!!! ATI CMS FUNDAMENTALS - STUDY SET
BEST POSITION FOR USE OF INCENTIVE SPIROMETER - ANSSemi-Fowler's or High
Semi-Fowler's position
allows for maximum expansion of the lungs
WHEN A PATIENT REFUSES TO USE INCENTIVE SPIROMETER - ANSalways assess the
patient first
using assessment skills, you can then try to determine why the patient is refusing
continue to encourage the patient, but if they still refuse, be sure to document.
IV CATHETER INSERTION FOR AN OLDER ADULT - ANSplace patient's arm in a dependent
position; veins will dilate due to gravity
insert catheter at 10-30 degree angle
WHEN USING AN OPEN IRRIGATION TECHNIQUE FOR INDWELLING URINARY
CATHETER - ANSsubtract the amount of irrigant used from the client's urine output
use 30-50 mL syringe to perform open irrigation
supine or dorsal recumbant position is best
DELIVERY OF OTIC MEDICATION - ADULT - ANSpull the ear up and back to straighten the
ear canal and instill drops
pressing gently on the tragus of the ear will help the medication get into the inner ear
have patient in side-lying position, with affected ear up. Patient should remain in this position for
2-5 minutes following Rx administration
NG TUBE FEEDING THROUGH AN OPEN SYSTEM - ANStell patient to keep head of the bed
elevated at least 30 degrees
this will reduce the risk of and prevent aspiration
NG TUBE FEEDING - ANSmake sure that enteral formula is at room temperature; this prevents
cramping
, clean the top the formula container to reduce the risk of contamination by microorganisms
rinse feeding bag with warm water
NG TUBE FEEDING - COMPLICATION DUE TO EXCESS RESIDUAL - ANSwhen gastric
residual exceeds 250 mL for two consecutive assessments...
- withhold the feeding
- notify provider
- keep patient in semi-fowler's
- recheck residual in 1 hour
NG TUBE FEEDING - COMPLICATION DUE TO DIARRHEA - ANSwhen patient has diarrhea
three times or more within 24-hour period...
- slow the instillation rate
- notify the provider
- confer with dietician
- provide skin care/protection
ASSESSMENT FINDINGS FOR A PATIENT WHO REPORTS DIARRHEA AND VOMITING
FOR THREE CONSECUTIVE DAYS - ANSthis patient is likely to have fluid-volume deficit
assessment findings include:
- tachycardia
- thready pulse
- tachypnea
- hypotension
- orthostatic hypotension
- decreased CVP
- hypoxia
ADVANCED DIRECTIVES - ANSinclude a living will, which permits the client to direct treatment
in the event of a terminal illness
indicate the form of treatment a client is willing to accept in the event of a serious illness
PAIN QUALITY - ANShow pain *feels*
sharp/dull
aching/burning
stabbing/pounding
throbbing/shooting
BEST POSITION FOR USE OF INCENTIVE SPIROMETER - ANSSemi-Fowler's or High
Semi-Fowler's position
allows for maximum expansion of the lungs
WHEN A PATIENT REFUSES TO USE INCENTIVE SPIROMETER - ANSalways assess the
patient first
using assessment skills, you can then try to determine why the patient is refusing
continue to encourage the patient, but if they still refuse, be sure to document.
IV CATHETER INSERTION FOR AN OLDER ADULT - ANSplace patient's arm in a dependent
position; veins will dilate due to gravity
insert catheter at 10-30 degree angle
WHEN USING AN OPEN IRRIGATION TECHNIQUE FOR INDWELLING URINARY
CATHETER - ANSsubtract the amount of irrigant used from the client's urine output
use 30-50 mL syringe to perform open irrigation
supine or dorsal recumbant position is best
DELIVERY OF OTIC MEDICATION - ADULT - ANSpull the ear up and back to straighten the
ear canal and instill drops
pressing gently on the tragus of the ear will help the medication get into the inner ear
have patient in side-lying position, with affected ear up. Patient should remain in this position for
2-5 minutes following Rx administration
NG TUBE FEEDING THROUGH AN OPEN SYSTEM - ANStell patient to keep head of the bed
elevated at least 30 degrees
this will reduce the risk of and prevent aspiration
NG TUBE FEEDING - ANSmake sure that enteral formula is at room temperature; this prevents
cramping
, clean the top the formula container to reduce the risk of contamination by microorganisms
rinse feeding bag with warm water
NG TUBE FEEDING - COMPLICATION DUE TO EXCESS RESIDUAL - ANSwhen gastric
residual exceeds 250 mL for two consecutive assessments...
- withhold the feeding
- notify provider
- keep patient in semi-fowler's
- recheck residual in 1 hour
NG TUBE FEEDING - COMPLICATION DUE TO DIARRHEA - ANSwhen patient has diarrhea
three times or more within 24-hour period...
- slow the instillation rate
- notify the provider
- confer with dietician
- provide skin care/protection
ASSESSMENT FINDINGS FOR A PATIENT WHO REPORTS DIARRHEA AND VOMITING
FOR THREE CONSECUTIVE DAYS - ANSthis patient is likely to have fluid-volume deficit
assessment findings include:
- tachycardia
- thready pulse
- tachypnea
- hypotension
- orthostatic hypotension
- decreased CVP
- hypoxia
ADVANCED DIRECTIVES - ANSinclude a living will, which permits the client to direct treatment
in the event of a terminal illness
indicate the form of treatment a client is willing to accept in the event of a serious illness
PAIN QUALITY - ANShow pain *feels*
sharp/dull
aching/burning
stabbing/pounding
throbbing/shooting
