When performing an abdominal examination on a preschooler, what should the nurse allow the child to do to promote relaxation
Allow the child to place their hand under the nurses
A nurse is examining an 18 month old child's ears during a well-child visit. How should the nurse have the child?
Have the parent hold the child securely in her lap.
True of False. A preschool child is able to describe symptoms they may be experiencing
True
True of false. Books and visual aids are a good aids for school age children for communication with the nurse
True
A disorder in which the two eyes do not line up in the same direction, and therefore do not look at the same object at the same time
Strabismus
A nurse is testing for strabismus. What is a correct technique for performing this exam?
Perform the cover-uncover test
Noticing that a pt makes good eye contact would be included in the nurses what?
General survey
When taking a child's blood pressure, should the cough be inflated fast of slow?
Fast!
when taking a child's bp, what is the rate that the cuff should be released at?
2 to 3 mm hg
When a obtaining a blood pressure for a child, how large should the cuff be?
80 -100% of the arm circumference
How do you test a child for scoliosis?
Bend forward witht the knees straight and the arms dangling
when performing an otoscopy examination, on a 2 year old child, the nurse should pull the pinna?
Down and back
when performing an otoscopy examination, on a 2 year old child, the nurse should pull the pinna?
Up and back. this is the correct technique for straightening the ear canal for children 3 years and older
Is this an example of correct charting:
"Regular heart rate and rhythm, S1, S2 heard.
yes
What should the nurse do immediately after inserting the tube to the predetermined length for a nasogastric intubation?
Inspect the oropharynx with a penlight and a tongue blade
a pt recovering from gastric surgery remain NPO and has a nasogastric tube connected to suction. How should the nurse prevent dry mucous membranes?
Provide frequent mouth care (brushing teeth, oral swab)
Also commonly called stomach pumping or Gastric irrigation, is the process of cleaning out the contents of the stomach
Gastric lavage
When using chilled normal saline solution during gastric lavage, the nurse should watch for what complication?
Hypothermia
This type of tube is the only tube that allows continuous suction. It has two lumens, one removes gastric contents and the other severs as an air vent
Salem Sump
This type of tube is a single-lumen tube that requires intermittent suction to drain stomach secretions
Levin
This type of tube is one in which a balloon is inflated to apply internal pressure to prevent esophageal or gastrointestinal bleeding.
Sengstaken-Blakemore
This type of tube is used to irrigate the stomach in cases of active bleeding
Ewald
What would be the job of the nasogartic intubation for the following pt. A 6-year old who drank a toxic substance
It would be placed for lavage to irrigate the stomach
What would be the job of the nasogartic intubation for the following pt. a 60 year old pt admitted with gastrointestinal hemorrhage
It would be placed for compression
What would be the job of the nasogartic intubation for the following pt. A 40 year old pt with a postoperative bowel obstruction.
it would be place for decompression to relieve abdominal distention.
What would be the job of the nasogartic intubation for the following pt. A 20 year old pt with a malabsorbtion syndrom.
the tube would be placed for feeding.
A nurse is caring for a pt whose ng tube has become occluded. which of the following would indicate this?
1) active bowel sounds
2)passing flatus
3) patient's report of nausea
3) pt report of nausea.
If a ng tube becomes occluded, will gastric secretions decrease or increase?
decrease
When planning morning hygiene for a postop pt, should the nurse consider the pt own personal routine?
yes
What is the greatest fisk for a patient who in on long term bed rest and requires frequent linen changes due to excessive diaphoresis?
Skin breakdown
Should the CNA reuse the patient's blanket and spread if they are not wet or soiled?
Yes
How does the CNA use to make a mitered corner with the blanket and spread
the Sheet, blanket, and spread
According to ATI, while performing a complete bed bath for a pt., should the nurse raise the rm temp?
yes. this will help keep the pt warm while various part of the body are exposed and washed
When assisting a patient with personal hygiene care, which of the following actions by the nurse will reduce the risk for infection
1) massaging reddened areas of the pt's skin
2)Washing the eyes from the outer canthus to the inner canthus
3)Cleaning the least soiled areas prior to cleaning the most-soiled areas
3) cleaning the least soiled areas to the most soiled
Would a pt who has a persistant UTI be likely to receive a unrinary catherization?
No. UTI are not treated this way
would a pt who has urge incontinence be likely to receive an order for urinary catheterization?
No. Treatment options for urge incontinence typically include pelvic floor excercises, meds and bladder retraining.
Would a pt who is in the ICU for a GI bleed be likely to recieve an order for a urinary catheterization
Yes, Precise measurement of urinary output is crucial for managing fluid balance in patients who are critically ill.
Whould a pt who is incontinent due to cognitive decline be likely to receive an order for urinary catheterization?
No (according to ATI)
while inserting a straight catheter in a male pt, the nurse should hold the penis _ to the body
perpendicular
The nurse should do what to the penis when preparing to insert a straight catheter in male?
Apply light traction to the penis holding it perpendicular. ths straightens the urethral canal to facilitate catheter insertion
Before removing a pt's indwelling urinary catheter, what should the nurse make sure is done?
the balloon is completely deflated before removal
The nurse notices that the pt's urin output is alot lower than their fluid intake. after checking the catheter tubing for kinks, what should be the nurses next action?
Milk the catheter. this is done by squeezing then releasing the drainage tube, started from the top to the drainage bag
True of False. For a condom catheter, the nurse should leave space between the penis and the tip of the catheter for a pt who is uncircumcised
True
When beginning the insertion procedure for an indwelling catheter for a female client, the nurse should instruct the patient to?
Bear down
When a pt is being transferred by a mechanical lift with a hammock sling to transfer a pt from the bed to a chair, should the bed be in the lowest or highest position?
Highest position, in order to prevent injury to the staff
What is the correct positioning of the sling for a pt who is going to be transferred by a mechanical lift?
Place the sling under the patient from shoulders to knees
What would indicate to the nurse that a pt had full range of motion in thier shoulder?
Flexing the shoulder by raising the arm from a side position to a 180 degrees
When helping a pt ambulate, if they begin to fall or faint, what should you do?
extend one lef and allow the pt to slide down it.
How should the nurse position herself when transferring a patient from a bed to a chair?
align the nurses knees with the pt's knees just before transfer
When performing a physical assessment, the nurse tells the pt to stand with his feet together and arms at his side. The purpose of positioning the pt in this manner is to test what?
balance
for a pt who is using crutches, when they sit in a chair, should they hold the crutches on the unaffected or affected side?
unaffected side.
how far should a person using crutches hold them from their feet?
6 inches in front and to the side
What would demonstrate hyperextionsion of the hip?
