ATI Learning System RN: Fundamentals 1, 2, and Final
first nursing action when receiving a new patient
1. obtain the pts information -other steps that follow this include: identify goals of care, document nursing findings, evaluate effectiveness of care
*F2* a nurse is caring for a patient who is postoperative following a vaginal hysterectomy and ask for a drink. Her postoperative diet is clear liquids; advance as tolerate. What response should the nurse make?
"I am going to listen to your abdomen" - determine presence of bowel sound before giving clear liquids to prevent postop n/v, d/t delayed gastric emptying time or decreased peristalsis after surgery -When appropriate to resume post surgical diet it is preferable to offer a choice of clear liquids, rather than only water, a clear liquid w/ nutrients -Use therapeutic communication to meet pts needs
a nurse is assessing a patient who is to undergo treatment for ovarian cancer. what statement indicated the patient is experiencing psychological distress?
"I keep having nightmares about my surgery." -nightmares and sleep disturbances are manifestations of anxiety and PTSD -social and emotional support systems decrease risk of psychological distress -open communication can improve relationships
*F1* nurse teaching a group of older adults about the expected changes of aging. what statement indicates an understanding of the teaching?
"I should expect my heart rate to take longer to return to normal after exercise as I get older." -d/t decreased cardiac output which causes an increased pulse rate during exercise -Bladder capacity decreases w/ age but urinary incontinence is not an expected finding of aging -Have an increase of ear wax buildup which may increase incidence problems w/ hearing loss -Decreased gastric emptying is an expected finding
first priority action when performing tracheostomy care
1. perform hand hygiene -The nurse should also- don sterile gloves, open all sterile supplies and solutions, and stabilize the tracheostomy tube but they all will come after hand hygiene in order to prevent contamination of the trach tube
what statement should a nurse make when a patient with DM1 is resistant to learning self-injection of insulin?
"Tell me what I can do to help you overcome your fear of giving yourself injections." -therapeutic, pt able to express feelings
proper hand hygiene teaching to an AP. what statement by the AP indicates an understanding?
"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." -perform w/ warm water, friction applied to hands for 15-20 seconds, and drying should be done from the cleanest area to the least clean area (from the fingertips and up)
a patient becomes agitated when asked to remove their dentures before a surgery. what should the nurse's response be?
"What worries you about being without your teeth?" -therapeutic response that validates pts feelings and seeking clarification on those feelings
which instructions should the nurse include in the teaching of four-point crutch gait for a patient with lower extremity weakness?
"bear weight on both legs" -should have 3 points on the ground at all times -pp on axillae increases risk to underlying nerves- partial paralysis of arms -keep elbows flexed at 30 degrees -move each leg alternatively w/ each opposite crutch to maintain 3 points of support
A patient is scheduled for an arthroplasty in the next month and may need a blood transfusion. The patient expresses concern about the risk of developing an infection from the transfusion. What statement should the nurse make to the patient?
"donate autologous blood before the surgery" -collection and reinfusion of the pts own blood, blood is drawn 3-5 weeks prior to surgery; safest form of blood tranfusions -taking epoetin prior to surgery can boost HCT levels but is inappropriate if their levels are w/in normal and this might not eliminate need for transfusion -taking iron supplement can boost hemoglobin levels but inappropriate if levels are w/in range and may not eliminate need for transfusion -blood donated from family member doesn't eliminate a possible infection from transfusion
a nurse in a long-term care facility is admitting a patient who is incontinent and smells strongly of urine. his partner, who has been taking care of him at home, is embarrassed and apologizes for the smell. what responses should the nurse make?
"it must be difficult to care for someone who is confined to bed" -therapeutic and addresses partner's feelings
a nurse observes and AP using a small B/P cuff on an obese patient. What explanation should the nurse give the AP?
"using a cuff that is too small will result in an inaccurately high reading." -a cuff that's too small for an obese pt will not result in an inaudible reading or an accurate reading -a B/P cuff should take up no more than 40% the circumference of the pts arm
*F2* what question should the nurse ask to encourage discussion with a patient who has an onset of sever back pain of unknown origin?
"what do you think caused the onset of your pain?" -Open-ended is best response to get most info -Closed-ended q's are to obtain info quickly
*F2* a nurse is changing the dressings for a patient with 2 penrose drains near an abdominal incision. what is the best type of adhering device to decrease skin irritation?
