ATI Learning System RN: Fundamentals
1, 2, and Final
*F1*
nurse coaching a set of older adults about the anticipated adjustments of getting old. What
declaration shows an understanding of the coaching? - ANS"I need to anticipate my heart
fee to take longer to return to normal after workout as I get older."
-d/t reduced cardiac output which reasons an expanded pulse rate in the course of
exercising
-Bladder capacity decreases w/ age however urinary incontinence isn't an anticipated
locating of growing old
-Have an boom of ear wax buildup which may boom occurrence issues w/ listening to loss
-Decreased gastric emptying is an anticipated finding
*F2*
a nurse caring for an older patient who has dysphagia after a CVA. What motion should the
nurse take while supporting the patient at mealtime? - ANSoffer tart/bitter foods first -
promotes saliva production which facilitates w/ chewing and swallowing
-Higher danger of choking while beverages are supplied w/ pts meals, endorsed 'dry
swallows' clean mouth btw bites
-Pt w/ impaired pharyngeal swallowing ought to tilt head forward to sell swallowing
-Minimize any distractions at mealtime to be able to focus on chewing and swallowing
*F2*
a nurse converting the dressing of a three day postoperative affected person following a
cholesystectomy observes yellow, thick drainage at the dressing. How ought to the nurse
chart this kind of drainage? - ANSPurulent exudate - thick yellow/green/brown drainage
which indicates wound sloughing/infection.
-*Serosanguineous exudate*, suggests plasma blended w/ blood drainage, light yellow to
blood-tinged or streaks of blood and watery drainage
-*Serous exudate*, mild yellow plasma from blood and watery
-*Sanguineous exudate*, lively bleeding; accumulation of RBC's from plasma that appears
vivid or darkish red
*F2*
a nurse is worrying for a affected person who has a history of dysrhythmias and upon
coming into the room discovers the patient is unresponsive to verbal or painful stimuli, has
no repsiraitons, is pulseless. What motion ought to the nurse take first? - ANSStart chest
compressions
,-Nurse ought to start CPR, which starts offevolved w/ chest compressions then beginning an
airway and respiration into pt mouth *CAB*
-Can use a manual resuscitation bag to oxygenate pt throughout CPR
*F2*
a nurse is being concerned for a patient who is postoperative following a vaginal
hysterectomy and ask for a drink. Her postoperative weight loss plan is clear drinks; improve
as tolerate. What response should the nurse make? - ANS"I am going to listen to your
stomach" - decide presence of bowel sound earlier than giving clear beverages to save you
postop n/v, d/t delayed gastric emptying time or decreased peristalsis after surgery
-When suitable to renew submit surgical food regimen it's far most effective to offer a
preference of clear beverages, instead of handiest water, a clear liquid w/ vitamins
-Use therapeutic conversation to fulfill pts wishes
*F2*
a nurse is changing the dressings for a patient with 2 penrose drains close to an stomach
incision. What is the first-rate sort of adhering tool to lower pores and skin infection? -
ANS*Montgomery straps* are the least restrictive; these adhesive straps are implemented to
the pores and skin on both side of a surgical wound, adhesive strips have holes for gauze to
tie dressing securely; ties are launched to trade dressing, dressing can be changed w/out
doing away with straps
-*Abdominal binder* is powerful in mattress, however will not keep dressings in location at
some stage in ambulation
-*Hypoallergenic tape* may be used however can nonetheless cause pores and skin
sensitivity while time and again removed and reapplied
-*Plastic tape* adheres to skin properly and reasons pores and skin inflammation when
removed and reapplied
*F2*
a nurse is accumulating a urine specimen for tradition and sensitivity for a affected person
who has a UTI and an indwelling urinary catheter in vicinity. What movement must the nurse
take? - ANSclamp tubing underneath series port - to allow sparkling uncontaminated urine to
acquire earlier than withdrawing specimen thru port in a sterile specimen cup
-Nurse have to cleanse port w/ *antimicrobial* swab
-Nurse should region the specimen in a *sterile* specimen cup to save you infection.
