Fundamentals ATI RN 2019
levels of consciousness <<<answer>>>,alert: patient is
responsive, opens eyes spontaneously, and answers questions
appropriately
lethargic: patient can open eyes, respond to questions, but falls
asleep easily
obtunded: patient responds to light shaking, but is confused
and slow to respond
stuporous: patient barely responds to painful stimuli (rubbing
sternum)
comatose: patient is unresponsive. abnormal posturing may be
present
,prevention of respiratory complications <<<answer>>>,teach pt
to turn, cough, breathe deeply every 1-2 hrs while awake
encourage use of incentive spirometer
increase fluid intake to 2,000 ml/day (unless restricted)
reposition every 1-2 hrs
pulmonary embolism (PE) <<<answer>>>,symptoms: dyspnea,
chest pain, increased HR, decreased BP, hemoptysis
nursing care: place pt in high-fowlers position
administer O2, monitor VS, get ABGs
administer thrombolytics or anticoagulants
Macule <<<answer>>>,flat area of discoloration, < 1 cm
(freckle)
patch <<<answer>>>,flat area of discoloration, > 1cm
(birthmark)
papule <<<answer>>>,elevated solid lesion, <1 cm (mole,
nevus)
,plaque <<<answer>>>,elevated solid lesion, > 1 cm (psoriasis)
Vesicle <<<answer>>>,elevated, serous filled, <1 cm (herpes,
varicella)
Bulla <<<answer>>>,elevated, serous filled, > 1 cm (bister)
nodule <<<answer>>>,firm, deep, 1-2 cm (wart)
tumor <<<answer>>>,solid mass, deep, > 1-2 cm (neoplasm)
pustule <<<answer>>>,pus-filled vesicle, < 1 cm (acne)
wheal <<<answer>>>,transient, elevated, irregular borders,
edematous, often pruritic (insect bites)
nursing care of NG tubes <<<answer>>>,verify tube placement
with X-ray before feeding first time
verify presence of bowel sounds before feeding
check gastric contents pH (should be between 0-4)
, discard bags/tubing every 24 hrs
measure gastric residual every 4-6 hrs, return residual to
stomach
hold feeding for residual over hospital policy (~500 ml)
flush feeding tubes with 30 ml of water every 4 hrs
formula should be at room temp
hand hygiene <<<answer>>>,soap & water: wash hands with
antimicrobial soap and water (vs. alcohol based) for these
situations:
-hands visibly soiled
-before eating
-after using the restroom
-after contact with bodily fluids
wash for > = 15 seconds. dry with clean paper towel before
turning off faucet.
alcohol based product: use 3-5 ml
rub until hands are dry
standard precautions <<<answer>>>,hand hygiene (pref.
alcohol based antiseptic unless hands are visibly soiled)
levels of consciousness <<<answer>>>,alert: patient is
responsive, opens eyes spontaneously, and answers questions
appropriately
lethargic: patient can open eyes, respond to questions, but falls
asleep easily
obtunded: patient responds to light shaking, but is confused
and slow to respond
stuporous: patient barely responds to painful stimuli (rubbing
sternum)
comatose: patient is unresponsive. abnormal posturing may be
present
,prevention of respiratory complications <<<answer>>>,teach pt
to turn, cough, breathe deeply every 1-2 hrs while awake
encourage use of incentive spirometer
increase fluid intake to 2,000 ml/day (unless restricted)
reposition every 1-2 hrs
pulmonary embolism (PE) <<<answer>>>,symptoms: dyspnea,
chest pain, increased HR, decreased BP, hemoptysis
nursing care: place pt in high-fowlers position
administer O2, monitor VS, get ABGs
administer thrombolytics or anticoagulants
Macule <<<answer>>>,flat area of discoloration, < 1 cm
(freckle)
patch <<<answer>>>,flat area of discoloration, > 1cm
(birthmark)
papule <<<answer>>>,elevated solid lesion, <1 cm (mole,
nevus)
,plaque <<<answer>>>,elevated solid lesion, > 1 cm (psoriasis)
Vesicle <<<answer>>>,elevated, serous filled, <1 cm (herpes,
varicella)
Bulla <<<answer>>>,elevated, serous filled, > 1 cm (bister)
nodule <<<answer>>>,firm, deep, 1-2 cm (wart)
tumor <<<answer>>>,solid mass, deep, > 1-2 cm (neoplasm)
pustule <<<answer>>>,pus-filled vesicle, < 1 cm (acne)
wheal <<<answer>>>,transient, elevated, irregular borders,
edematous, often pruritic (insect bites)
nursing care of NG tubes <<<answer>>>,verify tube placement
with X-ray before feeding first time
verify presence of bowel sounds before feeding
check gastric contents pH (should be between 0-4)
, discard bags/tubing every 24 hrs
measure gastric residual every 4-6 hrs, return residual to
stomach
hold feeding for residual over hospital policy (~500 ml)
flush feeding tubes with 30 ml of water every 4 hrs
formula should be at room temp
hand hygiene <<<answer>>>,soap & water: wash hands with
antimicrobial soap and water (vs. alcohol based) for these
situations:
-hands visibly soiled
-before eating
-after using the restroom
-after contact with bodily fluids
wash for > = 15 seconds. dry with clean paper towel before
turning off faucet.
alcohol based product: use 3-5 ml
rub until hands are dry
standard precautions <<<answer>>>,hand hygiene (pref.
alcohol based antiseptic unless hands are visibly soiled)
