ATI Learning System RN:
Fundamentals 1, 2, and Final
*F1*
nurse teaching a collection of older adults about the predicted changes of growing older. What
announcement indicates an information of the teaching? - ANS-"I need to anticipate my heart
price to take longer to return to regular after exercising as I grow old."
-d/t reduced cardiac output which causes an improved pulse charge in the course of exercise
-Bladder ability decreases w/ age however urinary incontinence isn't an expected finding of
getting old
-Have an boom of ear wax buildup which might also growth prevalence troubles w/ listening to
loss
-Decreased gastric emptying is an expected locating
*F2*
a nurse caring for an older affected person who has dysphagia after a CVA. What movement
ought to the nurse take when assisting the patient at mealtime? - ANS-provide tart/bitter meals
first - promotes saliva production which facilitates w/ chewing and swallowing
-Higher danger of choking whilst liquids are provided w/ pts food, advocated 'dry swallows' clear
mouth btw bites
-Pt w/ impaired pharyngeal swallowing ought to tilt head ahead to sell swallowing
-Minimize any distractions at mealtime that allows you to focus on chewing and swallowing
*F2*
a nurse changing the dressing of a three day postoperative affected person following a
cholesystectomy observes yellow, thick drainage on the dressing. How need to the nurse chart
this type of drainage? - ANS-Purulent exudate - thick yellow/green/brown drainage which
indicates wound sloughing/contamination.
-*Serosanguineous exudate*, suggests plasma combined w/ blood drainage, pale yellow to
blood-tinged or streaks of blood and watery drainage
-*Serous exudate*, light yellow plasma from blood and watery
-*Sanguineous exudate*, lively bleeding; accumulation of RBC's from plasma that appears
brilliant or darkish red
*F2*
a nurse is worrying for a affected person who has a records of dysrhythmias and upon coming
into the room discovers the patient is unresponsive to verbal or painful stimuli, has no
,repsiraitons, is pulseless. What movement need to the nurse take first? - ANS-Start chest
compressions
-Nurse have to begin CPR, which starts offevolved w/ chest compressions then establishing an
airway and breathing into pt mouth *CAB*
-Can use a guide resuscitation bag to oxygenate pt all through CPR
*F2*
a nurse is being concerned for a affected person who's postoperative following a vaginal
hysterectomy and ask for a drink. Her postoperative weight-reduction plan is obvious
beverages; boost as tolerate. What response have to the nurse make? - ANS-"I am going to pay
attention to your abdomen" - decide presence of bowel sound earlier than giving clear drinks to
save you postop n/v, d/t behind schedule gastric emptying time or reduced peristalsis after
surgical treatment
-When suitable to renew submit surgical weight loss plan it's far ideal to offer a desire of clean
liquids, as opposed to only water, a clean liquid w/ vitamins
-Use healing communique to satisfy pts needs
*F2*
a nurse is changing the dressings for a patient with 2 penrose drains near an abdominal
incision. What's the exceptional sort of adhering tool to lower pores and skin infection? -
ANS-*Bernard Law Montgomery straps* are the least restrictive; those adhesive straps are
implemented to the skin on both aspect of a surgical wound, adhesive strips have holes for
gauze to tie dressing securely; ties are launched to trade dressing, dressing may be replaced
w/out disposing of straps
-*Abdominal binder* is effective in mattress, however will now not maintain dressings in place
during ambulation
-*Hypoallergenic tape* may be used but can nevertheless cause skin sensitivity whilst
repeatedly eliminated and reapplied
-*Plastic tape* adheres to pores and skin well and reasons skin infection when eliminated and
reapplied
*F2*
a nurse is accumulating a urine specimen for tradition and sensitivity for a affected person who
has a UTI and an indwelling urinary catheter in region. What action must the nurse take? -
ANS-clamp tubing underneath collection port - to allow sparkling uncontaminated urine to gather
before taking flight specimen via port in a sterile specimen cup
-Nurse need to cleanse port w/ *antimicrobial* swab
-Nurse must location the specimen in a *sterile* specimen cup to prevent contamination.
