ATI Fundamentals Retake questions and answers

What do nurses use when preparing change-of-shift report? Standard handoff communication tools, such as Introduction, Situation, Background, Assessment, Recommendation (ISBAR) to facilitate transfers and discharges. When should discharge planning begin? On admission with every patient. Discharge documentation should include Type of discharge, date & time of discharge, who went with the client & transportation, where the client went, summary of clients current condition at discharge, description of any unresolved difficulties and disposition of valuables, medications brought from home & prescriptions. Documentation & abbreviations and symbols Being accurate & concise is an important element of documentation. Only abbreviations & symbols approved by The Joint Commission and the facility are acceptable. A nurse is discussing the HIPPA privacy rule with nurses during new employee orientation. Which of the following information should the nurse include? Family members should provide a code prior to receiving client health information, communication of a client can occur at the nurse's station, a client can request a hard copy of their records and a nurses may photocopy a client's medical record for transfer to another facility. A nurse is receiving a providers prescription for morphine by telephone for a client who is reporting moderate to severe pain. What are the appropriate nursing actions? Repeat the details of the prescription back to the provider, have another nurse listen to the telephone prescription and obtain the providers signature on the prescription within 24 hours. A problem is an ethical dilemma when I. A review of scientific data is not enough to solve it II. It involves a conflict between two moral imperatives III. The answer will have a profound effect on the situation and the client Ethical dilemmas are problems that involve more than one choice and stem from differences in the values and beliefs of decision makers Autonomy the right to makes one's own personal decisions, even when those decisions might not be in the that person's best interest. Beneifience positive actions to help others (do good) Fidelity agreement to keep promises Justice fairness in care delivery and use of resources Nonmaleficence avoidance of harm or injury (do no harm) Admission inventory of personal items include clothing, jewelry, money, credit cards, assistive devices, medications, cell phones and other technology devices, and religious articles... Nurses should discourage keeping valuables at the bedside. The nurse will document what related to personal items? The nurse will document communication with the client related to items left within the room and valuables locked in the facility's safe. Assault (International Tort) The conduct of one person makes another person fearful and apprehensive. Example: a nurse threatens to place an NG tube in a client who is refusing to eat. Battery (International Tort) Intentional & wrongful physical contract with a person that involves an injury of offensive contact. Example: A nurse restrains a client and administers an injection against her wishes. False Imprisonment (International Tort) A person is confined or retained against his will. The nurses uses restraints on a competent client to prevent his leaving the health care facility. What should the nurse teach older clients about home safety? To place electrical cords & extension cords against a wall behind furniture and use a nonskid mat in the tub or shower & place a shower chair in the shower and a beside commode if needed. The client who has heat stroke will have what sign? Hypotension One of the nurse's responsibility for a client in restraints is to make sure... the restraints are loose enough for range of motion & that there is enough room to fit two fingers between the restraints & the client. What is the priority action for a patient with a history of falls? Complete a fall risk assessment. What blood glucose level requires immediate action? 70 mg/dL of less What are manifestations of hypoglycemia? Mild shakiness, mental confusion, sweating, palpitations, headache, lack of coordination, blurred vision, seizures, and coma. What should clients with hypoglycemia do? Take 10 to 30 g of readily absorbed carbohydrate. Including two or three glucose tablets, six to ten hard candies, 1/2 cup of soda or juice, 1 tbsp honey or 4 tsp sugar. What should clients do when levels stabilize? Have the client take an additional carbohydrate and protein snack of small meal. What information should the nurse provide to a client with a new diagnosis of diabetes mellitus type 1? Usually occurs before the age 30, is treated with oral antiglycemic medications and regular exercise can reduce insulin requirements. What instructions should the nurse include when reinforcing dietary teaching to a client with type 2 diabetes mellitus? Carbohydrate intake should compromise of 55% of daily caloric intake, you can add table sugar to cereal, you can drink one alcoholic beverage with a meal and use the same portion size to exchange carbohydrates. What information should the nurse incorporate into the dietary plan for a client with type 2 diabetes mellitus? Weight management, lipid profile, cultural needs, and personal preferences. A nurse is caring for a family experiencing a crisis. What approach should the nurse use when working with a family using an open structure for coping with crisis? Convening a family meeting. What should you do before administering any medications? Obtain a complete medication and allergy history. What does diphenhydramine treat in relation to allergic reactions? Mild rashes and hives What should you do after hand-washing with ostomy skin care? Apply gloves & inspect the stoma, use mild soap and water to cleanse, then dry it gently and completely. What are the steps to take when administering a large-volume enema? 1. Position the client on the left side with right leg flexed forward. Put on gloves. Lubricate rectal tube or nozzle. (Also, warm to enema solution). 2. Slowly insert rectal tube (3 to 4 inches for an adult). Raise bag above anus, 18 inches (if client reports abd cramping, lower the enema fluid container) . Ask the client to retain the solution for prescribed amount of time, or until client is no longer able to retain it. 3. Discard bag. Assist the client to the appropriate position to defecate. Document results and the client's tolerance of the procedure. What should the nurse do to help prevent plantar flexion? Encourage active or provide passive ROM two or three times/day. Instruct clients to perform ROM while bathing, eating, grooming, and dressing. What should be done for a client to promote a proper sleep-wake cycle? Cluster care. ` Who is a fracture pan used for? Supine client and clients in body casts or leg casts. What should the nurse do for clients using a fracture pain? Raise the head of the bed to 30 degrees. If the client cannot lift his hips to get the bedpan under him, roll him onto one side, position the bedpan over his buttocks, and roll the client back onto the bedpan. Signs/symptoms of extracellular fluid volume deficit 1. Hypothermia, tachycardia, thready pulse, orthostatic hypotension, decreased central venus pressure, tachypnea, and hypoxia. 2. Dizziness, syncope, confusion, weakness and fatigue. GI findings related to extracellular fluid volume deficit Dry mucous membranes, dry furrowed tongue, nausea, vomiting, anorexia, and acute weight loss. The nurse should recognize which labs as a sign of dehydration? -Hct 55%