ATI Fundamentals

What is a Pyelogram?

An intravenous pyelogram (PIE-uh-low-gram), also called an excretory urogram, is an X-ray exam of your urinary tract. An intravenous pyelogram lets your doctor view your kidneys, your bladder and the tubes that carry urine from your kidneys to your bladder (ureters).

touching the face with a cotton ball tests which cranial nerve? can touch clients cornea with a wisp of cotton and measure light touch and pain across a clients face

CN 5 the trigeminal nerve

Braden Scale for Predicting Pressure Sore Risk

-6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear -A score of 23 means there is no risk for developing a pressure ulcer while the lowest possible score of 6 points represents the severest risk for developing a pressure ulcer. The Braden Scale assessment score scale: Very High Risk: Total Score 9 or less. High Risk: Total Score 10-12.

latex allergy precautions

-use powder-free glove, powder contains the latex protein -sterilize solution ethylene oxide can cause an allergic reaction -prevent contact of cords by covering them with non-latex material

when administering a 0.8mL of oral single-dose liquid medication to a client the nurse should?

1. Gently shake the liquid medication to ensure it is mixed 2. pre-measured dose should not be transferred 3. Place patient is High-fowlers, Not semi-fowlers upon admin. to prevent aspirations

Nursing considerations to know when a patient is receiving Patient- controlled analgesia (PCA) pump?

1. Only patient should activate pump button 2. Monitor patient every 1-2 hours during the first 12 hours. 3. Use pump as needed to when pain becomes unbearable.

Urine SG

1.005 - 1.030 <1.005 diluted >1.030 concentrated

How far do you hold the tip above the wound?

2.5cm (1 in) continue to flush until the irrigant flowing out of the wound is clear

Albumin levels show the amount of protein in the body which is needed for tissue repair, what is the normal albumin level?

3.5-5 g/dL anything below 3.5 will be at risk for delay in tissue repair

What does COLDSPA stand for?

C•O•L•D•S•P•A CHARACTER: Describe the sign or symptom. How does it feel, look, sound, smell, and so forth? ONSET: When did it begin? LOCATION: Where is it? Does it radiate? DURATION: How long does it last? Does it recur? SEVERITY: How bad is it? PATTERN: What makes it better? What makes it worse? ASSOCIATED FACTORS: What other symptoms occur with it?

water doubles in amount when conveted to ice: if you had 4oz of water how much would it be in ice chips?

8 oz of ice chips

how much pressure, amount, size gauge, and solution normal saline lactated ringer's, or antibiotic/antimicrobial solution needs to be applied to irrigate a wound?

8 psi of pressure 30 to 60ml syringe 19-gauge needle

Is Excessive thirst hyperglycemia or hypoglycemia?

Hyperglycemia

Is confusion hyperglycemia or hypoglycemia?

Hypoglycemia

How often do you check NG tube residual?

If using a PEG, measure residual every 4 hours (if residual is more than 200 ml or other specifically ordered amount, hold for one hour and recheck; if it still remains high notify doctor). If using a PEG, reinstall residual.

When should the position of the NG tube be checked via aspiration?

It is important to check the nasogastric tube position prior to administering anything via the feeding tube, after a coughing fit or vomiting episode. Never administer anything down the tube and do not start feeding before confirmation of pH. The pH reading shouldbe between 1-5.5.

what would you asses on a wound (sinus tracts, tunnel)?

Length width depth color swelling

A patient with a urinary catheter has a bladder scan of 525 mL, is this normal?

No, 400-500ml is normal...... the nurse should irrigate the catheter to resolve any existing blockage

What tests can be used for colon cancer? state appropriate age

Patients age 50 and up are at risk for colon cancer 1. double contrast barium enema every 5 years 2. colonoscopy every 10 years 3. fecal occult annually 4. flexible sigmoidoscopy every 5 years

mixed drainage of pus and blood occurring in newly infected wound is what type of drainage?

Purosanguineous drainage

what type of drainage is a result of an infection, thick, has WBC, tissue debris, and bacteria?

Purulent drainage

What is the RYB color code guide for wound care?

