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ATI NURSING vati fundamental remediation

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ATI NURSING vati fundamental remediation 1. What is pulse oximetry and what is a normal finding? What could cause an abnormal reading? Pulse oximetry is a noninvasive, measurement of the oxygen saturation of the bloo ...

ATI NURSING vati fundamental remediation 1. What is pulse oximetry and what is a normal finding? What could cause an abnormal reading? Pulse oximetry is a noninvasive, measurement of the oxygen saturation of the blood. The expected reference range is between 95% and 100% but a range between 91% and 100% is acceptable. Values can be slightly lower for older adult clients and clients with dark skin. Additional reasons for low readings include hypothermia, poor peripheral blood flow, too much light (sun, infrared lamps), low hemoglobin levels, jaundice, movement, edema and nail polish. 2. A nurse is caring for a client with a diabetic ulcer which has a bacterial infection. Identify the lab values the nurse will review to monitor for infection. The nurse will monitor the client's Leukocytosis (WBCs greater than 10,000/µL), Increases in the specific types of WBCs on differential (left shift = an increase in neutrophils), Elevated erythrocyte sedimentation rate (ESR) over 20 mm/hr, an increase indicates an active inflammatory process or infection. 3. A nurse in the treatment plan of a client with a stage III wound has an order to irrigate the wound site. Identify nursing measures to safely clean and irrigate the wound for this client. Irrigate the wound using a piston syringe or a sterile straight catheter for deep wounds with small openings. Apply 5 to 8 psi of pressure. A 30 to 60 mL syringe with a 19‑gauge needle provides approximately 8 psi. Use normal saline, lactated Ringer’s, or an antibiotic/antimicrobial solution. Cleanse from the least contaminated toward the most contaminated, use gentle friction when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound, isotonic solutions is the preferred cleansing agents for wound cleaning. Never use the same gauze to cleanse across an incision or wound more than once. Do not use cotton balls and other products that shed fibers. 4. A nurse is rounding on her clients and notes her client diagnosed with fluid volume deficit has an infiltrated intravenous (IV) access site. Identify three (3) clinical manifestations of IV infiltration. Clinical manifestations of IV infiltration include Pallor, local swelling at the site, and decreased skin temperature around the site.

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