Fundamentals ATI & RN 3.0
abdominal binder
hold dressings in place and decrease skin irritation BUT- when pt ambulates, the dressing slides out
a nurse is providing teaching to an older adult client who has constipation, what should the nurse include in the teaching?
"sit on the toilet 30 min after eating a meal"
airbone precautions
(measles, varicella, TB) -masks
Droplet precautions
(rubella, pneumonia, step. pharyngitis) -masks
contact precautions
(shigella, wound infections, scabies, multidrug resistant organisms, MRSA, impetigo, herpes simplex) -gown and gloves
hypovolemic shock
*most common* loss of circulating blood vessels (supply issue, body cannot meet demands)-body can shift up to 10% of blood to support CO (anything higher than this- the body is compensating) cause: trauma and burns
ventrogluteal site
*preferred site for an adult client* & safest
sanguineous drainage
-RBC mixed with the plasma -thick and reddish/bright red bright drainage (fresh bleeding) dark drainage (older bleeding)
stage 3 pressure ulcer (full thickness skin loss)
-damage or necrosis -extends down but not through -deep crater with or w/o undermining or tunneling -WITHOUT exposed bone/muscle -infection and drainage are common!!!
stage 4 pressure ulcer
-destruction, tissue necrosis, damage to muscle/bone -can be deep pockets of infection/undermining/tunneling, eschar (black scab like material), slough (yellow/tan/green scab like material) *apply calcium alginate*- for wounds with a lot of exudate
a nurse is performing a mental status exam on a client who has dementia. what should the nurse do to evaluate the pt's ability to think abstractly?
-discuss the meaning of a common proverb subtract 7 serially from 100 (attention span), previous illness (remote memory), what to do if there is a fire (judgment)
vastus lateralis site
-divide thigh into 3 equal parts between greater trochanter and knee -use middle third portion -divide anterior thigh in half and lateral thigh in half -give injection anywhere in rectangle formed
a nurse is planning to assess the abdomen of a pt. which of the following should the nurse use first? -inspection -auscultation -percussion -palpation
inspection
Crutch instructions
-don't alter after fitting -support body weight at the hand grips with elbows flexed at 30 degrees -position crutches on the unaffected side when sitting or rising from a chair -15 cm (6 in) to the side and front of the client's feet (forming a triangular position) when using stairs: put all the weight on uninjured foot and step up on first step, bring crutches into the step, then bring up affected leg
routine health screening
-eye exam every 2 years -PAP every 3 yr (30-65) -mammogram annually (45) -colonoscopy every 10 years
Romberg test
-have pt stand with feet together and arms at the sides (first with eyes open, then closed) + Romberg test= can't maintain balance
purulent exudate
-infection -thick yellow, green, or brown drainage -foul odor
Stage 1 pressure ulcer (nonblanchable erythema)
-intact skin -usually over a bony prominence -feels warmer/cooler to adjacent tissue -discomfort at site
cane instructions
-keep on stronger side of body -support body weight on body legs -move the cane forward 15 cm (6-10 inch) -then move weaker leg forward -next stronger leg (cane forward, weak leg, strong leg)
Primary intention healing
-little to no tissue loss -edges are approximated -heals rapidly -low risk for infection -no or minimal scarring ex: surgical wound closed w/ staples, sutures, glue to seal laceration
secondary intention healing
-loss of tissue -edges are widely separated -longer healing time -increase risk of infection -scar -heals by granulation tissue filling the wound ex: pressure ulcer left open to heal
Hydrogel dressing
-mostly water -gels after contact w/ exudate (fills dead space in a wound) *for deep infected wounds, or necrotic tissue* *not for moderately to heavily draining wounds* *provides a moist wound bed* *can stay in place for 3 days*
24 hour urine specimen
-must remain chilled and can not contain anything but urine (no menstrual blood)
when preparing to transfer a client who is unable to walk from a bed to a wheelchair what should you do?
-place the wheelchair at a 45 degree angle to the bed -stand on the pt side that requires the most support (weak side) -have the pt lean forward with the hips, not backward
serosanguineous drainage
-plasma mixed with light blood drainage -pale yellow to blood tinged -can also be watery
serous drainage
-portion of the blood that is watery and clear/slightly yellow in appearance ex: fluid inside of blisters
when inserting a cleansing enema to a client:
-position pt on the Left side (allows the enema to flow into the sigmoid, then descending colon)
a nurse is caring for a pt that has a cuffed endotracheal tube in place. what is the purpose of inflating the cuff?