RYB Red= cover "pressure ulcer" Yellow= clean "purulent drainage" Black= decried, remove, necrotic tissue (eschar)

Test used to identify alterations in balance: Have client stand with their arms at their side and their feet together to observe for swaying and loss of balance

Romberg Test

Regular insulin and NPH start and end with?

Strat with cloudy NPH Ends with cloudy NPH REG=CLEAR

IV in the radial or cephalic vein...... Which vein is best for an IV?

The three main veins of the antecubital fossa (the cephalic, basilic, and median cubital) are frequently used. These veins are usually large, easy to find, and accomodating of larger IV catheters. Thus, they are ideal sites when large amounts of fluids must be administered.

how often do the elderly need: a. eye examinations b. tetanus booster c. shingles vaccine d.pneumococal vaccine

a. every year b. ten years c. age 60 "60 keys shingle" d. age 65

Chap: 55 color of open wounds? (RED, YELLOW, BLACK)? a. health regeneration of cells b. presence of purulent drainage and slough c.presence of eschar that hinders healing and requires removal

a. red b.yellow c.black

Chap:42 Natural Products and Herbal Remedies What does chamomile do?

anti-inflammatory, calming: *chamomile is commonly regarded as a mild tranquilizer or sleep inducer. Its calming effects may be attributed to an antioxidant called apigenin, which is found in abundance in chamomile tea. Apigenin binds to specific receptors in your brain that may decrease anxiety and initiate sleep *Chamomile has anti-swelling properties and it can soothe sensitive tissues. - Brew chamomile tea and allow the bags to adequately cool down. - They can be applied for up to 15 minutes at a time.

Chap:42 Natural Products and Herbal Remedies What does ginger do?

antiemetic "stops vomiting and nausea" which aids in digestion

where is the popliteal pulse ?

behind the knee

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? a. Activate the emergency fire alarm b. Extinguish the fire c. Evacuate the client d. Confine the fire

c. Evacuate the client What does the RACE acronym stand for? -Rescue The Patient -Activate Alarm -Confine -Extinguish/Evacuate

inc. risk for hypertension?

clients 60 years of age cigarette smokers since it constricts blood vessels

ALL of these are in the nurses scope of practice for enteral feedings except? a. nasoenteric b. gastrostomy c. jejunostomy d. endotracheal tubes

d. endotracheal tubes An endotracheal tube is a flexible plastic tube that is placed through the mouth into the trachea (windpipe) to lungs help a patient breathe. The endotracheal tube is then connected to a ventilator, which delivers oxygen to the lungs. The process of inserting the tube is called endotracheal intubation.

Chap:42 Natural Products and Herbal Remedies What does feverfew do?

decrease inflammation and promote wound healing (aids in arthritis)

ethical principle of autonomy means?

do what patient requests I am the patients advocate and must honor the patients autonomy (ability to make their won decisions)

Chap:42 Natural Products and Herbal Remedies What does echinacea do?

enhances immunity stands with chin up cause he has immunity!!! *Echinacea tea is an extremely popular remedy that's said to prevent and shorten the common cold. Evidence has shown that echinacea may help boost the immune system, which could help the body fight off viruses or infections

Chap:42 Natural Products and Herbal Remedies: What does Ginkgo Biloba do?

improves memory and reduce stress

Chap:42 Natural Products and Herbal Remedies: Ginseng uses

increases physical endurance

Chap:42 Natural Products and Herbal Remedies What does garlic do?

inhibits platelet aggregation "anti-coagulant"

What is normally used to clean a wound?

isotonic solutions -remember to never use the same gauze to cleanse across an incision or wound more than once -Do not use cotton balls or anything that shed fiber

what foods are a good source of protein?

meat, fish, poultry, eggs, dairy vegan-nuts, whole grains, beans

Manifestations of IV fluid bolus therapy or IV fluid volume excess for dehydration?

moist crackles in lung fields dyspnea shortness of breath distended neck veins edema tachycardia bounding pulse increase in BP

What should be included in a patients discharge summary?

patients medication to ensure safety and continued care

This promotes psychomotor skills when learning?

practice sessions

valerian and chamomile both?

promote sleep and reduce anxiety

This promotes cognitive and affective learning?

