Fundamentals ATI Study Guide PDF

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Fundamentals Study Guide Management of Care Advance Directives/Self-Determination/Life Planning - (1) -

Legal Responsibilities: Teaching About Advance Directives(Fund 10.0 Ch 4)

Ans: Clients provide implied consent when they adhere to the instruction the nurse provides. For invasive procedures or surgery, the client must provide written consent. Parent of a minor, legal guardian, court specified rep, and an individual who is durable power of attorney can grant consent for another person. If client refuses procedure, they must sign document saying they refuse. The purpose of advance directives is to communicate a clients wish regarding end of life care should the client become unable to do so.

Advocacy – (1) -

Cultural and Spiritual Nursing Care: Effective Communication When Caring for a Client Who Speaks a Different Language Than the Nurse(Fund 10.0 Chp 35)

Ans: Provide language assistance to clients who have communication needs, inform clients of language services verbally in writing, provide competent and trained interpreters, give the client learning materials such as videos and handouts and having signs in all language

Client Rights - (1) -

Ethical Responsibilities: Responding to a Client's Need for Information About Treatment(Fund 10.0 Chp 3)

Ans: Beneficence which is an action that promotes good for others, without any self interest

Establishing Priorities - (1) -

Client Education: Discharge Planning for a Client Who Has Diabetes Mellitus(RM Fund 10.0 Chp 17)

Ans: speak and provide printable materials, select age appropriate teaching materials at a 68th grade level, avoid nursing terminologies, organize learning activities to move from simple to complex task. Incorporate active participation in the learning process and schedule teaching sessions

Information Technology - (2) -

Information Technology: Action to Take When Receiving a Telephone Prescription(Fund 10.0 Chp 5)

Ans: have a 2nd nurse listen to phone prescriptions, repeat it making sure to include med name (spell if necessary), dosage, time and route. Make sure prescriber signs prescription within facility time frame which is typically 24 hours -

Information Technology: Identifying Proper Documentation(Fund 10.0 Chp 5)

Ans: conduct reporting in a confidential manner, making sure its accurate and concise, complete and current, & organized

Safety and Infection Control Accident/Error/Injury Prevention - (2) -

Client Safety: Implementing Seizure Precautions(Active Learning Template - Basic Concept, RM Fund 10.0 Chp 12)

Ans: make sure rescue equipment is at bedside including O2, oral airway, suction, and padding for rails. Clients at high risk should have saline lock in place for immediate IV access. Ensure rapid intervention to maintain airway patency. Inspect the clients environment for items that could cause injury during seizure, and remove items that are not necessary for treatment. Assist client at risk for seizures with ambulation and transferring to reduce the risk of injury. Advise caregiver and family to not put anything in clients mouth except an airway for status epilepticus. Advise caregiver not to restrain during seizure, but to lower client to the floor or bed, protect head, remove nearby furniture, provide privacy, put them on one side with the head flexed slightly forward if possible and loosen their clothing. After seizure stay with pt and call for help, maintain airway and suction PRN, administer meds, note duration and sequence of seizure, determine mental status and measure vitals, mention what happened and provide comfort. Document seizure -

Medical and Surgical Asepsis: Planning Care for a Client Who Has a Latex Allergy(Fund 10.0 Chp 10)

Ans: Check for latex allergies. Use latex free gloves, equipment and supplies.

Standard Precautions/Transmission-Based Precautions/Surgical Asepsis - (1) -

Medical and Surgical Asepsis: Preparing a Sterile Field(Fund 10.0 Chp 10)

Ans: Avoid coughing, sneezing or talking over the sterile field. Ask client to avoid sudden movement. Refrain from touching supplies, drapes or nurse gloves and gown. Only sterile items can be in sterile field. 1 inch edge of packaging is not sterile. Grab 1 inch boarder before donning sterile gloves. Discard anything that comes in contact with 1 inch boarder. Touch sterile materials only with sterile gloves. Any object held below the waist or above the chest contaminated. Sterile materials can touch other sterile materials, but not with unsterile materials. Do not reach across or above sterile field, do not turn you back to sterile field, and hold items to add to sterile field at a minimum of 6 inches above the field.

Health Promotion and Maintenance Health Promotion/Disease Prevention - (1) -

Health Promotion and Disease Prevention: Stages of Health Behavior Change(Fund 10.0 Chp 16)

Ans: Men & Women Routine physical exams are done Generally 1-3 years for female and every 5 years for males from age 20-40 and more often after each 40. Dental exam every six months, TV screening every 2 years Blood pressure at least every two years annually if previously elevated, BMI at each routine health care visit, Blood cholesterol starting at age 20 minimum of every 5 years, Blood glucose starting at age 45 and a minimum of every 3 years, Visual at age 40 and under every 3-5 years. Every 2 years ages 40-64. Every year 65 and older Hearing checks as needed More frequently of hearing loss is noted Skin assessment every three years by a skin specialist for ages 20-40, annually over age 40 years Digital rectal exam during routine physical examination or annually have at least a 10 year life expectancy. Consult with your provider if screen should continue after Colorectal screening every year between the age of 50-75 for high sensitivity fecal occult blood testing, or flexible sigmoidoscopy every f5 years, or colonoscopy every 10 years. Consult with your provider if screen should continue age 76 Women

Cervical cancer screening between the ages of 21-65 years. Pap smear every 3 years at age 30, can decrease pap screening to every 5 years is HPV screening performed as well. After age 65 no testing is needed if previous testing is normal and not high risk for cervical cancer Breast cancer screening between the ages of 20-30. Clinical breast examination every 3years, then annually. Client ages 40-44 years should have the choice to start annual mammogram, ages 40- 54 annual mammogram. Ages 55 and older should have the choice to have a mammogram every 1-2 years Men Clinical testicular examination at each routine health care visits starting at puberty prostate specific antigen test comma digital rectal starting at age 50, and then again whether to continue after age 76