*Montgomery straps* are the least restrictive; these adhesive straps are applied to the skin on either side of a surgical wound, adhesive strips have holes for gauze to tie dressing securely; ties are released to change dressing, dressing can be replaced w/out removing straps -*Abdominal binder* is effective in bed, but will not hold dressings in place during ambulation -*Hypoallergenic tape* can be used but can still cause skin sensitivity when repeatedly removed and reapplied -*Plastic tape* adheres to skin well and causes skin irritation when removed and reapplied
what actions should a charge nurse teach as the first response in CPR?
1. confirm unresponsiveness -nurse should also, call for assistance, give rescue breaths, and perform chest compressions but first must check pts pulse and monitor for chest expansion
what method of assessment should a nurse use first when assessing a patient who reports feeling bloated for several weeks?
1. inspection 2. auscultation 3. percussion 4. palpation
correct sequence of steps for an abdominal assessment
1. inspection 2. auscultation 3. percussion 4. palpation -prevents alerting the bowel sounds and causing false results
a nurse is responding to a parent's questions about his infant's expected physical development during the first year of life. what information should the nurse include?
10-month old can pull up to standing position -can do this from 8-10 months -turn from back to abdomen by 5 months -6-8 months can sit up w/out support -8-10 months can crawl
a nurse at a screening clinic assesses a patient who reports a history of a heart murmur related to aortic valve stenosis. at which anatomical region should the nurse place the stethoscope to auscultate the aortic valve?
2nd intercostal space to the right of the sternum -aortic stenosis causes a midsystolic ejection murmur heard clearly at the aortic area w/ pt leaning forward -5th intercostal space and medial to the clavicular line is the mitral valve -2nd intercostal space and to the left of the sternum is the pulmonic valve -5th intercostal space and to left of sternum is the tricuspid valve
what action by an AP indicates the need for further teaching about care of a female patient who has an indwelling urinary catheter?
AP hangs collection bag at level of bladder -place below bladder level to ensure proper drainage by gravity -cleanse perianal area w/ warm soap and water at least 3X/day to reduce risk of infection -should tape catheter to inner thigh of F pt to prevent pulling on urethra and decrease risk of infection -make sure there's no kinks to promote proper drainage by gravity
when should a nurse obtain a sputum specimen for a culture and sensitivity?
Collect specimen upon arising in the morning -pt is able to more easily cough up secretions that have accumulated during the night; pt should rinse the mouth, take a deep breath, and cough prior to expectorating into sterile container -nurse should encourage fluids to help thin respiratory secretions but should not collect specimen at night -collect before recieving antibiotic therapy -collect 4-10mL of sputum before sending to lab
*F2* what action should a nurse take first when a patient grabs her neck with both hands and appears frightened during mealtime?
Determine if pt can breathe -can place O2 mask on pt to provide supplemental O2; but other action 1st -should begin rescue breathing as part of CPR if pt becomes unconscious; but other action 1st -wrap arms around pt from behind to perform abdominal thrust if breathing is obstructed; but 1st ask if can breath
*F2* what action should a nurse take when replacing a surgical dressing on a patient who had abdominal surgery?
Don clean gloves to remove old dressing: this part is not sterile. -Remove tape by loosening and pulling toward wound or dressing to decrease tension/ stress on healing wound edges -Remove old dressings one layer at a time to prevent removal of drains and allow assessment of drainage -Open sterile supplies after removal of old dressing, after washing hands, and before applying sterile gloves to apply dressings and prevent contamination
*F2* nurse is changing the dressing for a patient recovering from an appendectomy following a ruptured appendix. what observation should the nurse report to the provider?
Halo of erythema on surrounding skin - might indicate underlying infection; other manifestations of infection include; sever pain, purulent drainage, swelling, warmth, strong odor should all be reported -Tenderness when touched, pink and shiny tissue w/ granular appearance, *serosanguineous drainage* are all expected findings -Pink, shiny tissue w/ *granular appearance indicates proliferative stage of wound healing*, and is expected for post-op wound healing *by 2ndary intention*
what information should a nurse include in the teaching for a patient who is learning how to use an insentive spirometer?
Hold breath for 3-5 sec after goal volume is reached. This decreases collapse of alveoli and helps prevent risk of atelectasis and pneumonia. -Inhale slowly to reach goal volume and decrease collapse alveoli -Breathe normally for short periods of time b/w each cycle of breaths to reduce hyperventilation and fatigue -Repeat patterns for 10-20 breaths q hr while awake, to prevent risk of atelectaiss and pneumonia
what should a nurse do first, prior to transferring a pt for a chest xray?
ID the pt using 2 pt identifiers -pt safety is key and a pt should only receive what has been prescribed to them -nurse should explain the procedure, nurse should have the pt ready for the procedures, and should ask if the pt has any questions
*F2* what finding indicates the toddler has an airway obstruction?