*F2*
, a nurse is making plans to administer ache remedy to a affected person who has pain following
stomach surgical operation. What movement should the nurse take first? - ANS-use ache scale
to decide pts pain level
-Think Maslow's hierarchy, meet pts physiological desires first
-ought to discuss unfavourable consequences of ache meds w/ pt; but any other action must be
1st
-need to attain VS before choosing an intervention to alleviate pain to provide a baseline to
compare to when monitoring after treating ache; however any other movement should be 1st
-must check for pt allergies; however any other motion have to be 1st
*F2*
a nurse notes no urine output for a postoperative affected person with an indwelling urinary
catheter after 2 hours. What action should the nurse take first? - ANS-take a look at to
determine if catheter tubing is kinked; inspection is a concern movement
-If there is no kink, the nurse can also palpate the bladder or do a bladder experiment to decide
if there may be urine within the bladder and may encourage to pt to drink more fluids to sell
kidney perfusion
-Nurse can gain a *Px to irrigate* the catheter w/ .9% sodium chloride if absent urine is d/t
obstruction from blood clots or sloughing of bladder tissue
*F2*
a nursing worrying for a affected person who had a mastectomy and has a self-suction drainage
evacuator in place. What movements need to the nurse take to make certain right operation of
the device? - ANS-disintegrate device of air after emptying
-To create suction to pull fluid exudate into series location of device
-Keep diaphragm of device compressed to keep suction and prevent clotting of consanguineous
drainage; no longer made for irrigating
-Cleanse drain establishing w/ alcohol wipe after establishing to decrease access of microorgs
-Maintain drainage tubing below level of incision to decorate drainage
*F2*
at what area ought to a nurse anchor the tubing of a urinary catheter for a male patient? -
ANS-decrease stomach or upper aspect of thigh to do away with penoscrotal angle and prevent
tissue damage
-can cause soreness and tissue harm whilst secured to lateral/ outdoor of the thigh, mid-belly
area
-can purpose soreness and pressure on urethra at penosacral junction and cause tissue injury
while secured at medial thigh
*F2*
Fundamentals 1, 2, and Final
*F1*
nurse teaching a collection of older adults about the predicted changes of growing older. What
announcement indicates an information of the teaching? - ANS-"I need to anticipate my heart
price to take longer to return to regular after exercising as I grow old."
-d/t reduced cardiac output which causes an improved pulse charge in the course of exercise
-Bladder ability decreases w/ age however urinary incontinence isn't an expected finding of
getting old
-Have an boom of ear wax buildup which might also growth prevalence troubles w/ listening to
loss
-Decreased gastric emptying is an expected locating
*F2*
a nurse caring for an older affected person who has dysphagia after a CVA. What movement
ought to the nurse take when assisting the patient at mealtime? - ANS-provide tart/bitter meals
first - promotes saliva production which facilitates w/ chewing and swallowing
-Higher danger of choking whilst liquids are provided w/ pts food, advocated 'dry swallows' clear
mouth btw bites
-Pt w/ impaired pharyngeal swallowing ought to tilt head ahead to sell swallowing
-Minimize any distractions at mealtime that allows you to focus on chewing and swallowing
*F2*
a nurse changing the dressing of a three day postoperative affected person following a
cholesystectomy observes yellow, thick drainage on the dressing. How need to the nurse chart
this type of drainage? - ANS-Purulent exudate - thick yellow/green/brown drainage which
indicates wound sloughing/contamination.