role play group discussion question-answer meetings

contains serum and RBC but reddish in appearance? Bright red= active bleeds (colon) Dark red= older bleeds (stomach)

sanguineous drainage

contain both serum and blood but looks pale and pink? good sign means tissue is is healing

serosanguineous drainage

blood that is watery and clear?

serous drainage

This impairs oxygenation and clotting

smoking

Chapter 55: Primary, secondary, or tertiary? widely spread deep spontaneous opening of a previously closed wound "dehiscence/eviceration" closure of wounds occurs when they are free of infection and edema risk of infection extensive drainage and tissue debris closed later long healing time ex: abdominal wound initially left open until infection is resolved and then closed

tertiary intentions

ethical principle of veracity means?

to tell the truth at all times

What pathogen require droplet precaution smaller than 5 microns in diameter?

varicella tuberculosis measles Measles is a highly contagious infectious disease caused by measles virus. Initial symptoms typically include fever, often greater than 40 °C (104 °F), cough, runny nose, and inflamed eyes. Red Rash

what precaution must be noted when preparing a sterile field for dressing change?

1. Place cap with sterile side up on clean surface NOT sterile field b/c cap is not sterile and can contaminate the sterile field 2. edges of the sterile field are contaminated. Nurse should place all items inside or within the 1 inch border of sterile field 3. The field is sterile, anything that needs to be poured must remain outside the edge of the field 4. object must remain at or above waist to remain sterile

What can the nurse delegate to an Assistive Personnel (AP)?

1. ambulating a patient 2. tasks that do not require much skill, assessment, or teaching 3. Not client education b/c advanced nursing knowledge 4. Not evaluating pain level b/c advanced nursing knowledge

what implications should a patient consider in regards to their new home oxygen concentrator?

1. check cord frequently for frays 2. keep the unit at least 10 ft away from open flames (fire, gas stove) and 8ft away from other heat sources 3. consider purchasing a generator for power backup so machine is always working 4. observe signs of hypoxia 5. choose clothing and bedding made from material that does not generate static like cotton NOT synthetic fabric

When a nurse is preparing to administer multiple medications to a client who has an enteral feed tube what precautions should the nurse consider?

1. each Medicine should be dissolved in at least 30mL of warm sterile water"U NEED ATLEAST 30-60mL for the right pressure anyway" 2.Medication should be drew up separately, NEVER mixed 3. Nurse should STOP and contact provider if she pushes the syringe plunger gently and encounters resistance during administration of med. 4. Feeding tube should be flushed with 15-30mL of sterile water before and between each admin. 5. Once med. admin is finished flush with 2x the amount of sterile water that was used before and between admin (30-60mL) to clean out tube

Chapter 55: What are the 3 stages of wound healing?

1. inflammatory stage: Initially promotes vasoconstriction, finer accumulation, and clot formation. Leaky capillaries deliveres O2, WBC, and nutrients to the area via blood supply. Macrophage engulf microbes and cellular debris (phagocytes). 2.proliferative stage: replace lost tissue with granulated tissue and collagen. Edges contract to reduce area that require healing. New epithelial cells resurface. 3. maturation stage: strengthening of collagen scar

Nursing considerations for a patient with clostridium difficile?

1. private room required 2. use soap and water for hand hygiene because alcohol based hand sanitizer does not kill spores, chlorine bleach can kill spores though 3. Clean contaminated surfaces with chlorine bleach, phenol solutions clean bacteria and fungi not c.diff 4. family members and staff must wear gown and gloves when visiting patient with c.diff to prevent transmission

What should the nurse consider when having a patient with a tracheostomy (trachea to lungs)? Remember Suctioning clears mucus from the tracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop.

1. use resuscitation bag with 100% oxygen (not 80%) before suctioning to prevent hypoxia 2. select a suction catheter half the size of the lumen to prevent hypoxemia and trauma to the lungs 3. lubricate the end of the suction catheter with sterile saline water or 0.9% sodium chloride irrigation solution, NOT water soluble lubricant. 4. adjust the pressure to 120 no higher than +30 mmHg (150mmHg) to prevent hypoxemia (higher the pressure, less the saturation like high altitudes)/ 170mmHg is too high!!!

