proliferative phase, focusing on the strengthening and reorganization of collagen, which is not relevant as the wound is still in the inflammatory stage.
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. No drainage is noted. The nurse would treat the area with which dressing to promote healing?
Explanation
Rationale:
A. A wet-to-dry dressing is typically used for debridement and is not appropriate for a shallow pressure ulcer without necrotic tissue, as it can damage healthy tissue during dressing changes.
B. Leaving the area without a dressing is not advisable as it exposes the wound to contaminants and increases the risk of infection; a dressing should be used to protect the area.
C. A hydrocolloid dressing is ideal for shallow partial-thickness wounds as it provides a moist environment, promotes healing, and helps to cushion the area while maintaining a barrier against bacteria.
D. Alginate dressings are primarily used for wounds with moderate to heavy exudate and would not be suitable in this case due to the lack of drainage.
The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?
Explanation
Rationale:
A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.
B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.
C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.
D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
Explanation
Rationale:
A. Sanguineous drainage is characterized by bright red blood; it indicates fresh bleeding and does not include watery components.
B. Serosanguineous drainage is a combination of clear, watery fluid and blood, often appearing light pink to red. The description of watery red drainage fits this category, making it the correct choice.
C. Serous drainage is clear, pale yellow fluid without blood, indicating a non-bloody exudate. It does not match the description of watery red drainage.
D. Purulent drainage is thick, opaque, and often yellow, green, or brown due to the presence of pus and infection. It does not apply here as the drainage is described as watery red.
A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?
Explanation
Rationale:
A. Emptying the pouch when it becomes 1/3 full is appropriate and helps prevent leakage and odor. This statement shows understanding of proper pouch management.
B. Enteric-coated medications can be problematic for clients with an ileostomy as they may not dissolve properly in the digestive system, potentially leading to decreased absorption. The client should be aware that these medications may not be suitable for their condition.
C. Changing the entire pouch system at least weekly is a common recommendation to maintain hygiene and skin integrity. This indicates the client understands the need for regular pouch maintenance.
D. Caution when eating high-fiber foods is important, as these foods can cause blockages in the ileostomy. This statement reflects the client’s awareness of dietary considerations for managing their ileostomy.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?
Explanation
Rationale:
A. Changing the catheter once each shift is unnecessary and can increase the risk of infection. Catheters should be replaced only when clinically indicated.
B. Checking the catheter tubing for kinks or twisting is essential to ensure proper drainage and reduce the risk of infection. This action promotes unobstructed urine flow, which is critical for infection prevention.
C. Replacing the catheter every 3 days is not a standard practice; catheters should be changed based on clinical need rather than a set schedule. This could unnecessarily increase the risk of infection.
D. While cleaning the perineal area is important, using an antiseptic solution daily may cause irritation and disrupt the normal flora of the area. Routine cleaning with mild soap and water is typically recommended instead.
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
Explanation
Rationale:
A. Requesting an indwelling urinary catheter is not appropriate for preventing skin breakdown; catheters can increase the risk of urinary tract infections and skin irritation.
B. Cleaning the skin and perineum with hot water can cause irritation and dryness. Instead, using mild soap and warm water is recommended for cleaning.
C. Checking the client's skin every 8 hours may not be frequent enough for a client with incontinence, as more frequent assessments are needed to catch signs of breakdown early.
D. Applying a moisture barrier ointment to the skin protects it from moisture and irritants, helping to prevent skin breakdown in clients with urinary incontinence. This action is proactive and aligns with best practices for skin care.
A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?
Explanation
Rationale:
A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.
B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.
C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.
D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.
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