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Flashcards in ATI final exam Deck (36):
1

Montgomery straps

Used for abdominal drainage

Decreased skin irritation

2

Where to adhere catheter tubing to male?

Lower abdomen

3

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

4

How often to change colostomy pouch

3-7 days

5

When to change colostomy bag

Before breakfast

6

NG feeding when to auscultate bowel sounds

Before feeding

7

Elevation of head for NG tube

30-45 degrees

8

How much water to flush NG tube after feeding ?

30 mL

9

Eye irrigation

2.5 cm (1 in) above eye

Lower conjunctiva sac

Hold bony prominences

Direct solution from inner canthus to outer

10

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

11

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

12

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

13

Proliferation stage

Wound healing

Pink, shiny tissue with granular appearance

14

IV local infection

Redness at IV entry site

15

Phlebitis

Palpable cord felt along vein used for infusion

Inflamm of inner vein

Discontinue and start at another location

16

IV infiltration

Taut skin

Skin cool to touch

1. Stop infusion
2. Elevate
3. Apply warm or cold compress

17

Primary intention

Wound healing

Edges are well-approximated

18

Tertiary intention

Wound healing

Wound closed at later date

Skin graft placed over wound bed

19

Secondary intention

Wound healing

Beefy, red tissue called granulation

Left open to drain and heal

5-21 days

20

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

21

Manifestations of thrombophlebitis

Calf swelling

22

Cdiff and family

Family must gown and glove

23

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

24

Anti-embolic stockings

Remove once per shift

Should keep on when sitting in chair

Avoid crossing legs

25

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

26

Role ambiguity

Person unclear of expectations

27

Role conflict

Person assume opposite roles with incompatible expectations

28

Priority assessment when admin IV fluid to older adult

Auscultation of lung sounds

29

Narrowed arterial lumen

Arterial bruits blowing sounds

Blood flowing through occluded or narrowed arteries

30

Distended jugular veins

Produce no sound

31

Impaired ventricular contraction

Produces extra heart sounds

S3 or S4

32

Asynchronous closure of aortic and pulmonic valves

“Splitting” of S2

Two “dub” sounds heard

33

Urine specific gravity during fluid deficit

1.030

34

Fluid volume excess

Neck vein distention

35

Fluid volume deficit

Rapid heart rate

Hypotension

36

Chickenpox

Airborne