ATI comprehensive practice A
Displacement (defense mechanism)
- The transfer of feelings from one target to some other that is considered less threatening or
that is neutral.
EX: A patron is angry at his physician, does now not explicit it, however becomes verbally
abusive with the nurse.
Regression (protection mechanism)
A individual goes lower back to an earlier or much less mature country or behavior
Suppression: Defense Mechanism
the denial of traumatic feeling or scenario
sublimation (protection mechanism)
channeling socially unacceptable impulses into optimistic, even admirable, conduct
SE of alprazolam
Orthostatic hypotension, dizziness, confusion and lethargy
Initiate fall precautions
how to turn a affected person onto the proper side
Use draw sheet to move pt to left facet
Place pillow beneath the pt left arm
lower draw sheet on left side
Nurse precaution for MRSA
Contact
Nurse precaution for pneumonia and influenza
Droplet
,Nurse precaution for tuberculosis and measles
Airborne
sx of a couple of sclerosis
vision issues
ache
fatigue
impaired coordination
Difficulty swallowing
Constipation
How nurse delegate following challenge? (AP or LVN)
A. Collect of a stool specimen
B. Preparation of a consumer's postop bed
C. Prepare teaching plan for pneumonia
D. Insertion of NG tube
AB-AP
C-Nurse
D- LVN
Suction for tracheostomy
Use surgical asepsis while acting system
Insert the catheter
Once resistance is met, nurse withdraw the catheter 1-2cm to prevent damage bronchial
tissues
Nurse follow suction for 5-15s to reduce oxygen loss
Suction can provoke the cough reflex as its opens the airway further and lets in for more
effective removal of mucus
Why customers received TPN in the event that they has an in depth burn harm?
When nutritional desires are more than oral or enteral nutrients can offer.
TPN (general parenteral nutrients)
Pt who receiving TPN is at chance for hyperglycemia
Priority patient with stroke *right sided weak spot
Referral to bodily therapist (high risk harm from falls)
, Nursing care for a customer with deficit with CN II
clear objects from the patron's on foot area
Nursing take care of a client with CVIII
Ask the client to restate instructions
Nursing care for a purchaser with deficit with CN IX
Evaluate swallowing
Stage of pressure damage
Stage I: superficial ,skin
Stage II: partial thickness skin loss blister formation
Stage III: Visiable sub-q tissue
Stage IV: muscle harm, tendon exposure
If the infusion pump does no longer paintings, how does the nurse deliver pt TPN?
Use manual drip tubing to infuse dextrose 10% in water answer at the equal charge with
TPN infusion.
Nurse must administer TPN to ensure accurate dosage and taper the infusion fee before
discontinuing the answer to prevent hypoglycemia
Triage pt for special tag
Green tag: damage is nonurgent
Black tag: Pt isn't always probably to recovery
Yellow tag: patron has predominant harm that calls for interest within 30min-2hr
Red tag: existence-threatening harm and requires at once tx
purpose of constipation in being pregnant at some point of 2d and 3rd trimester
- Estrogen and progesterone stage increase during pregnancy, leading to lower peristalsis
and rest of easy muscle mass of intestine which result in constipation
- The length and weight of the developing uterus reason each displacement and
compression of the gut. These changes cause a decrease in motility, main to constipation
recommendation for pt with impaired vision
Displacement (defense mechanism)
- The transfer of feelings from one target to some other that is considered less threatening or
that is neutral.
EX: A patron is angry at his physician, does now not explicit it, however becomes verbally
abusive with the nurse.
Regression (protection mechanism)
A individual goes lower back to an earlier or much less mature country or behavior
Suppression: Defense Mechanism
the denial of traumatic feeling or scenario
sublimation (protection mechanism)
channeling socially unacceptable impulses into optimistic, even admirable, conduct
SE of alprazolam
Orthostatic hypotension, dizziness, confusion and lethargy
Initiate fall precautions
how to turn a affected person onto the proper side
Use draw sheet to move pt to left facet
Place pillow beneath the pt left arm
lower draw sheet on left side
Nurse precaution for MRSA
Contact
Nurse precaution for pneumonia and influenza
Droplet
,Nurse precaution for tuberculosis and measles
Airborne
sx of a couple of sclerosis
vision issues
ache
fatigue
impaired coordination
Difficulty swallowing
Constipation
How nurse delegate following challenge? (AP or LVN)
A. Collect of a stool specimen
B. Preparation of a consumer's postop bed
C. Prepare teaching plan for pneumonia
D. Insertion of NG tube
AB-AP
C-Nurse
D- LVN
Suction for tracheostomy
Use surgical asepsis while acting system
Insert the catheter
Once resistance is met, nurse withdraw the catheter 1-2cm to prevent damage bronchial
tissues
Nurse follow suction for 5-15s to reduce oxygen loss
Suction can provoke the cough reflex as its opens the airway further and lets in for more
effective removal of mucus
Why customers received TPN in the event that they has an in depth burn harm?
When nutritional desires are more than oral or enteral nutrients can offer.
TPN (general parenteral nutrients)
Pt who receiving TPN is at chance for hyperglycemia
Priority patient with stroke *right sided weak spot
Referral to bodily therapist (high risk harm from falls)
, Nursing care for a customer with deficit with CN II
clear objects from the patron's on foot area
Nursing take care of a client with CVIII
Ask the client to restate instructions
Nursing care for a purchaser with deficit with CN IX
Evaluate swallowing
Stage of pressure damage
Stage I: superficial ,skin
Stage II: partial thickness skin loss blister formation
Stage III: Visiable sub-q tissue
Stage IV: muscle harm, tendon exposure
If the infusion pump does no longer paintings, how does the nurse deliver pt TPN?
Use manual drip tubing to infuse dextrose 10% in water answer at the equal charge with
TPN infusion.
Nurse must administer TPN to ensure accurate dosage and taper the infusion fee before
discontinuing the answer to prevent hypoglycemia
Triage pt for special tag
Green tag: damage is nonurgent
Black tag: Pt isn't always probably to recovery
Yellow tag: patron has predominant harm that calls for interest within 30min-2hr
Red tag: existence-threatening harm and requires at once tx
purpose of constipation in being pregnant at some point of 2d and 3rd trimester
- Estrogen and progesterone stage increase during pregnancy, leading to lower peristalsis
and rest of easy muscle mass of intestine which result in constipation
- The length and weight of the developing uterus reason each displacement and
compression of the gut. These changes cause a decrease in motility, main to constipation
recommendation for pt with impaired vision