-preventing aspiration of secretions -preventing air leaks -stabilizes position of the tube (DOES NOT HOLD IT IN PLACE) -pt cannot speak
when instilling eyedrops
-put the medication into the conjunctival sac & apply pressure to the puncta for 1-2 minutes -have pt close eyes gently but AVOID blinking -look upward -hold dropper 1-2 cm (.4-.8 inch) away from eye
stage 2 pressure ulcer (partial thickness)
-reddish, pink bed w/o slough or bruising -edema -pain and scant drainage -look like an abrasion, blister or crater *hydrocolloid dressing*
kidney function
-regulate body fluids -regulation of acid base balance
Hydrocolloid dressing
-swells in the presence of exudate -composed of gelatin and pectin -forms a seal at the wound's surface to prevent evaporation of moisture *maintains a granulating wound bed* *can stay for up to 7 days*
lung secretion pH
>6
A nurse is caring for a pt who has a 101.7 temp. what should the nurse do?
keep the pt bed linens dry -in order to maximize heat loss
Scoliosis
lateral curvature of the spine
a nurse is assessing the pH of a client's gastric fluid to confirm placement of an NG tube in the stomach. which of the PH values should the nurse expect?
2 pH for gastric fluid is b/t 0-4
Modified Trendelenburg position
legs above the level of the heart -prevent and treats hypovolemia & venous return
BP cuffs that are too large...
give a falsely low reading
Self-adhesive, transparent film
A temporary "second skin" ex: for small, superficial wounds
sims' or semi-prone position
halfway b/t lateral and prone positions -lower arm is behind while upper arm is in front -comfortable sleeping position and promotes oral drainage
Woven gauze (sponges)
Absorb exudate from the wound
strabismus
Crossed eyes resulting from a weakness in eye muscles
Protective precautions
HEPA filtration, mask for pt when out of room, positive airflow ex: pt w/ compromised immune system
Fowler's position
HOB 45-60 degrees -ex: NG suctioning
High Fowler's Position
HOB 60 to 90 degrees -promotes lung expansion by lowering the diaphragm & relieves SOB -prevents aspiration
insensible fluid loss
Occurs daily through lungs and skin-cannot be measured for accurate output skin: 500-600 mL lungs: 400 mL
A nurse is planning to document care. which of the following abbreviations should the nurse use?
PC for after meals -approved and not error prone
Semi-Fowler's Position
Supine with the HOB elevated 15-45 degrees (usually 30) -prevents regurgitation of enteral feedings & aspiration -promotes good lung expansion for SOB or those w/ mechanical ventilation
air conduction is less than bone condutction
hearing loss
a nurse is caring for a pt getting a blood transfusion. the pt states flank pain and has reddish brown urine in the catheter bag. which of the following transfusion reactions is occuring? a. hemolytic b. febrile c. circulatory overload d. sepsis
a-hemolytic
which of the following muscle groups is responsible for movement at the knee joint?
antagonistic
when using a portable ultrasound bladder scanner to measure a pt's post-void residual volume, the nurse should?
apply light pressure to the scanner head once it is in position -pt should urinate 10 min before screening -pt should be in a supine position (put scanner head 2.5-4 cm, 1-1.6 inch above the symphysis pubis)
When inserting an indwelling urinary catheter- what should the nurse instruct the pt to do?
bear down
4 point crutch gait
bear down on both of your legs -pt should keep 3 points on the ground at all times -move each leg alternatively
Trendelenburg position
bed is tilted w/ HOB lower than foot of bed -postural drainage and venous return
foods high in fiber
black beans, whole grains, brown rice (not white)
circulatory overload reaction
blood is administered too quickly for the pt circulatory system to handle -SOB (dyspnea, coughing, HA, HTN)
a home health nurse is visiting an older adult client with severe dementia. the pt's son who is the primary caregiver reports being exhausted from working part time and caring for his mother at home. which should the nurse suggest? a. rehabilitation b. assisted living c. respite care
c- respite care -service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance -rehabilitation is for pt after and illness or injury (severe dementia will not improve with rehab)
a nurse is collecting a urine specimen for culture that has an indwelling urinary catheter. what should the nurse do?
clamp the tubing below the collection port ( to allow fresh uncontaminated urine to collect)
lordosis
curvature of the lumbar spine -common in toddlers or pregnancy
kyphosis
curvature of the thoracic spine -common among older adults -hunchback
hypovolemic shock symptoms
depends on amount of blood volume lost -increased HR -clammy, cool skin -decreased BP -decreased urine output -delayed capillary refill -decreased LOC
Nonadherent Material (Dressing)
does not stick to wound bed
unstageable pressure ulcer
eschar or slough obscures the wound -depth of injury is unknown *apply proteolytic enzyme*-softens eschar
Reverse Trendelenburg's position
foot of the bed is lower than the head of the bed -gastric emptying, prevents GERD
Calcium alginate
for wounds w/ a lot of exudate (ex: stage 4 pressure ulcer)
BP cuffs that are too small...
