ATI final exam Flashcards
Montgomery straps
Used for abdominal drainage
Decreased skin irritation
Where to adhere catheter tubing to male?
Lower abdomen
Removal of NG tube
Disconnect from suction
Instill 50 mL air into tube
Pinch tubing
Instruct to take deep breath and hold breath on removal
How often to change colostomy pouch
3-7 days
When to change colostomy bag
Before breakfast
NG feeding when to auscultate bowel sounds
Before feeding
Elevation of head for NG tube
30-45 degrees
How much water to flush NG tube after feeding ?
30 mL
Eye irrigation
2.5 cm (1 in) above eye
Lower conjunctiva sac
Hold bony prominences
Direct solution from inner canthus to outer
Cleansing enema
Lubricate 5-8cm (2-3 in)
Lie on left side
Insert tip 8cm (3.1 in)
Hold 45 cm (18 in) above rectum
Incentive spirometer
Inhale slowly
Homey breath 3-5 sec after reaching max inspiratory volume
Breathe normally between cycle
Repeat every 10-20 breaths while awake
Tracheostomy suctioning
Pull suction 1cm (.5 in) when coughing occurs
Allow 1 min between suctioning passes
Hyperventilate 100% oxygen 2 min prior
Max : 3 passes
Proliferation stage
Wound healing
Pink, shiny tissue with granular appearance
IV local infection
Redness at IV entry site
Phlebitis
Palpable cord felt along vein used for infusion
Inflamm of inner vein
Discontinue and start at another location
IV infiltration
Taut skin
Skin cool to touch
- Stop infusion
- Elevate
- Apply warm or cold compress
Primary intention
Wound healing
Edges are well-approximated
Tertiary intention
Wound healing
Wound closed at later date
Skin graft placed over wound bed
Secondary intention
Wound healing
Beefy, red tissue called granulation
Left open to drain and heal
5-21 days
Cane use
Top of cane parallel to greater trochanter
Client moves can 18 in forward
Client holds cane on stronger side of body
Move weaker leg forward first
Manifestations of thrombophlebitis
Calf swelling
Cdiff and family
Family must gown and glove
Assessing older adult for risk of falls (eyes)
Pupil clarity (cloudy-cataracts)
Visual fields
Visual acuity (distance vision, card for near vision)
*should wear glasses during assessment
Anti-embolic stockings
Remove once per shift
Should keep on when sitting in chair
Avoid crossing legs
TB nurse priorities
Negative pressure airflow room
Wear gloves for oral care
Nurse should wear N95 respirator
Use antimicrobial sanitizer
No need to limit visitors
Role ambiguity
Person unclear of expectations
Role conflict
Person assume opposite roles with incompatible expectations
Priority assessment when admin IV fluid to older adult
Auscultation of lung sounds
Narrowed arterial lumen
Arterial bruits blowing sounds
Blood flowing through occluded or narrowed arteries
Distended jugular veins
Produce no sound
Impaired ventricular contraction
Produces extra heart sounds
S3 or S4
Asynchronous closure of aortic and pulmonic valves
“Splitting” of S2
Two “dub” sounds heard
Urine specific gravity during fluid deficit
1.030
Fluid volume excess
Neck vein distention
Fluid volume deficit
Rapid heart rate
Hypotension
Chickenpox
Airborne