Inability of toddler to cry/speak -Nurse should use heimlich maneuver to dislodge obstruction -Cyanosis finding of poor oxygenation, indicates airway obstruction -Emesis (vomit) should be cleared from the oral cavity to prevent possible airway obstruction -Expected capillary refill time is <2 seconds
a nurse is planning to document care provided for a patient. which of the following abbreviations should the nurse use?
PC for after meals -approved, not error prone -BT (bedtime), SC (subcutaneous), HS (half-strength) should be avoided d/t possible confusion/ mistaken for other abbreviated meanings; use full word
*F2* what patient should a nurse plan to see fist when planning the care for a group of patients who are receiving oxygen therapy?
Patient who has HF and is receiving 100% O2 via partial rebreather mask: frequently check to ensure the bag inflates properly; if deflated pt will rebreathe own exhaled CO2 instead of Px O2; higher concentrations of O2 increase risk of pt injury -Pts w/ chronic lung conditions are educated on how to use transtracheal O2 cannula device; can provide adequate oxygenation w/ low flow rates -Client who has an old tracheostomy includes administration of humidified oxygen or air via tracheostomy collar. *Therefore, there is another client the nurse should plan to see first*. Nurse should administer humidified O2 or air via tracheostomy collar for an old tracheostomy to promote loosening of resp secretions and prevent cannula obstruction -routine COPD Tx is low dose O2 therapy which drives their resp rate
*F2* what action should a nurse take when removing a NG tube for a patient who had a partial colectomy?
Pinch the NG tube while removing it - to decrease risk of aspirating on gastric content -Disconnect from suction before removal to decrease injury to GI mucosa -Instill 50 mL of air into tube to clear contents of gastric drainage and decrease risk of aspiration -Pt should take a deep breath and hold it during removal process to close off glottis and prevent aspiration of gastric content
*F2* what action should a nurse take when performing suctioning for a patient who has a tracheostomy?
Pull suction catheter back 1 cm (0.5") if pt starts coughing or resistance is meet - this removes catheter from mucosal wall of trachea -Allow 1 min b/w suctioning passes to prevent hypoxia and hyperventilation -Hyperventilate w/ 100% O2 for at least 2 min before suctioning to decrease hypoxia -Perform max of 3 passes w/ the suction d/t risk of hypoxia and induced dysrhythmias
*F2* a nurse changing the dressing of a 3 day postoperative patient following a cholesystectomy observes yellow, thick drainage on the dressing. how should the nurse chart this type of drainage?
Purulent exudate - thick yellow/green/brown drainage which indicates wound sloughing/infection. -*Serosanguineous exudate*, indicates plasma mixed w/ blood drainage, pale yellow to blood-tinged or streaks of blood and watery drainage -*Serous exudate*, light yellow plasma from blood and watery -*Sanguineous exudate*, active bleeding; accumulation of RBC's from plasma that appears bright or dark red
*F2* a nurse is caring for a patient who has a history of dysrhythmias and upon entering the room discovers the patient is unresponsive to verbal or painful stimuli, has no repsiraitons, is pulseless. what action should the nurse take first?
Start chest compressions -Nurse should start CPR, which begins w/ chest compressions then opening an airway and breathing into pt mouth *CAB* -Can use a manual resuscitation bag to oxygenate pt during CPR
*F2* what findings indicates infiltration of the IV infusion site?
Taut skin around the IV catheter site that is cool to the touch: nurse should stop infusion, elevate extremity, and apply warm moist compress or cold compress according to type of infiltration -Redness at IV site indicates possible infection -Palpable cord felt along vein indicates phlebitis/inflammation of inner layer of vein: d/c infusion and start new IV -Bleeding might indicate IV system is not intact; might need to start new IV if bleeding doesn't stop
*F2* what nursing action indicates maintaining sterile technique when performing a straight urinary catheterization?
Wipes labia minora in anteroposterior direction, this destroys any microorganisms in the area that would contaminate the catheter. -Wipe from top to bottom using a separate cotton swab for both right and left labia minora and majora -Use nondominant hand to spread labia
a nurse should ensure that a written consent form has been signed by which of the following patients?
a pt who has a Px for a transfusion of RBC's -procedure which carries risk -pts admitted to hospital sign general consent form when admitted which allows consent for diagnostic exams -implied consent is given through acts such as holding out an arm or cooperation during painful, uncomfortable procedures
abdominal assessment of a patient postoperative with a paralytic ileum
absent bowel sounds w/ distention -paralytic ileus is an immobile bowel w/ absent bowel sounds, abdominal distention, decreased peristalsis, no flatulence or stool
what action should a nurse take when taking care of a child postop following a tonsillectomy?
