ATI Moderate Fundamental 3.0

Enema for softening the feces

Administer an oil retention enema prior to the removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client. Carminative = expel flatus Hypertonic fluid = cleanse the client's bowel in preparation for surgery Sodium polystyrene sulfate enema = who has a high potassium level

The client's wound has eviscerated SATA

Place the client in a supine position with hips and knees flexed to prevent further tearing Cover the wound and intestine with a sterile, moistened dressing 0.9% NaCl to prevent further contamination Monitor the client for manifestations of shock; the nurse should monitor the client for increased heart rate and RR, changes in blood pressure or mentation and cool or clammy skin

A client is incontinent and smell strongly of urine, his partner is embarrassed and apologizes for the smell

Say, " It must be difficult to care for someone who is confined to bed." = nonjudgmental and encourages the partner to express her feelings

Class about body mechanics for country office workers SATA

Sit with your back supported Keep your knees at hip level Use an ergonomically designed computer keyboard *keeping the upper arms and elbows close to the body limits straining of the shoulders and the upper back muscles *tilting the screen and tilting the head to look at it can strain the cervical spine

Teaching a newly licensed nurse about pain management in clients age 65 and older

They are reluctant to report pain because they might not want to bother or anger caregivers and might believe that pain is expected

Would healing by secondary intention

Granulation tissue fills the wound during healing A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5-21 days. Open wounds increase the risk of wound infection Primary intention = closing with sutures or staples at the time the incision is made => well-approximated during healing Tertiary intention 1. using sutures to close an open wound at a later date after the wound drains and start to heal 2. placing grafted skin over the client's wound; grafting is required for deeper wounds such as full-thickness burns

A gastric ulcer patient, nurse should explain that prolonged exposure of the body to stress can also cause?

Hyperglycemia; stress causes an increased secretion of cortisol, which can lead to HTN and hyperglycemia *Prolonged stress can lead to platelet aggregation and can increase the client's risk of MI and stroke

Be careful of abbreviations

PC for after meals no abbreviation for these example, "bedtime." "subcut" or "subcutaneously" "half-strength"

Thyroid gland assessment before inspect and palpate

Instruct patient "Tilt your head back and swallow."