Nursing considerations to know when a patient is going through tonic- clonic seizures?

1. wrap blankets around all sides of the bed 2. do not apply restraints this increases risk for injury 3. turn the client to the side so the tongue does not occlude the occlude the airway and allow secretions to flow out of the side of the mouth 4.Never, absolutely never, put a scissors, tongue depressor, pencil, wallet or any other object in the mouth of a person having a seizure. This can cause the person great damage such as obstructing the airway or breaking the jaw and teeth.

measurements: 1oz=Tbs?=?mL? 1 cup= ?mL 1 Tbs=?mL=?tsp 1 tsp= ?mL 1Kg=?Ibs 1 inch= ?cm

1oz=2Tbs=30mL 1 cup= 180mL 1 Tbs=15mL=3tsp 1 tsp= 5ml 1Kg=2.2Ibs 1 inch= 2.54cm Use 0.3 NOT .3....leading zeros ok! Use 5 not 5.0..... DO NOT use trailing zeros Doses for thousands, use proper comma: 5,000 NOT 5000

How many ML of urine do adults produce a day?

2-3L (2,000-3,000mL) ATI BOOK says: 1-2L

What steps must be performed if evisceration and or dehiscence occurs?

Call for help. Notify provider. Stay with patient. Cover the wound and any protruding organs with sterile towels or dressings soaked with sterile normal saline solution to decrease the chance of bacteria invasion and drying tissue. Do not re-insert the organs. Position Client supine with hips and knees bent. observe indications of shock. Maintain calm environment. Keep patient NPO.

What is coude catheter?

Coudé is French for "bend" therefore a coudé catheter is a type of catheter that is mostly straight but has a tip that curves/bends slightly. Some people refer to these types of catheters as a bent tip catheter—they are the same thing and used interchangeably.

What pathogens require droplet precaution larger than 5 microns in diameter?

influenza rubella: Rubella is a contagious viral infection best known by its distinctive red rash. It's also called German measles or three-day measles. meningococcal pneumonia streptococcal pharygitis

ethical principal of fidelity means?

keep ur word/promise? infidelity means broke promise on being faithful

how many bowel movements must occur before it is seen as constipation

less than 3x per week

Chapter 55: Healing Process Primary, secondary, or tertiary? little to no tissue loss edges approximated "touch" as with surgical incision heals rapidly low risk of infection no or normal scarring ex: closed surgical incision with staples, sutures, or liquid glue to seal laceration

primary intention

Chap:42 Natural Products and Herbal Remedies: valerian uses

promotes sleep and reduces anxiety

client who have a compromised immune system (allogenic hematopoietic stem cell) require what type of environment? An allogeneic hematopoietic cell transplant uses a donor's bone marrow or blood. The donor is usually a relative of the patient, although unrelated donors or umbilical cord blood are sometimes used. A bone marrow transplant is a type of stem cell transplant in which the stem cells are collected (harvested) from bone marrow. After being removed from the donor, they're transplanted into the recipient. The procedure takes place in a hospital or outpatient facility.

protective environment

Chap:42 Natural Products and Herbal Remedies What does aloe do?

provides wound healing

green purulent drainage is due to which microbe?

pseudomonas aeruginosa infection

Chapter 55: Healing Process Primary, secondary, or tertiary? loss of tissue wound edges widely separated as with pressure injury or open burn areas longer healing time inc.risk of infection scarring replace lost tissue with granulated tissue "proliferative stage" ex:pressure injury left open to heal

secondary intention

how would you document the location of a sinus tract or tunnel?

use a clock face with 12:00 towards the clients head

How do you irrigate a wound?

use a piston syringe or sterile straight catheter for deep wounds with small openings.

indications of fluid volume deficit?

weak pulse slow capillary refill hypotension dry mucous membranes sunken eye balls increased hematocrit "inc. osmolality" A. Male: 42-52% B. Female: 37-47% increased urine specific gravity (1.005 - 1.030) urine less than 30mL/1hr, suppose to be at least 83mL/1hr

Test used to identify sound lateralization when assessing hearing by applying a vibrating tuning fork to the clients forehead

webers test

For accurate measuring of drainage on wound what should you do?

weigh the dressing