N330: ATI content mastery

what to do for patient with pain before activites

administer analgesia

what duty can assistive personnel do

apply sequential compression devices

MS for magnesium sulfate can be confused with

morphine sulfate

quality of pain

sharp or dull

intensity of pain

rate on scale 0 - 10

sign of hyponatremia

abdominal cramp, lethargy, headache

sign of hypocalcemia

Chvostek’s: twitch of facial muscle

Trousseau: flexion of wrist

sign of hyperkalemia

numbness of extermities

if use open irrigation to indwelling catheter

subtract irrigation amount from urine output

contact for rubella

droplet

next step after notify HCP about patient’s hemorrhagic shock

notify nursing manager (next chain of command)

fluid volume deficit leads to

tachycardia

transmission precaution for major wounds

contact precautions: gown, glove, private room

transmission precaution for shigella

contact: fecal-oral

when is irrigation required for catheter

urine accumulation in bladder scan

role overload

more responsibilities in a role than one can handle

what tasks can nurse delegate to AP

tasks require no special skills, assessment, or teaching

whose job this is: assess swallowing for aspiration risk

nurse’s task

how to prevent skin breakdown

use trapeze bar when change position

when should discharge be initiated

during admission process

how to protect allogeneic stem cell transplant pt

protect from infection, i.e. masks

palliative care focuses on

comfort & manifestation control

how to prevent latex allergy rxn

use non-latex material like stockinette

what does semi-Fowler position do

improve breathing

correct technique for 24-hr urine collection

discard 1st voiding, then save the rest

dressing for stage 1st pressure ulcers

transparent: prevent friction & shearing

dressing for stage 2nd pressure ulcers

hydrocolloid: create moist wound bed

dressing for stage 3rd & 4th pressure ulcers

alginate: soft gel

dressing for stage 4th & unstageable pressure ulcers

gauze: allow granulation of wound bed

FLACC pain scale is suitable for

2 months - 7 years old

elders have eye exam every

year

elders have tetanus booster every

10 years

people have shingles vaccine when

50 y/o

people have pneumococcal vaccine when

50 y/o

herbal echinacea is for

improve immunity, reduce infection risk

herbal feverfew is for

wound healing, decrease arthritis inflammation

herbal ginger is for

relieve n/v, aid digestion

herbal ginkgo biloba is for

improve memory, reduce stress

X-ray shows correct NG tube placement

above pylorus

steps in taking care dead patient

• obtain pronouncement of death

• place name tag on body

• remove tubes & lines

• wash body

• ask family to view

how should nurse documentation be

descriptive, objective of what nurse sees, no opinions

what to monitor with heart failure

sodium 2g daily, less processed food, daily weigh

proper airway position for seizure patient

turn to side w/ head tilted forward

anger as rxn to cancer diagnosis

expected response to grief

where is heparin administered

abdomen, 45-90°; pinch/spread skin at injection site

how to ensure medication reaches inner ear

press gently on tragus of ear

how often to screen for fecal occult blood test

annually

how often to screen for sigmoidoscopy

every 5 years

how often to screen for colonoscopy

every 10 years; begin age 50

8oz ice chips is equivalent of

4oz liquid = 120mL

is giving O2 through nasal cannula a resuscitative method

no, since it only brings comfort

is giving intubation a resuscitative method

yes

what clothing material doesn’t generate static electricity

cotton

what lube is suitable for O2 therapy

water-based

how much to irrigate wound

30-60mL syringes

ethical principle: veracity

nurse must tell truth & never deceives

proper way to descend stairs with crutches

first shift weight to unaffected leg

proper sitting techniques with crutches

hold both crutches by hand bards in 1 hand

exercise plan for osteoporosis

weight-bearing: move upright against gravity

proper technique for nasotracheal suctioning

intermittent suction when withdraw catheter to prevent mucosa injury

safety needs for older patient with fall risks

pupil clarity, visual fields, visual acuity

what are advance directives

living will: treatment pt accepts in case of emergency

first step when found pt fell on floor

check for injuries

steps in obtaining regular & NPH insulin

1. inject air into NPH w/o touch solution

2. inject air into regular insulin

3. withdraw correct amt regular insulin

4. withdraw correct amt NPH

foods for hypokalemia

bananas, oranges, (sweet) potatoes w/ skin, avocados, tomatoes

strategies to manage time effectively for client care

use planning step to prioritize care delivery

Romberg test

identify alteration in balance i.e. sways; arms at sides & feet together

should outer cannula of tracheostomy be removed

no, it helps stabilizing airway

proper size for suction catheter in tracheostomy

½ size of lumen → prevent hypoxemia

how to waste controlled substance

requires additional witness

signs of infiltration

skin blanching, edema, coolness

what is acupuncture contraindication of

skin infection, i.e. herpes zoster

how often to perform passive ROM

2-3 times/day

1st action in performing medication reconciliation

ask if pt takes any OTC meds

proper technique to administer IV bolus through saline lock

check blood return before inject med

extravasation

vesicant fluid leaks into surrounding tissue

benefit of chamomile

anti-inflammatory, relieve swollen joints

benefit of sage

lower GI distress, treat depression

benefit of jasmine

stimulate mood, relieve period cramps

benefit of lavender

calming, sedative for insomnia

how to prevent plantar flexion for coma patient

apply ankle-foot orthotics

patient with spina bifida is also at risk for

latex allergy

proper technique when ambulate with cane

move cane forward before taking a step

proper documenting technique

use subjective data (direct quotes pt says), objective data (nurse observe)