give a falsely high reading
Deltoid Site
located by placing four fingers across the deltoid muscle with the top finger along the acromion process. injection site is 3 fingers below acromion process
prone
lying flat on abdomen and chest with head to one side & back in correct alignment -promotes drainage from the mouth after throat/oral surgery -inhibits chest expansion -short term use only
lateral or side-laying position
lying of side w/ most of weight on dependent hip and shoulder and arms in flexion in front of body -pillow under head and neck -*30 degree lateral is essential for pt @ risk for pressure ulcers*
supine or dorsal recumbent position
lying on back with head and shoulders elevated on pillow and forearms on pillows at the side -foot support prevents a foot drop
a nurse is changing dressing for a client who has 2 penrose drains near an abdominal incision. which of the following adhering devices should be the best choice?
montgomery straps
Antagonist Muscle Group
movement of joints by contracting while others relax
Synergistic muscle groups
muscles that work in concert with one another -ex: 2 muscles contract
purosanguineous exudate
newly infected wound -mix of pus and blood
a nurse is measuring a pt and notes a loss in height from the previous year. the nurse should identify this as what?
osteoporosis -early indication is loss of height (d/t loss of calcium in the vertebrae)
infiltration of IV
pallor, local swelling at IV site, taut skin, cool to the touch
Phlebitis
palpable cord along a vein (a red line up the arm), pain, edema, throbbing, increased skin temperature
client who has pain with inspiration. high pitched scratching sound during systole and diastole at L sternal border. which should the nurse document?
pericardial friction rub
macrobiotic diet
plant based but includes fish and seafood
flexitarian diet
plant based w/ occasional meat fish and dairy
Hemolytic transfusion reaction
pt blood is incompatible with the donors blood -chills -low back pain -hypotension -tachycardia
Febrile hemolytic reaction
pt blood is sensitive to the WBC and platelets in the donors blood -fever, chills, HA, flushing
a nurse is inserting an NG tube and the pt begins to cough and gag. What should the nurse do?
pull the NG tube back slightly -instruct the pt to breathe slowly *do NOT remove if pt begins to cough or gag* *do NOT insert is pt is coughing*
A nurse is changing the dressing for a pt who is 3 days post op. the nurse observes yellow, thick, drainage on the dressing- what should she document this type of drainage as?
purulent exudate
the site around a peripheral IV catheter is red and feels warm. what should the nurse do?
remove the IV -could be phlebitis -then apply a warm compress
a nurse is giving an IM injection to a client who is overweight. which of the following sites should the nurse select?
side hip b/t the iliac crest and anterior iliac spine
orthopneic position
sits in bed or at the bedside w/ a pillow on the overbed table resting arms on the overbed table -good for COPD pt's
Montgomery straps
special adhesive strips that are applied when dressings must be changed frequently at the surgical site -have holes for using gauze to tie the dressing securely -when the dressing is changed, the ties are released, dressing is replaced, and ties are secured again WITHOUT removing the adhesive strips
antigravity muscles
stabilize joints; these muscles continuously oppose the effect of gravity on the body and permit a person to maintain an upright or sitting posture
skeletal muscle group
supporting posture and voluntary movement
ovo-vegetarian diet
the only animal foods consumed are eggs
a nurse is teaching a middle aged pt who has a sedentary job. what should the nurse include?
the pt's basal metabolic rate could decrease -basal metabolic rate decreases as adipose tissue replaces skeletal muscle mass (puts pt at risk for weight gain)
dorsogluteal site
upper lateral quadrant of the buttox -can cause injury and risk of hitting sciatic nerve
Damp to damp 4-inch by 4-inch dressings
used to mechanically debride a wound until granulation tissue starts to form in the wound bed -Must keep moist at all times to prevent pain and disruption of wound healing
injection site for infants and children
vastus lateralis
sepsis hemolytic reaction
when blood is contaminated with bacteria HIGH fever, vomiting, diarrhea
a nurse is obtaining a capillary blood sample to determine blood glucose. the nurse punctures the pt finger but does not get an adequate amnt of blood. which of the following should the nurse do next?
wrap the client's finger in a warm washcloth (this helps increase blood flow to the client's finger) -smearing a small amnt of blood onto the testing stip can lead to an inaccurate result -instead of holding the finger above heart level, hold the hand in a dependent position -massaging can hemolyze the specimen, can lead to an inaccurate result
a nurse is evaluating the development of a group of pt. according to erikson the developmental task of intimacy vs. isolation occurs during which of the following states of development?
young adulthood -middle adulthood (generativity vs. stagnation) -adolescence (identity vs. role confusion) -childhood (industry vs. inferiority)