*F2*
a nurse is making plans to manage pain remedy to a affected person who has pain following
abdominal surgical operation. What movement need to the nurse take first? - ANSuse pain
scale to determine pts ache degree
-Think Maslow's hierarchy, meet pts physiological needs first
-must talk destructive effects of pain meds w/ pt; but every other action ought to be 1st
-have to reap VS before deciding on an intervention to relieve ache to provide a baseline to
evaluate to while monitoring after treating pain; however some other motion have to be 1st
, -ought to take a look at for pt allergies; however every other movement ought to be 1st
*F2*
a nurse notes no urine output for a postoperative affected person with an indwelling urinary
catheter after 2 hours. What action must the nurse take first? - ANScheck to decide if
catheter tubing is kinked; inspection is a priority motion
-If there is no kink, the nurse may also palpate the bladder or do a bladder experiment to
decide if there may be urine in the bladder and might encourage to pt to drink extra fluids to
sell kidney perfusion
-Nurse can achieve a *Px to irrigate* the catheter w/ .Nine% sodium chloride if absent urine
is d/t obstruction from blood clots or sloughing of bladder tissue
*F2*
a nursing worrying for a patient who had a mastectomy and has a self-suction drainage
evacuator in place. What actions should the nurse take to ensure proper operation of the
tool? - ANScollapse tool of air after emptying
-To create suction to drag fluid exudate into collection place of device
-Keep diaphragm of tool compressed to keep suction and prevent clotting of
consanguineous drainage; not made for irrigating
-Cleanse drain opening w/ alcohol wipe after opening to decrease access of microorgs
-Maintain drainage tubing below stage of incision to decorate drainage
*F2*
at what region ought to a nurse anchor the tubing of a urinary catheter for a male affected
person? - ANSlower stomach or top component of thigh to put off penoscrotal angle and
prevent tissue damage
-can cause pain and tissue damage while secured to lateral/ outdoor of the thigh, mid-belly
vicinity
-can cause discomfort and pressure on urethra at penosacral junction and cause tissue
harm when secured at medial thigh
*F2*
nurse is converting the dressing for a affected person convalescing from an appendectomy
following a ruptured appendix. What statement should the nurse file to the company? -
ANSHalo of erythema on surrounding pores and skin - might indicate underlying
contamination; other manifestations of infection consist of; sever ache, purulent drainage,
swelling, warmth, strong scent ought to all be reported
-Tenderness when touched, crimson and bright tissue w/ granular appearance,
*serosanguineous drainage* are all anticipated findings
-Pink, brilliant tissue w/ *granular appearance suggests proliferative degree of wound
healing*, and is anticipated for put up-op wound recovery *with the aid of 2ndary aim*
*F2*
1, 2, and Final
*F1*
nurse coaching a set of older adults about the anticipated adjustments of getting old. What
declaration shows an understanding of the coaching? - ANS"I need to anticipate my heart
fee to take longer to return to normal after workout as I get older."
-d/t reduced cardiac output which reasons an expanded pulse rate in the course of
exercising
-Bladder capacity decreases w/ age however urinary incontinence isn't an anticipated
locating of growing old
-Have an boom of ear wax buildup which may boom occurrence issues w/ listening to loss
-Decreased gastric emptying is an anticipated finding
*F2*
a nurse caring for an older patient who has dysphagia after a CVA. What motion should the
nurse take while supporting the patient at mealtime? - ANSoffer tart/bitter foods first -
promotes saliva production which facilitates w/ chewing and swallowing
-Higher danger of choking while beverages are supplied w/ pts meals, endorsed 'dry
swallows' clean mouth btw bites
-Pt w/ impaired pharyngeal swallowing ought to tilt head forward to sell swallowing
-Minimize any distractions at mealtime to be able to focus on chewing and swallowing
*F2*
a nurse converting the dressing of a three day postoperative affected person following a
cholesystectomy observes yellow, thick drainage at the dressing. How ought to the nurse
chart this kind of drainage? - ANSPurulent exudate - thick yellow/green/brown drainage
which indicates wound sloughing/infection.
