ATI - Review

Statement of patient experiencing psychological distress after undergoing treatment for ovarian cancer

"I keep having nightmares about my upcoming surgery"

Collecting 24 hour urine for creatinine clearance , statements said by patient that they understand.

"I'll make sure to keep the collection bottle in the container of ice"

During completion of health history , client reports intermittent chest pain for the past week,what question is nurse's priority?

"can you tell me what the pain felt like and show me where?"

Patient: onset severe back . what question to ask?

"what do you think caused the onset of your pain?"

teaching a patient with asthma , the proper use of an albuterol inhaler

- shake well before using - rinse with water after inhaler usage to reduce irritation and infection -wait 20-30 secs between inhalations -place inhaler in mouth , close lips, depress canister , take deep breath, hold for 10 seconds

Patient has right sided weakness while walking with a cane, indications patient knows cane walking?

- the client keeps 2 points of support on the ground -cane should be on the unaffected or stronger side of the body -when walking, cane first then unaffected or stronger leg next -support weigh on both legs when moving the cane forward

client with fluid volume deficit, what to expect?

-when client is supine , flat neck vein - postural hypotension - dark yellow urine

Bicep reflex: 1. 1+ or less 2. 3+ or more 3. 4+

1. diminished 2. Brisk 3. hyperactive

Secondary intention healing

Extensive tissue loss Edges cannot be approximated Repair time is longer Scarring is greater Susceptibility to infection is greater granulation tissue fills the wound during healing

Tertiary intention healing

Wound is left open for 3-5 days to allow edema or infection to resolve

kinesthetic sensation test

ability to identify the position in which the examiner is holding the client's middle finger or great toe

what substances indicates adequate protein uptake and synthesis?

albumin

which of the following actions should the nurse take to convey empathy when using therapeutic communication ?

assume an open position, lean towards patient, direct eye contact, face the client

The Romberg test is used to assess:

balance (neurological assessment)

Calcium level reflect?

bone and tooth formation , blood clotting , nerve impulse transmission, muscle contraction and relaxtion

when preparing to irrigate the wound for a stage III pressure ulcer whats the first thing the nurse should do?

check the patient's pain level

administer hypertonic fluid solution when?

cleanse client's bowel in preparation for surgery

what contributes to patients with insomnia almost every night?

client watches tv in her bed during the day

Primary intention healing

closing of wound using sutures or staples

client has fluid volume excess, what to expect?

crackles in the lung fields

Bicep reflex as 2+

document: average

carminative enema for?

expel flatus

Sodium level indicates?

fluid balnce, nerve impulse transmission,acid-base balance, other cellular activities

Calcium alginate

for stage IV pressure ulcer. with significant exudate and covered with secondary dressing

when to apply proteolytic enzyme ?

for unstageable pressure ulcer. facilitate debridement and soften eschar . (dry /hard wound)

Weber test

hearing screening that uses tuning fork

dressing for stage II pressure ulcer?

hydrocolloid

Patient has a temp of 38.7 (101.7), nurse should?

keep client's bed linen dry

PROM: what joint to exercise first?

large joint first

otoscopic exam: a pink eardrum + difficulty hearing/ understanding

mild inflammation/referral to audiologist

patient stroke and risking of falling? action should the nurse take?

monitor patient once every hour

otoscopic exam: cerumen blocking visualization

needs irrigation

2 point discrimination test

nurse touches many areas of body with 1 and 2 points objects= patient discriminate between them

Fecal impaction, before digital removal of mass, which enemas to soften feces?

oil retention

enema: sodium polystyrene sulfate for?

patient with high potassium level

Passive range of motion exercises, following action to take?

repeat each joint motion 5x during session

passive range of motion(PROM) : move the joint to the point of ______

slight resistance

PROM: where to stand?

stand at the side of the bed closest to the joint being exercised

potassium level reflect?

status of many metabolic activities, nerve impulse transmission, cardiac conduction , skeletal and smooth muscle contraction

proper surgical handwashing technique

the nurse holds her hands higher than her elbows while washing

A nurse is witnessing a client sign an informed consent form for surgery, what is the nurse affirming by this action?

the signature on the preoperative consent form is the client

wound: when to apply collagen ?

to clean, moist wound to stop bleeding , bring cells into the wound , stimulate their proliferation to facilitate healing

Tube placement for NG tube , what to look for to verify correct tube placement:

verify with x ray exam, measure length of tube, determine ph fluid

The light of the otoscope reflects off the tympanic membrane , in left ear.

visible in the left lower quadrant

The light of the otoscope reflects off the tympanic membrane , in right ear.

visible in the right lower quadrant

surgical scrubbing requires nails to be scrubbed

with 15 strokes and each other part of the hand with 10 strokes