ATI fundamentals tough ones
Crackles in lungs indicates
fluid volume overload (not cleared by cough)
Cyanosis can be caused by _________
impaired venus return OR hypoxia
Normal order of assessment
inspect palpate percuss auscultate
Rhonchi in lungs indicates
mucus (try coughing)
Narcolepsy
sudden sleep attacks
Net fluid intake means
total intake
cranial nerve 5
trigeminal (whole face sensation)
What is S2 (dub) called
ventricular diastole (rest)
How high above the antecubital space should the bp cuff go?
1 inch above
Lvls of edema
1+ = trace (2mm rapid skin response) 2+ = mild (4mm - 10-15s skin response) 3+ = moderate 6mm (prolonged skin response) 4+ = severe 8mm, prolonged skin response
How often should you do leg exercises post-op?
10 per waking hour!
How long should a patient with orthostatic hypotension sit on the bed before standing
3-10 mins
For manual bp, how much should you hyperinflate it?
30mmHg more than palpated systolic pressure
Normal temp range in Celcius
36-38 ˚C (96.8-100.4 ˚F)
What day do post-op infections normally occur
3rd day
What % of the arm should the bp cuff cover
40% of arm circumference
A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100mL intermittent IV bolus, 200mL emesis, 40mL voided urine, and 20mL urine from straight catheterization. The nurse should record the client's net fluid intake as how many mL? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
700
Pale skin indicates
anemia, shock, decreased blood flow
Hypersolomnence
excessive sleepiness for >3 months
Cranial nerve VII
facial nerve/raise eyebrow/smile/frown
Lung percussion: dullness indicates
fluid build up or tumor in lung
Pleural friction rub indicates
inflammation
S4 (atrial gallop)
"ten-es-see" Hear with bell Occurs before S1 Indicates strong atrial contraction in athletes
Heart S1 (lub)
Ventricular contraction
A nurse in a well-child clinic receives a telephone call from a parent who states that their child accidentally swallowed paint thinner. The child is awake and alert. Which of the following responses should the nurse make? A. Have your child drink one large glass of water. B. Hang up and call a poison control center hotline. C. Bring your child into the clinic later today. D. Induce vomiting in your child with syrup of ipecac.
A.
The nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis
A. Hemolytic
A nurse is teaching a middle-aged female client about disease prevention. Which of the following tests should be done as part of the client's routine health screening? A. Annual Pap testing B. Mammogram every 2 years C. Eye examination every 2 years D. Annual colonoscopy
C. Eye exam q2years
A nurse is administering prefilled opioid analgesic to a client. Which action should the nurse take? A. Return unused portion to pharmacy B. Dispose of wasted portion in sharps C. Record amount wasted on the controlled substance inventory record D. Ask an AP to witness the wasting
C. Record amount wasted
Rhine test
Compares Air conduction (AC) with bone conduction (BC). Place fork on mastoid process, then quickly place next to ear canal comparing how long pt could hear the tuning fork in each location.
Manifestations of approaching death
Decreased LOC Decreased muscle tone Labored breathing Cyanosis Decreased senses Incontinence No PERRLA Slow, weak pulse Low BP Cool extremities Sweating X swallow
kussmaul respirations
Increase respiratory rate, regular pattern, but abnormally deep
In which phase of operative care is the client transferred to the surgical table prior to being transferred to the PACU
Intraoperative
What 3 things must occur to discharge a patient from post-anesthesia care
O2 at least 95% Vitals stable for 30 minutes Gag reflex present
S3 (ventricular gallop)
Occurs after S2 Indicates rapid ventricular filling "ken - tuck y"
Cranial nerve 2
Optic - vision
Weber test
Place a vibrating tuning fork on top of client's head (temporal bone - forehead) Ask client where they can hear the sound the best (right ear, left ear, or both) Expected Finding: The client hears sound equally in both ears = a negative Weber's test
When should you assess the BP of a patient with ortho hypotention
Right before sitting up, right after sitting up, and right after standing up