-*Serosanguineous exudate*, suggests plasma blended w/ blood drainage, light yellow to
blood-tinged or streaks of blood and watery drainage
-*Serous exudate*, mild yellow plasma from blood and watery
-*Sanguineous exudate*, lively bleeding; accumulation of RBC's from plasma that appears
vivid or darkish red
*F2*
a nurse is worrying for a affected person who has a history of dysrhythmias and upon
coming into the room discovers the patient is unresponsive to verbal or painful stimuli, has
no repsiraitons, is pulseless. What motion ought to the nurse take first? - ANSStart chest
compressions
,-Nurse ought to start CPR, which starts offevolved w/ chest compressions then beginning an
airway and respiration into pt mouth *CAB*
-Can use a manual resuscitation bag to oxygenate pt throughout CPR
*F2*
a nurse is being concerned for a patient who is postoperative following a vaginal
hysterectomy and ask for a drink. Her postoperative weight loss plan is clear drinks; improve
as tolerate. What response should the nurse make? - ANS"I am going to listen to your
stomach" - decide presence of bowel sound earlier than giving clear beverages to save you
postop n/v, d/t delayed gastric emptying time or decreased peristalsis after surgery
-When suitable to renew submit surgical food regimen it's far most effective to offer a
preference of clear beverages, instead of handiest water, a clear liquid w/ vitamins
-Use therapeutic conversation to fulfill pts wishes
*F2*
a nurse is changing the dressings for a patient with 2 penrose drains close to an stomach
incision. What is the first-rate sort of adhering tool to lower pores and skin infection? -
ANS*Montgomery straps* are the least restrictive; these adhesive straps are implemented to
the pores and skin on both side of a surgical wound, adhesive strips have holes for gauze to
tie dressing securely; ties are launched to trade dressing, dressing can be changed w/out
doing away with straps
-*Abdominal binder* is powerful in mattress, however will not keep dressings in location at
some stage in ambulation
-*Hypoallergenic tape* may be used however can nonetheless cause pores and skin
sensitivity while time and again removed and reapplied
-*Plastic tape* adheres to skin properly and reasons pores and skin inflammation when
removed and reapplied
*F2*
a nurse is accumulating a urine specimen for tradition and sensitivity for a affected person
who has a UTI and an indwelling urinary catheter in vicinity. What movement must the nurse
take? - ANSclamp tubing underneath series port - to allow sparkling uncontaminated urine to
acquire earlier than withdrawing specimen thru port in a sterile specimen cup
-Nurse have to cleanse port w/ *antimicrobial* swab
-Nurse should region the specimen in a *sterile* specimen cup to save you infection.
*F2*
a nurse is making plans to manage pain remedy to a affected person who has pain following
abdominal surgical operation. What movement need to the nurse take first? - ANSuse pain
scale to determine pts ache degree
-Think Maslow's hierarchy, meet pts physiological needs first
-must talk destructive effects of pain meds w/ pt; but every other action ought to be 1st
-have to reap VS before deciding on an intervention to relieve ache to provide a baseline to
evaluate to while monitoring after treating pain; however some other motion have to be 1st
, -ought to take a look at for pt allergies; however every other movement ought to be 1st
*F2*
a nurse notes no urine output for a postoperative affected person with an indwelling urinary
catheter after 2 hours. What action must the nurse take first? - ANScheck to decide if
catheter tubing is kinked; inspection is a priority motion
-If there is no kink, the nurse may also palpate the bladder or do a bladder experiment to
decide if there may be urine in the bladder and might encourage to pt to drink extra fluids to
sell kidney perfusion
-Nurse can achieve a *Px to irrigate* the catheter w/ .Nine% sodium chloride if absent urine
is d/t obstruction from blood clots or sloughing of bladder tissue
*F2*
a nursing worrying for a patient who had a mastectomy and has a self-suction drainage
evacuator in place. What actions should the nurse take to ensure proper operation of the
tool? - ANScollapse tool of air after emptying
-To create suction to drag fluid exudate into collection place of device
-Keep diaphragm of tool compressed to keep suction and prevent clotting of
consanguineous drainage; not made for irrigating
-Cleanse drain opening w/ alcohol wipe after opening to decrease access of microorgs
-Maintain drainage tubing below stage of incision to decorate drainage
*F2*
at what region ought to a nurse anchor the tubing of a urinary catheter for a male affected
person? - ANSlower stomach or top component of thigh to put off penoscrotal angle and
prevent tissue damage
-can cause pain and tissue damage while secured to lateral/ outdoor of the thigh, mid-belly
vicinity
-can cause discomfort and pressure on urethra at penosacral junction and cause tissue
harm when secured at medial thigh
*F2*
nurse is converting the dressing for a affected person convalescing from an appendectomy
following a ruptured appendix. What statement should the nurse file to the company? -
ANSHalo of erythema on surrounding pores and skin - might indicate underlying
contamination; other manifestations of infection consist of; sever ache, purulent drainage,
swelling, warmth, strong scent ought to all be reported
-Tenderness when touched, crimson and bright tissue w/ granular appearance,
*serosanguineous drainage* are all anticipated findings
-Pink, brilliant tissue w/ *granular appearance suggests proliferative degree of wound
healing*, and is anticipated for put up-op wound recovery *with the aid of 2ndary aim*
*F2*
