Rationale: Clients who have macular degeneration should use an electric razor to prevent injury. 4 ATI Practice Test - Final Exam A nurse is preparing a client for a Romberg test. Which of the following statements is appropriate for the nurse to make to this client at this time? A. "Stand with your feet together and your arms at your sides." B.
Administer all the daily medications. 3. Verify the client has not eaten for the last 24 hours. 4. Teach and practice postoperative breathing exercises. 1. Ensure that the client has voided. The nurse is caring for a client who recently returned from the operating room.
A patient who is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b.
The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action? 1. Take the pulse oximetry reading from any finger. 2. Remove one of the artificial nails and then obtain the reading from the finger. 3.
The nurse teaches the patient that sexual activity can be resumed when the incision is healed. ANS: C. The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.
The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started.
Electrical cardioversion is used for some tachydysrhythmias but would not be used for sinus tachycardia. When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next.
Ventricular fibrillation is irregular and does not have a consistent QRS duration. DIF: Cognitive Level: Apply (application) The nurse notes that a patient's heart monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape.
A comprehensive preoperative nursing assessment of the total hip patient is important in helping to achieve a positive outcome. Preoperatively identifying a patient’s individual needs and comorbidities can assist in this process. In preparing a patient for surgery, the following areas should be addressed.
A thorough medical history and physical examination can identify comorbidities that may adversely affect one’s outcome. Further consultation may be necessary when a patient has a significant cardiac, respiratory, hematologic, dermatologic, renal, vascular, or neurologic condition. Certain conditions may predispose a patient to a perioperative infection. Evaluating any previous infection history is important to determine what additional preoperative testing may be recommended. A patient’s skin should be examined for ulcerations, infections, and abnormalities that may affect incision healing postoperatively. Psoriasis, acne, and other skin conditions around the hip area should be treated and cleared prior to surgery.
Formal preoperative classes allow for a multidisciplinary approach for preparing the patient for surgery and may be provided by any combination of hospital-based nurses, office nurses, therapists, social workers, and physicians.
The goal of prehabilitation is to help prepare the patient for surgery by improving muscle strength , functionality , and range of motion.
In general, patients are usually admitted approximately 2 hours prior to the procedure. Certain medical conditions may require the admission of a patient 1 or more days prior to surgery. Preparing the patient for surgery should focus on decreasing patient anxiety by providing reassurance and answering additional questions. The preoperative nurse initiates correct site verification policies, reviews the consent, medical record number, and availability of blood products requested. Correct site identification is based on the fourth goal developed by The Joint Commission on Accreditation of Healthcare Organization ( 13 ).
Some of the key components to this program should include warm-up, cardiovascular conditioning, strength training, and flexibility. The physical therapist will focus on the techniques and protocols that will be used to help the patient gain functional independence.
End stage arthritis is a painful condition which leads to joint stiffness, muscle weakness, and difficulty performing activities of daily living (ADLs). Recovering from hip replacement surgery can place a significant stress on a person’s functional capacity.