administer analgesics on a routine schedule throughout the day and night -discourage child from coughing or clearing throat d/t risk of bleeding -nurse should offer ice collar to ease pain -milk products should be avoided because they can coat the throat and initiate coughing/ clearing throat; give ice chips
the nurse should convey the patient's pain status in which portion of the I-SBAR report?
assessment -Situation= problems pt experiencing -Background= medical history, lab findings, allergies, code status -Assessment= assessment data and findings collected by nurse for pt -Recommendation= recommendations about Tx and asks provider about additional Tx
a nurse is admitting a patient to a med-surg floor. what should be charted in the patient's medical record first?
assessment -plan of care, nursing interventions, and evaluation of progress should be charted but the assessment is the priority action
what actions by a nurse will improve a patients commitment to a long-term goal of weight loss?
attempt to increase pts self motivation -detailed records helps keep track of pts progress -testing learning helps determine whether outcomes are reached -anxiety interferes w/ learning and should be addresses early on in teaching
what should a nurse's priority action be when they notice a patient's pulse is irregular?
auscultate the apical pulse and listen for 1 minute to obtain and accurate rate and document the irregularity in the chart -check peripheral pulses bilaterally to determine equality of blood perfusion -check pedal pulses to determine circulation in pts lower extremities -a doppler ultrasound should be used when a pt has a nonpalpable pulse/ very difficult to palpate
a nurse is assessing a patient who has heart failure and has gained weight since her last visit and he ankles are edematous. what findings by the nurse is another clinical manifestation of fluid volume excess?
bounding pulse -sunken eye balls, hypotension, poor skin turgor are all expected findings of FVD
*F2* what action should a nurse perform first for a patient who has major fecal incontinence and reports irritation in the perianal area?
check the pts perineum - priority action is to collect more data by assessment All other response are correct but other action should be 1st. -should apply a fecal collection system to divert feces away from area of irritation -should apply barrier cream to decrease skin breakdown -should cleanse and dry area to decrease further breakdown
*F2* a nurse notes no urine output for a postoperative patient with an indwelling urinary catheter after 2 hours. what action should the nurse take first?
check to determine if catheter tubing is kinked; inspection is a priority action -If there's no kink, the nurse could also palpate the bladder or do a bladder scan to determine if there is urine in the bladder and can encourage to pt to drink more fluids to promote kidney perfusion -Nurse can obtain a *Px to irrigate* the catheter w/ .9% sodium chloride if absent urine is d/t obstruction from blood clots or sloughing of bladder tissue
*F2* a nurse is collecting a urine specimen for culture and sensitivity for a patient who has a UTI and an indwelling urinary catheter in place. what action should the nurse take?
clamp tubing below collection port - to allow fresh uncontaminated urine to collect before withdrawing specimen through port in a sterile specimen cup -Nurse should cleanse port w/ *antimicrobial* swab -Nurse should place the specimen in a *sterile* specimen cup to prevent contamination.
*F2* what should a nurse include in the teaching for a patient who has a new colostomy for proper care?
cleanse skin around stoma w/ warm water, b/c soap can leave residue and cause poor adherence of pouch adhesive -*Change bag before a meal* b/c drainage from ostomy is least likely to occur -*Change pouch every 3-7 days* to avoid skin breakdown around stoma -*Do not place aspirin in ostomy pouch* to decrease odor d/t stoma bleeding
*F2* a nursing caring for a patient who had a mastectomy and has a self-suction drainage evacuator in place. what actions should the nurse take to ensure proper operation of the device?
collapse device of air after emptying -To create suction to pull fluid exudate into collection area of device -Keep diaphragm of device compressed to maintain suction and prevent clotting of consanguineous drainage; not made for irrigating -Cleanse drain opening w/ alcohol wipe after opening to decrease entry of microorgs -Maintain drainage tubing below level of incision to enhance drainage
a newly licensed nurse is preparing to administer medications and notes a prescription that is unfamiliar to her. what action should the nurse take?
consult the medication reference book available on the unit -to become familiar w/ medication -should not rely on fellow coworkers for this info -only verify w/ provider if nurse believes it's a medication Px error -asking the pt if they take the med at home isn't sufficient enough
what action should the nurse take after discovering the wounds of a patient who is postoperative following an abdominal surgery has eviscerated?
cover the incision w/ moist sterile dressing -open wound= increased risk of peritonitis and exposed tissue can dry out and covering the wound is highest priority -have pt also lie on back w/ knees flexed to reduce pp on incision -notify surgeon also -also reassure the pt
what assessment provides the most accurate measure of a patients fluid status for a patient who has acute renal failure?