-*Serosanguineous exudate*, suggests plasma combined w/ blood drainage, pale yellow to
blood-tinged or streaks of blood and watery drainage
-*Serous exudate*, light yellow plasma from blood and watery
-*Sanguineous exudate*, lively bleeding; accumulation of RBC's from plasma that appears
brilliant or darkish red
*F2*
a nurse is worrying for a affected person who has a records of dysrhythmias and upon coming
into the room discovers the patient is unresponsive to verbal or painful stimuli, has no
,repsiraitons, is pulseless. What movement need to the nurse take first? - ANS-Start chest
compressions
-Nurse have to begin CPR, which starts offevolved w/ chest compressions then establishing an
airway and breathing into pt mouth *CAB*
-Can use a guide resuscitation bag to oxygenate pt all through CPR
*F2*
a nurse is being concerned for a affected person who's postoperative following a vaginal
hysterectomy and ask for a drink. Her postoperative weight-reduction plan is obvious
beverages; boost as tolerate. What response have to the nurse make? - ANS-"I am going to pay
attention to your abdomen" - decide presence of bowel sound earlier than giving clear drinks to
save you postop n/v, d/t behind schedule gastric emptying time or reduced peristalsis after
surgical treatment
-When suitable to renew submit surgical weight loss plan it's far ideal to offer a desire of clean
liquids, as opposed to only water, a clean liquid w/ vitamins
-Use healing communique to satisfy pts needs
*F2*
a nurse is changing the dressings for a patient with 2 penrose drains near an abdominal
incision. What's the exceptional sort of adhering tool to lower pores and skin infection? -
ANS-*Bernard Law Montgomery straps* are the least restrictive; those adhesive straps are
implemented to the skin on both aspect of a surgical wound, adhesive strips have holes for
gauze to tie dressing securely; ties are launched to trade dressing, dressing may be replaced
w/out disposing of straps
-*Abdominal binder* is effective in mattress, however will now not maintain dressings in place
during ambulation
-*Hypoallergenic tape* may be used but can nevertheless cause skin sensitivity whilst
repeatedly eliminated and reapplied
-*Plastic tape* adheres to pores and skin well and reasons skin infection when eliminated and
reapplied
*F2*
a nurse is accumulating a urine specimen for tradition and sensitivity for a affected person who
has a UTI and an indwelling urinary catheter in region. What action must the nurse take? -
ANS-clamp tubing underneath collection port - to allow sparkling uncontaminated urine to gather
before taking flight specimen via port in a sterile specimen cup
-Nurse need to cleanse port w/ *antimicrobial* swab
-Nurse must location the specimen in a *sterile* specimen cup to prevent contamination.
*F2*
, a nurse is making plans to administer ache remedy to a affected person who has pain following
stomach surgical operation. What movement should the nurse take first? - ANS-use ache scale
to decide pts pain level
-Think Maslow's hierarchy, meet pts physiological desires first
-ought to discuss unfavourable consequences of ache meds w/ pt; but any other action must be
1st
-need to attain VS before choosing an intervention to alleviate pain to provide a baseline to
compare to when monitoring after treating ache; however any other movement should be 1st
-must check for pt allergies; however any other motion have to be 1st
*F2*
a nurse notes no urine output for a postoperative affected person with an indwelling urinary
catheter after 2 hours. What action should the nurse take first? - ANS-take a look at to
determine if catheter tubing is kinked; inspection is a concern movement
-If there is no kink, the nurse can also palpate the bladder or do a bladder experiment to decide
if there may be urine within the bladder and may encourage to pt to drink more fluids to sell
kidney perfusion
-Nurse can gain a *Px to irrigate* the catheter w/ .9% sodium chloride if absent urine is d/t
obstruction from blood clots or sloughing of bladder tissue
*F2*
a nursing worrying for a affected person who had a mastectomy and has a self-suction drainage
evacuator in place. What movements need to the nurse take to make certain right operation of
the device? - ANS-disintegrate device of air after emptying
-To create suction to pull fluid exudate into series location of device
-Keep diaphragm of device compressed to keep suction and prevent clotting of consanguineous
drainage; no longer made for irrigating
-Cleanse drain establishing w/ alcohol wipe after establishing to decrease access of microorgs
-Maintain drainage tubing below level of incision to decorate drainage
*F2*
at what area ought to a nurse anchor the tubing of a urinary catheter for a male patient? -
ANS-decrease stomach or upper aspect of thigh to do away with penoscrotal angle and prevent
tissue damage
-can cause soreness and tissue harm whilst secured to lateral/ outdoor of the thigh, mid-belly
area
-can purpose soreness and pressure on urethra at penosacral junction and cause tissue injury
while secured at medial thigh
*F2*
