ATI Fundamentals Retake

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.