daily weight -gain/loss of 1 kg (2.2 lbs) indicates gain/loss of 1 L of fluid -B/P and USP can indicate gain/loss of fluid but not most accurate -I&O's reflect pts fluid status but not most accurate
what should a nurse do when an electronic B/P machine taking vitals on an instable patient every 15 minutes begins to measure the B/P at varied intervals and with inconsistent readings?
disconnect the machine and measure B/P manually Q15min -operating the equipment differently doesn't ensure accurate B/P readings
*F2* what action should a nurse take when instilling eye drops to a patient following an eye surgery?
drop eye medication in the *outer third* of lower conjunctival sac, to avoid putting drops on cornea and causing damage -apply gentle pp to nasolacrimal duct after instilling medication for 30-60sec to prevent medication from running down duct or out of eye -hold dropper .4-.8 inch away from lower conjunctival sac to protect cornea from injury -close eyes gently after instilling medication to avoid expelling it
nurse should identify which findings indicate infiltration of a peripheral IV site?
edema at infusion site -d/t fluid entering subcutaneous tissue -redness, warmth at site indicates phlebitis/ infection -oozing blood at site indicates that IV system isn't intact
a home health nurse is planning to provide health promotion activities to a community. what activities is an example of primary prevention?
educating pts about recommended immunization schedule for adults -primary prevention = education on disease prevention -secondary prevention focuses on measures to ID early stages of a condition; screening -tertiary prevention occurs after diagnosis of condition and focuses to limit complications
*F2* What action should a nurse take for a patient who has an NG tube for intermittent enteral feedings?
elevate HOB to 45 degrees before feeding -HOB elevated b/w 30-45 deg to prevent aspiration -Auscultate bowel sounds before each feeding to ensure peristalsis activity -Formula at room temp before administering to prevent cramping/discomfort -Flush tubing w/ 30 mL water after enteral feeding to maintain patency
terminal illness and questions directed to nurse about religion and death
encourage the patient to express feeling about death and dying -therapeutic technique of reflection
priority nursing action for a patient admitted with decreased circulation of the left leg
evaluate pedal pulses -nurse should also obtain a medical history, assess vitals and assess for leg pain but these aren't the first priority
*F2* what action should a nurse take when performing eye irrigation on a patient exposed to smoke and ash?
exert pp on the bony prominences when holding the eyelids open - hold upper eyelid on the brow and lower lid on the cheekbone -Hold irrigator 1 in from eye to prevent irrigator from touching eye and solution from damaging eye -Direct solution onto lower conjunctiva sac to prevent injuring cornea and having contaminated fluid down nasolacrimal duct -Irrigate from the inner canthus to the outer canthus of eye to prevent injuring cornea and contaminated fluid from going down the nasolacrimal duct
*F2* what action should a nurse take first for a patient who is being prepared for the insertion of a NG tube?
explain the proceudre -measure length of tubing to be inserted to ensure proper tube placement (nose to ear lobe, ear lobe to xyphoid process) -place pt in high fowler's sitting position (90), more easily insert NG tube and allow gravity to help facilitate passage of tube -provide water to facilitate swallowing during insertion
*F2* what intervention should the nurse use when speaking to a patient who has a hearing problem?
face pt when speaking -should speak toward best/normal ear -nurse should accentuate words, especially consonants but exaggerated lip movements inhibit lip reading ability -shouting/yelling can cause distortion
*F2* what information should a nurse include in teaching to a group of nurses about wound healing by secondary intention?
granulation tissue (beefy, red tissue) fills wound during healing: wound left open to drain and heal by 2ndary intention that occurs w/in 5-21 days -Open wound places pt at greater risk for infection -*Primary intention* occurs when closing of wound using sutures or staples occurs at same time incision is made; suture line edges become well-approximated during healing -*Tertiary intention* includes using sutures to close an open wound at a later date after the wound drains and starts to heal or re-closer of a open that was previously closed
An ER nurse is assessing a patient who reports diarrhea and decreased urination for 4 days. What action should be taken to assess skin turgor of the patient?
grasp a skin fold of the chest under the clavicle, release it , and note whether it springs back -pushing on the pts nail beds determines capillary refill time -pressing the skin above the ankle for 5 seconds is used to determine pitting edema -measuring skin fold thickness is used to determine body fat percentage
*F2* what action should a nurse take when changing the linens of a patient who is on bed rest?
