ATI comprehensive practice A 2023

displacement (defense mechanism) - The transfer of feelings from one target to another that is considered less threatening or that is neutral. EX: A client is angry at his doctor, does not express it, but becomes verbally abusive with the nurse. Regression (defense mechanism) A person goes back to an earlier or less mature state or behavior Suppression: Defense Mechanism the denial of disturbing feeling or situation sublimation (defense mechanism) channeling socially unacceptable impulses into constructive, even admirable, behavior SE of alprazolam Orthostatic hypotension, dizziness, confusion and lethargy Initiate fall precautions how to turn a patient onto the right side Use draw sheet to move pt to left side Place pillow under 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 multiple sclerosis vision issues pain fatigue impaired coordination Difficulty swallowing Constipation How nurse delegate following task? (AP or LVN) A. Collect of a stool specimen B. Preparation of a client'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 when performing procedure Insert the catheter Once resistance is met, nurse withdraw the catheter 1-2cm to prevent damage bronchial tissues Nurse apply suction for 5-15s to minimize oxygen loss Suction can initiate the cough reflex as its opens the airway further and allows for more effective removal of mucus Why clients received TPN if they has an extensive burn injury? When nutritional needs are greater than oral or enteral nutrition can provide. TPN (total parenteral nutrition) Pt who receiving TPN is at risk for hyperglycemia Priority patient with stroke *right sided weakness Referral to physical therapist (high risk injury from falls) Nursing care for a client with deficit with CN II clear objects from the client's walking area Nursing care for a client with CVIII Ask the client to restate directions Nursing care for a client with deficit with CN IX Evaluate swallowing