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/ hearing loss -Decreased gastric emptying is an expected finding what statement should a nurse make when a patient with DM1 is resistant to learning self-injection of insulin? "Tell me what I can do to help you overcome your fear of giving yourself injections." -therapeutic, pt able to express feelings A patient is scheduled for an arthroplasty in the next month and may need a blood transfusion. The patient expresses concern about the risk of developing an infection from the transfusion. What statement should the nurse make to the patient? "donate autologous blood before the surgery" -collection and reinfusion of the pts own blood, blood is drawn 3-5 weeks prior to surgery; safest form of blood tranfusions -taking epoetin prior to surgery can boost HCT levels but is inappropriate if their levels are w/in normal and this might not eliminate need for transfusion -taking iron supplement can boost hemoglobin levels but inappropriate if levels are w/in range and may not eliminate need for transfusion -blood donated from family member doesn't eliminate a possible infection from transfusion What action by a newly licensed nurse during tracheostomy care requires intervention? obtaining cotton balls for tracheostomy care -cotton balls can be aspirated possible causing tracheal abscess -high-strength peroxide solution is used to clean inner cannula -trach care is sterile procedure and sterile gloves are needed -pipe cleaners, small sterile brush can be used to remove thick/crusty secretions from inner cannula a nurse observes and AP using a small B/P cuff on an obese patient. What explanation should the nurse give the AP? "using a cuff that is too small will result in an inaccurately high reading." -a cuff that's too small for an obese pt will not result in an inaudible reading or an accurate reading -a B/P cuff should take up no more than 40% the circumference of the pts arm correct sequence of steps for an abdominal assessment 1. inspection 2. auscultation 3. percussion 4. palpation -prevents alerting the bowel sounds and causing false results a nurse is assessing a patient who is to undergo treatment for ovarian cancer. what statement indicated the patient is experiencing psychological distress? "I keep having nightmares about my surgery." -nightmares and sleep disturbances are manifestations of anxiety and PTSD -social and emotional support systems decrease risk of psychological distress -open communication can improve relationships what should a nurse do first, prior to transferring a pt for a chest xray? ID the pt using 2 pt identifiers -pt safety is key and a pt should only receive what has been prescribed to them -nurse should explain the procedure, nurse should have the pt ready for the procedures, and should ask if the pt has any questions proper hand hygiene teaching to an AP. what statement by the AP indicates an understanding? "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." -perform w/ warm water, friction applied to hands for 15-20 seconds, and drying should be done from the cleanest area to the least clean area (from the fingertips and up) secondary prevention of the seasonal influenza screening groups of older adults in a nursing care facility for early influenza manifestations -2ndary prevention focuses on preventing complications of illness and providing care to prevent illness from becoming severe -holding a comm clinical and administering a vaccine is ex. of primary prevention -education on the dangers of influenza is ex. of primary prevention -finding rehabilitation programs for older adults w/ influenza complications is ex of tertiary prevention proper surgical hand-washing tehcnique nurse washes w/ hands held higher than elbows -water and soapsuds wash frain away from clean area to dirty area -nails should be stroked w/ 15 strokes and each other part of the hand w/ 10 strokes -scrub hands first then work your way to the elbows -scrubbing is done w/ special brush and mechanical friction is necessary what action should a nurse take when observing a patient with terminal cancer is crying? sit and hold the pts hand -therapeutic communication of silence, touch, and offering of self -other responses do not respond to pts immediate needs An ER nurse is assessing a patient who reports diarrhea and decreased urination for 4 days. What action should be taken to assess skin turgor of the patient? grasp a skin fold of the chest under the clavicle, release it , and note whether it springs back -pushing on the pts nail beds determines capillary refill time -pressing the skin above the ankle for 5 seconds is used to determine pitting edema -measuring skin fold thickness is used to determine body fat percentage a nurse is obtaining a lower extremity B/P. what action should the nurse take? place the bladder of the cuff over the posterior aspect of the thigh -should position the cuff 2.5 cm above popliteal artery -measure w/ pt prone or supine w/ knees flexed -auscultate B/P at popliteal artery what action should a nurse take when taking care of a child postop following a tonsillectomy? administer analgesics on a routine schedule throughout the day and night -discourage child from coughing or clearing throat d/t risk of bleeding -nurse should offer ice collar to ease pain -milk products should be avoided because they can coat the throat and initiate coughing/ clearing throat; give ice chips an older adult is prescribed soft wrist restraints. what actions should the nurse take while the patient is on restraints? remove restraints one at a time -for a pt who is violent/ noncompliant -do not tie restraints to side rails d/t risk of pt injury -remove restraints to perform ROM exercises Q2 -restraint pre3scription can only be written for 24hrs, no PRN what action should a nurse plan to take when performing oral care to an unresponsive patient? raise the level of the bed -allow proper body mechanics -raise HOB to 30 degrees or turn pt to side-lying position to prevent aspiration -lower side rail on the side you are standing on to prevent strain and promote use of proper body mechanics -do not insert finger into mouth of unresponsive pt to avoid care-giver injury what actions should a charge nurse teach as the first response in CPR? 1. confirm unresponsiveness -nurse should also, call for assistance, give rescue breaths, and perform chest compressions but first must check pts pulse and monitor for chest expansion what should a nurse do when an electronic B/P machine taking vitals on an instable patient every 15 minutes begins to measure the B/P at varied intervals and with inconsistent readings? disconnect the machine and measure B/P manually Q15min -operating the equipment differently doesn't ensure accurate B/P readings