ATI Learning System RN: Fundamentals 1, 2, and Final (Answered) Graded A+

ATI Learning System RN: Fundamentals 1, 2, and Final (Answered) Graded A+ terminal illness and questions directed to nurse about religion and death encourage the patient to express feeling about death and dying -therapeutic technique of reflection first priority action when performing tracheostomy care 1. perform hand hygiene -The nurse should also- don sterile gloves, open all sterile supplies and solutions, and stabilize the tracheostomy tube but they all will come after hand hygiene in order to prevent contamination of the trach tube what should a nurse's priority action be when they notice a patient's pulse is irregular? auscultate the apical pulse and listen for 1 minute to obtain and accurate rate and document the irregularity in the chart -check peripheral pulses bilaterally to determine equality of blood perfusion -check pedal pulses to determine circulation in pts lower extremities -a doppler ultrasound should be used when a pt has a nonpalpable pulse/ very difficult to palpate first nursing action when receiving a new patient 1. obtain the pts information -other steps that follow this include: identify goals of care, document nursing findings, evaluate effectiveness of care transferring a patient from a stretcher to a bed following an abdominal surgery lock the wheels of the stretcher and the bed -pt should cross their arms over the chest to prevent injury -stretcher should be no more than 1.3 cm above the height of bed -logroll technique used to prevent injury of pts requiring immobilization of neck, back, spine priority nursing action for a patient admitted with decreased circulation of the left leg evaluate pedal pulses -nurse should also obtain a medical history, assess vitals and assess for leg pain but these aren't the first priority abdominal assessment of a patient postoperative with a paralytic ileum absent bowel sounds w/ distention -paralytic ileus is an immobile bowel w/ absent bowel sounds, abdominal distention, decreased peristalsis, no flatulence or stool teaching for an older adult who has constipation sit on the toilet for 30 minutes after eating a meal -increased peristalsis occurs after eating, sitting on the toilet for 30 min after eating is recommended bowel retraining to treat constipation -consume a minimum of 1500 mL of water increase intake of coarse-fiber and whole grains, not refined-fiber -do not use daily softeners because it hinders bowel retraining process patient who has chest pain that worsens upon inspiration and a high-pitched scratching sounds is auscultated during systole and diastole by the nurse with the diaphragm of the stethoscope positioned at the left sternal border. What heart sound should the nurse document? pericardial friction rub -pericardial friction rub high-pitched scratching, grating, squeaking leathery sound heard best w/ the diaphragm of the stethoscope at the left sternal border -common manifestation of pericardial inflammation; can be heard w/ ineffective pericarditis w/ MI, following cardiac surgery or trauma, or some autoimmune disorders such as rheumatic fever -typically has signs of chest pain that increases w/ inspiration or coughing and is relieved by sitting up or leaning forward -audible click, occurs in pts after prosthetic valve replacement surgery -murmur = swishing, whistling sound, hear best w/ bell of stethoscope -third heart sound = low-pitched sound after 2nd heart sound caused by rapid ventricular filling during diastole, best heard at mitral area w/ pt on L side; commonly heard in pts w/ HD and indicative of HF a nurse demonstrates postop breathing and coughing excises to a patient having an emergency surgery for appendicitis. What statement indicates the patient has a lack of readiness to learn? pt reports severe pain -pt w/ pain is unable to concentrate and perform exercises -Pt asking to repeat the instructions, how often to perform the exercises, and stating that it will probably be painful to perform them. Are all statements that show a readiness to learn F1 nurse teaching a group of older adults about the expected changes of aging. what statement indicates an understanding of the teaching? "I should expect my heart rate to take longer to return to normal after exercise as I get older." -d/t decreased cardiac output which causes an increased pulse rate during exercise -Bladder capacity decreases w/ age but urinary incontinence is not an expected finding of aging -Have an increase of ear wax buildup which may increase incidence problems w/