hold linens away from body and clothes -prevent soiling and transmission of microorganisms -place soiled linens in linen bag immediately to prevent spread of microorganisms -shaking the linens can spread dust and microorganisms in the air and increase risk of infection
*F2* what action should a nurse take when administering a cleansing enema to a patient who is scheduled for a diagnostic procedure?
insert tip of tubing 8 cm (3.1 in) -Insert 7-10 cm (3-4in) along rectal wall to prevent dislodging tube during procedure and injury to rectal mucosa -Lubricate 2-3in of tip before inserting to decrease risk of irritation and injury -Position pt on L side in Sims position to allow solution to flow downward into sigmoid colon and rectum and promote retention of enema -Hold container a max of 45 cm (18 in) above rectum to prevent painful distention of colon
a nurse is providing dietary teaching for a patient who has heart failure. what is the most important factor in determining a patient's ability to learn new dietary habits?
involvement of the pt during the planning -provider emphasis of teaching, the nurses learning theory, and the extent of changes can have an influence on the pts ability to learn but these aren't most important
a nurse should instruct a patient that large doses of acetaminophen could cause what adverse effect?
liver damage -limit daily intake to 3-4 g/d for health individuals and 2.4g/d for older adults w/ history of liver impairement -constipation and respiratory depression = adverse effect of opioids -gastric ulcers= adverse effect of NSAID's
transferring a patient from a stretcher to a bed following an abdominal surgery
lock the wheels of the stretcher and the bed -pt should cross their arms over the chest to prevent injury -stretcher should be no more than 1.3 cm above the height of bed -logroll technique used to prevent injury of pts requiring immobilization of neck, back, spine
*F2* at what location should a nurse anchor the tubing of a urinary catheter for a male patient?
lower abdomen or upper aspect of thigh to eliminate penoscrotal angle and prevent tissue injury -can cause discomfort and tissue injury when secured to lateral/ outside of the thigh, mid-abdominal region -can cause discomfort and pressure on urethra at penosacral junction and lead to tissue injury when secured at medial thigh
a patient starts to experience a seizure while sitting in a chair. what actions should the nurse take?
lower the pt to the flood and place a pad under pts head -reduce risk of injury -avoid inserting anything into the mouth d/t injury such as broken teeth -do not attempt to lift during active seizure
a nurse is preparing a patient scheduled for a hysterectomy for transport to the OR and the patient states they no longer want to surgery. what should the nurse do frist?
notify the provider about the pts decision -be a pt advocate -pt has a right to refuse -only the surgeon and pt can make the decision of cancelling the procedure -respect pt confidentiality
proper surgical hand-washing tehcnique
nurse washes w/ hands held higher than elbows -water and soapsuds wash frain away from clean area to dirty area -nails should be stroked w/ 15 strokes and each other part of the hand w/ 10 strokes -scrub hands first then work your way to the elbows -scrubbing is done w/ special brush and mechanical friction is necessary
after helping to reposition a patient who reports SOB what actions should the nurse take next?
observe rate, depth, character of pts respirations -priority: nurse must first assess and collect further data before notifying the provider or applying another nursing intervention -nurse can also encourage deep breathing -nurse can administer O2 if pt is experiencing dyspnea -nurse can give pt a back rub to promote relaxation to reduce dyspnea
What action by a newly licensed nurse during tracheostomy care requires intervention?
obtaining cotton balls for tracheostomy care -cotton balls can be aspirated possible causing tracheal abscess -high-strength peroxide solution is used to clean inner cannula -trach care is sterile procedure and sterile gloves are needed -pipe cleaners, small sterile brush can be used to remove thick/crusty secretions from inner cannula
*F2* a nurse caring for an older patient who has dysphagia after a CVA. what action should the nurse take when assisting the patient at mealtime?
offer tart/sour foods first - promotes saliva production which helps w/ chewing and swallowing -Higher risk of choking when liquids are offered w/ pts food, recommended 'dry swallows' clear mouth btw bites -Pt w/ impaired pharyngeal swallowing should tilt head forward to promote swallowing -Minimize any distractions at mealtime in order to focus on chewing and swallowing
patient who has chest pain that worsens upon inspiration and a high-pitched scratching sounds is auscultated during systole and diastole by the nurse with the diaphragm of the stethoscope positioned at the left sternal border. What heart sound should the nurse document?