Psychosocial Integrity Coping Mechanisms - (1) -

Coping: Priority Intervention for a Client Who Has a Terminal Illness(Fund 10.0 Chp 33)

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Grief and Loss - (1) -

Self-Concept and Sexuality: Providing Client Support Following a Mastectomy (Fund 10.0 Chp 34)

Ans: Establish a therapeutic relationship with the client. A caring and nonjudgmental manner puts the client at ease and fosters meaningful communication. Ensure privacy and confidentiality. Let the client know that sensitive issues are safe to discuss. depression and denial as feelings to be expected when Adjusting to body changes. arrange for a visit from a volunteer who has experienced a similar body image change period reinforced client strength and help them find assistance they need

Basic Care and Comfort Assistive Devices - (1) -

Sensory Perception: Evaluating a Client's Understanding of Hearing Aid Use(Fund 10.0 Chp 45)

Ans: Use the lowest setting that allows hearing without feedback. To clean the air mold, use mild soap and water while keeping the hearing aid dry period when the hearing aid is not in use for an extended period of time, turn it off and remove the battery to conserve battery power and avoid corrosion of the hearing aid . Keep replacement batteries on hand

Mobility/Immobility - (1) -

Mobility and Immobility: Preventing Thrombus Formation(Fund 10.0 Chp 40 )

Ans: Increase activity as soon as possible by dangling feet on side of bed or transferring to a chair. Change position as often as possible. Move the client gradually during position change. Instruct the client to avoid the valsalva maneuver. Give us to software to prevent straining. Teach ROM at anti embolic exercises. Use elastic stockings. Use sequential compression devices or intermittent pneumatic compression. increase fluid intake if no restriction. Administer low dose heparin or enoxaparin subcut prophylactically. Contact the provider immediately if there is absence of a peripheral pulse in the lower extremities or assessment data that indicates venous thrombosis.

Nutrition and Oral Hydration - (2) -

Fluid Imbalances: Calculating a Client's Net Fluid Intake(Fund 10.0 Chp 57)

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Nasogastric Intubation and Enteral Feedings: Unexpected Findings(Fund 10.0 Chp 54)

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Pharmacological and Parenteral Therapies Medication Administration - (1) -

Pharmacokinetics and Routes of Administration: Enteral Administration of Medications (Fund 10.0 Chp 46)

Ans: do not mix meds with enteral feeding.

Pharmacological Pain Management - (1) -

Safe Medication Administration and Error Reduction: Administering a Controlled Substance(Fund 10.0 Chp 47)

Ans: Keep them in a secure area. Have another nurse Witness the discarding of controlled substances

Reduction of Risk Potential

Diagnostic Tests - (1) -

Diabetes Mellitus Management: Identifying a Manifestation of Hyperglycemia(AMS RN 11.0 Chp 82)

Ans: Hyperglycemia is fasting glucose greater than 100 or taking hyperglycemic meds. Manifestations of hyperglycemia include hot, dry skin, and fruity breath. Treatment include encouraging oral fluid intake of sugar free fluids to prevent dehydration, administering insulin as prescribed, test urine for ketones and report if outside of the expected reference range, and consulting the provider if manifestations progress

Potential for Alterations in Body Systems - (1) -

Hygiene: Teaching a Client Who Has Type 2 Diabetes Mellitus About Foot Care(Fund 10.0 Chp 37)

Ans: It is important to prevent any infection or paint that can interfere with gait. A qualified professional Should perform foot care for clients who have diabetes, peripheral vascular disease, or immunosuppression to evaluate the feet and prevent injury. Do not soak the feet due to the risk of infection, and do not cut the nails. Instead file the nails using a nail file. Do not apply lotion between the fingers or toes because the moisture can cause skin irritation and breakdown

System Specific Assessments - (1) -

Thorax, Heart, and Abdomen: Priority Action for Abdominal Assessment(Fund 10.0 Chp 29)

Ans: Ask the client to urinate before the abdominal examination. Have the client Lisa pine with arms at both side and knee slightly bent. Imagine vertical and horizontal lines through the umbilical divide the argument into four quadrants with the xiphoid process as the upper boundary.

Physiological Adaptation

Alterations in Body Systems - (2) -

Airway Management: Performing Chest Physiotherapy(Fund 10.0 Chp 53 Airway)

Ans: Schedule treatment 1 hour before or 2 hours after meal, and at bedtime to decrease the likelihood of vomiting or aspiration. Administer a bronchodilator medication or nebulizer treatment 30 minutes to 1 hour prior To postural drainage. Offer the client an emesis basin and facial tissue. Apply manual percussion to the chest wall using cupped hands or a specific device. Please hands on the affected area, tense hand and arm muscle, and move the heel of the Hands to create vibration as the client exhales, have the client cough after each set of vibration. Have the client remain in each position for 10-15 minutes to allow time for percussion, vibration, and postural drainage. Discontinue the procedure if the client reports faintness or dizziness. Note that the older adult clients have decreased respiratory muscle strength and the chest wall compliance, which puts them at risk for aspiration. They require more frequent position changes and other interventions to promote mobility and secretion. -

Vital Signs: Caring for a Client Who Has a High Fever(Fund 10.0 Chp 27)

Ans: Provide antipyretics such as aspirin Tylenol and ibuprofen. Do not give aspirin to manage fever for children in a dollar sense who have a viral illness such as influenza and Chickenpox due to the risk of Reyes syndrome....