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Nursing 104 VATI Remediation- Los Angeles City College

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Geupload op 14 juli 2023
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1/ List three (3) best practices to prevent injury when moving a client up in bed.
- Lower the head of the client so that it is flat or as the client tolerate¸ this action will avoid
shearing and the client does have to move against gravity.
- Raise the bed to a comfortable working height. raise the height of the bed to move it close to
your center of gravity and reduce the strain on your back.
- Grab the slide sheet or draw sheet at the patient's upper back and hips on the side of the bed
closest to you. Put one foot forward as you prepare to move the patient. Put your weight on your
back leg. On the count of three, move the patient by shifting your weight to your front leg and
pulling the sheet toward the head of the bed.
2/ List steps the nurse will take to administer a vaginal suppository.
-The nurse will perform hand hygiene and don gloves.
-The nurse will apply a water-soluble lubricant to the patient's vaginal opening.
-Place the patient in the correct position (on the back in the lithotomy position) and unwrap a
vaginal suppository that has been warmed to room temperature and lubricate it with a water
soluble lubricant.
-The nurse will insert the suppository into the patient's vagina using a gloved finger.
-The nurse will ask the patient to hold the suppository in place for a few minutes to prevent it
from falling out.
-The nurse will remove her gloves and wash her hands with soap and water.
3/ nurse is caring for a client who has a tracheostomy. Identify how often oral care should be
completed for this client and the reason why.
The nurse should provide oral hygiene for the patient who has tracheostomy every four hours in
order to reduce the risk of infection and maintain a clean environment surrounding the
tracheostomy. Because the tracheostomy aperture provides a direct connection to the lungs, it is
essential to ensure that the region is kept clean and clear of any bacteria or secretions that can
result in an infection.
4/ Explain the steps involved in providing an intermittent enteral feeding.
The nurse will first verify the prescription. After verification, the nurse will set up the equipment
which include the feeding bag, tubing 30 to 60 mL syringe, stethoscope, pH indicator strip,
infusion pump, appropriate enteral formula, irrigating solution, clean gloves, supplies for blood
glucose, and suction equipment. The nurse will then check the formula’s expiration dates and
content, ensuring the formula is at room temperature. The nurse will set up the feeding system,
mix the formula into the container, prime the tubing and clamp it. The nurse will then place the
patient in Fowler’s position or elevate the head of the bed to 30 degrees. Once complete, the

,nurse will auscultate bowel sounds, and monitor tube placement by checking gastric contents of
pH, aspirate for residual volume, and inspect the appearance of the aspirate. Next, the nurse will
flush the tubing with as least 30 mL of water and administer the formula by hanging it to drain
via gravity for about 30 to45 minutes.

5/ What questions would a nurse ask to assess a client’s sensory function?
Assess light touch by asking the client to report when and where they feel a cotton ball touching
their skin . Assess temperature using two tubes containing water ( one warm and one cold ) and
ask the client to identify which they feel . Assess pain sensation by alternating sharp and dull
objects on the skin and asking the client to report what they feel.
6/ A nurse is teaching a client about pursed-lip breathing. What should be included?
-To perform pursed-lip breathing, the person inhales deeply through the nose and then exhales
slowly through pursed lips.
-Pucker or "purse" your lips as if you were going to whistle or gently flicker the flame of a
candle.
-Breathe out (exhale) slowly and gently through your pursed lips while counting to four.
-Pursed-lip breathing can help to ease shortness of breath and improve the person's ability to
exercise.
-Do not force the air out. Always breathe out for longer than breathing in. Breathe slowly, easily,
and relaxed, in and out, until in complete control.

● Explain the steps
involved in providing an
intermittent enteral
feeding.

, ● The nurse will first verify
the prescription. After
verification, the nurse will
set up the equipment
● which include the feeding
bag, tubing 30 to 60 mL
syringe, stethoscope, pH
indicator strip,
● infusion pump,
appropriate enteral
formula, irrigating
solution, clean gloves,
supplies for blood
● glucose, and suction
equipment. The nurse will

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