pericardial friction rub -pericardial friction rub high-pitched scratching, grating, squeaking leathery sound heard best w/ the diaphragm of the stethoscope at the left sternal border -common manifestation of pericardial inflammation; can be heard w/ ineffective pericarditis w/ MI, following cardiac surgery or trauma, or some autoimmune disorders such as rheumatic fever -typically has signs of chest pain that increases w/ inspiration or coughing and is relieved by sitting up or leaning forward -audible click, occurs in pts after prosthetic valve replacement surgery -murmur = swishing, whistling sound, hear best w/ bell of stethoscope -third heart sound = low-pitched sound after 2nd heart sound caused by rapid ventricular filling during diastole, best heard at mitral area w/ pt on L side; commonly heard in pts w/ HD and indicative of HF
*F2* what action should a nurse take when collecting a stool specimen for ova and parasites from a patient who has diarrhea?
place in biohazard bag - w/ label placed on container and bag, for easy identification and prevent contamination -Pt defecate into bedpan, avoid contamination in toilet -Sterile container not required, place stool specimen in clean container using tongue depressor -Send specimen to lab immediately after labeling to prevent contamination
a nurse is providing oral care for a patient who is unconscious. what action should the nurse take?
place pt in lateral position w/ head turned to side before beginning to reduce risk of aspiration of fluids and secretions -use padded tongue blade to keep mouth open and prevent injury to nurse -use alcohol-free mouth wash or water to rinse mouth of pt -use foam swab b/c lemon-glycerin dries and irritates mouth and can cause teeth damage
a nurse is obtaining a lower extremity B/P. what action should the nurse take?
place the bladder of the cuff over the posterior aspect of the thigh -should position the cuff 2.5 cm above popliteal artery -measure w/ pt prone or supine w/ knees flexed -auscultate B/P at popliteal artery
what transferring technique should a nurse use when a patient is unable to to walk from bed to a wheelchair?
place the wheelchair at 45 degree angle to bed -allows pt to pivot, lessening amount of rotation -nurse should stand in front of pt and toward the side requiring more support -the pt should be instructed to lean forward from the hips -nurse should assume a wide stance
a nurse demonstrates postop breathing and coughing excises to a patient having an emergency surgery for appendicitis. What statement indicates the patient has a lack of readiness to learn?
pt reports severe pain -pt w/ pain is unable to concentrate and perform exercises -Pt asking to repeat the instructions, how often to perform the exercises, and stating that it will probably be painful to perform them. Are all statements that show a readiness to learn
what action should a nurse plan to take when performing oral care to an unresponsive patient?
raise the level of the bed -allow proper body mechanics -raise HOB to 30 degrees or turn pt to side-lying position to prevent aspiration -lower side rail on the side you are standing on to prevent strain and promote use of proper body mechanics -do not insert finger into mouth of unresponsive pt to avoid care-giver injury
an older adult is prescribed soft wrist restraints. what actions should the nurse take while the patient is on restraints?
remove restraints one at a time -for a pt who is violent/ noncompliant -do not tie restraints to side rails d/t risk of pt injury -remove restraints to perform ROM exercises Q2 -restraint pre3scription can only be written for 24hrs, no PRN
*F2* what action should a nurse take first when changing the gown of a patient with an IV infusion that is on an infusion pump?
remove sleeve of gown from arm w/out IV line - will enable nurse to move gown fully off (first action), and last stop the system to remove the gown off the line, resulting in minimal interruption of the IV flow. -Should slow infusion rate using the roller clamp while changing the gown; evidence-based practices recommend other actions 1st -should disconnect the IV line from pump while removing and reapplying gown quickly to maintain infusion rate Px w/ pump; evidence-based practices recommend other actions 1st -should bring IV solution and tubing through outside to end side of the sleeve of gown to prevent tangling of the tubing and gown; evidence based practices recommends other actions 1st
*F2* what intervention should the nurse include in the plan of care for a patient who is confused and requires a prescription for wrist restraints?
renew Px for use w/in 24 hrs: only after provider has evaluated pt in person -Should secure restraints w/ softer side next to pt skin -Ensure 2 fingers can be inserted under restraint -Remove restraints at least every 2hrs and check pts skin, change pt position, or exercise pt, and check ROM
what action should the nurse take when a patient is performing passive range-of-motion exercises?
repeat each joint movement 5X during each session - PROM is inniated by the nurse -repeat 3-5X -should move joint to point of slight-resistance -stand at side of bed closely to joint being exercised -should exercise large joints 1st
secondary prevention of the seasonal influenza
screening groups of older adults in a nursing care facility for early influenza manifestations -*2ndary prevention focuses on preventing complications of illness and providing care to prevent illness from becoming severe* -holding a comm clinical and administering a vaccine is ex. of *primary prevention* -education on the dangers of influenza is ex. of *primary prevention* -finding rehabilitation programs for older adults w/ influenza complications is ex of *tertiary prevention*
*F2* what site should a nurse select for an IM injection site for an overweight patient?
side hip b/w iliac creast and anterior iliac spine: forms the boundaries for ventrolgluteal injections -IM injection @ dorsogluteal site is the upper lateral quadrant of buttocks -Outer, posterior tissue of pts arm is for a subcutaneous injection: for IM injections of <1 mL into the deltoid, nurse must place 4 fingers on deltoid mm and place injection at site of 3 finger widths beneath acromion process (5cm or 2") -For IM injection using the vastus lateralis site, the nurse should select the middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh
what is the nurse affirming by witnessing a patient sign an informed consent for surgery?
signature is the pts -not necessary for the nurse to witness the explanation of the procedure -providers responsibility to determine the pt fully understands the procedure and the risks and benefits of it
what action should a nurse take when observing a patient with terminal cancer is crying?
sit and hold the pts hand -therapeutic communication of silence, touch, and offering of self -other responses do not respond to pts immediate needs
teaching for an older adult who has constipation
sit on the toilet for 30 minutes after eating a meal -increased peristalsis occurs after eating, sitting on the toilet for 30 min after eating is recommended bowel retraining to treat constipation -consume a minimum of 1500 mL of water increase intake of coarse-fiber and whole grains, not refined-fiber -do not use daily softeners because it hinders bowel retraining process
a nurse is inserting an IV catheter and spills blood on his/her gloves. the patient has jno known blood infection. what should the nurse's following action be?
take the gloves off carefully and follow w/ hand hygiene -washing hands w/ gloves on isn't recommended -preparing an incident report and asking the provider to order a blood culture are not needed b/c no further info is needed to gathered
a nurse is planning care for a patient complaining of abdominal pain. An assessment reveals a temperature of 102.6F, heart rate of 105 bpm, soft nontender abdomen, and menses overdue by 2 days. what is the nurse's priority?
temperature -fever and pain can contribute to an elevated HR -soft nontender abdomen is an expected finding -irregularity of menses is common finding for a pt under stress
a nurse is planning on obtaining vitals on a 2 year old patient who is experiencing diarrhea and might have a right ear infection. how should the nurse get the patient's temperature?
temporal -not as accurate as the rectal but it's noninvasive and can be used on a toddle that might have an ear infection -child is under 3 yrs of age so the oral route isn't appropriate -tympanic route should be avoided d/t possible ear infection -rectal route should be avoided d/t diarrhea (however, most effective route for children)
*F2* what action should a nurse take when applying antiembolitic stockings to a patient who has a history of deep vein thrombosis?
turn stockings inside out up to heal before applying - makes application easier and cause less constriction wrinkles -Should apply another size of stockings if too long b/c this can decrease venous return and cause skin irritation -Remove stockings q shift and check circulation -Should slide stocking over pts calf all at once to lessen constrictive wrinkles that can decrease venous return
*F2* what action should a nurse take to decrease risk of falls when assisting an older adult patient in ambulating after being on bedrest for 3 days?
use gait belt during ambulation; to keep pt center of gravity midline and decrease fall risk -Wear nonskid shoes or slippers for ambulation -Dangle legs on edge of bed for *1 min* before ambulation -Walk *beside* pt to provide physical support and decrease fall risk
*F2* a nurse is planning to administer pain medication to a patient who has pain following abdominal surgery. what action should the nurse take first?
use pain scale to determine pts pain level -Think Maslow's hierarchy, meet pts physiological needs first -should discuss adverse effects of pain meds w/ pt; but another action should be 1st -should obtain VS before choosing an intervention to relieve pain to provide a baseline to compare to when monitoring after treating pain; but another action should be 1st -should check for pt allergies; but another action should be 1st
*F2* to promote healing & fight infection, what vitamins and minerals should a nurse plan to increase in the patient's diet?
vitamin C and zinc - both help fight wound infection; should receive multivitamin of both and a mineral supplement of both; vitamin E supp are needed to aid in skin and wound healing -Vitamin D used w/ Ca to prevent osteoporosis -Vitamin K is important for clotting factor and impaired intestinal synthesis caused by antibiotics; Fe is needed to rebuild RBC's for pt
the provider instructed a patient recovering from lung cancer he could resume lower-intensity activities of daily living. what activities should the nurse recommend to the patient?
washing dishes -cleaning windows and -sweeping is moderate-intensity -shoveling snow is high-intensity
*F2* what intervention should a nurse plan to include to monitor a patient's weight when the patient has fluid volume excess?
weight the pt on arising - after voiding and before breakfast. -accurate daily weighing is the easiest way to measure volume status -calibrate scales to 0 each day before use -use same scale each time -weight taken w/ same type of clothing each time
