ATI RN Fundamentals Flashcards 2023

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Questions and Answers

Which of the following indications might suggest malnutrition? (Select all that apply)

Skin dry and scaly with bruises on extremities (correct)

Cachectic, with flaccid muscle tone (correct)

Temperature 39.2° C (102.6° F)

Pulse rate 118/min (correct)

An elevated temperature can indicate malnutrition.

False

A nurse should first _ followed by _.

review medications that might be causing confusion, using other methods to keep the client safe

Which actions should the nurse plan to take for the client? (Select the 3 actions)

Delegate the application of sequential compression devices to assistive personnel Signup and view all the answers

Which statements indicate understanding of teaching for a client with heart failure? (Select the 3 statements)

I know to call my doctor if I gain 3 pounds or more in 2 days. Signup and view all the answers

Which instructions should the nurse include for a client with diarrhea? (Select the 4 instructions)

Drink hot liquids several times a day. Signup and view all the answers

What indicates a client's readiness to learn?

I can concentrate best in the morning. Signup and view all the answers

Which statement indicates a client is not ready to learn?

I'm wondering why I need to learn this. Signup and view all the answers

What should a nurse instruct family members of a client with Clostridium difficile infection?

Wear a gown and gloves when visiting. Signup and view all the answers

What is the correct statement regarding a 24-hr urine collection?

I flushed what I urinated at 7:00 a.m. and have saved all urine since. Signup and view all the answers

Which response should a nurse give to a middle adult feeling useless due to independence of children?

People in middle adulthood often find satisfaction in nurturing and guiding young people. Signup and view all the answers

What type of precautions should be taken for a client with rubella?

Droplet precautions Signup and view all the answers

What is the correct age for receiving a pneumococcal vaccine?

When 65 years old Signup and view all the answers

Which tasks can an assistive personal (AP) perform for a client who has had a stroke?

Use a communication board to ask what the client wants for lunch. Signup and view all the answers

What is the first step after a client dies during a nurse's shift?

Obtain the pronouncement of death from the provider. Signup and view all the answers

What should the nurse do when caring for a client with shigella?

Wear a gown when caring for the client. Signup and view all the answers

Indicate a statement that shows a client is ready for palliative care information.

I want you to tell me about measures available to keep me comfortable. Signup and view all the answers

What is the priority action during a dressing change for a postoperative client?

Administer pain medication 45 min before changing the dressing. Signup and view all the answers

What objective statement should be documented after a client falls?

Client found lying on floor. Signup and view all the answers

What action should a nurse take to prevent self-injury when lifting a bedside cabinet?

Stand close to the cabinet when lifting it. Signup and view all the answers

Which action is appropriate for a nurse caring for a client with frequent tonic-clonic seizures?

Wrap blankets around all four sides of the bed. Signup and view all the answers

Restraining a client who is having a seizure increases their risk for injury.

True Signup and view all the answers

During seizure activity, the nurse should turn the client to the side so that the tongue does not occlude the ________.

airway Signup and view all the answers

Which task can the nurse safely delegate to an assistive personnel (AP)?

Ambulating a client who is postoperative Signup and view all the answers

Which finding indicates fluid volume excess?

Distended neck veins Signup and view all the answers

Which documentation practice should be taught regarding magnesium sulfate?

Use the complete name of the medication magnesium sulfate. Signup and view all the answers

What indicates correct placement of a nasogastric tube?

An x-ray shows the end of the tube above the pylorus. Signup and view all the answers

Which question should the nurse ask to assess the quality of a client's pain?

Is your pain sharp or dull? Signup and view all the answers

What should a nurse do during medication reconciliation?

Compare the client's home medications with the provider's prescriptions. Signup and view all the answers

What precaution should a nurse plan for a client who has had an allogeneic stem cell transplant?

Make sure the client wears a mask when outside their room if there is construction. Signup and view all the answers

Which transmission precautions should a nurse initiate for a client with an abdominal wound?

Contact precautions Signup and view all the answers

The nurse should first address the client's followed by the client's .

physical safety, positioning Signup and view all the answers

Which findings should the nurse report for a client with a pressure injury?

Odor of wound Signup and view all the answers

Which assessment finding should a nurse report for a postoperative client?

Urinary output Signup and view all the answers

Which actions should the nurse take upon admitting a client with pneumonia?

Request a prescription for an antipyretic medication. Signup and view all the answers

Which findings indicate that a client is malnourished?

Low serum albumin levels Signup and view all the answers

Which of the following findings should the nurse expect for a client with a sodium level of 125 mEq/L?

Abdominal cramping Signup and view all the answers

Which client statement indicates an understanding of herbal supplement use?

I can take echinacea to improve my immune system. Signup and view all the answers

What action should the nurse take while irrigating a client's urinary catheter?

Subtract the amount of irrigant used from the client's urine output. Signup and view all the answers

Which of the following changes should the nurse identify as an indication that the treatment was successful for a postoperative client with fluid volume deficit?

Decrease in heart rate Signup and view all the answers

What type of role-performance stress is the partner of a dementia patient experiencing?

Role overload Signup and view all the answers

What intervention should the nurse include in the care plan for a client with vision loss?

Arrange food in a consistent pattern on the client's plate. Signup and view all the answers

Which of the following responses made by the nurse is appropriate when a client's family questions about the transfer to a long-term care facility?

Would you like it if we discussed the transfer with your family member? Signup and view all the answers

What should the nurse instruct while caring for a client using a PCA pump?

Instruct the family to refrain from pushing the button for the client while the client is asleep. Signup and view all the answers

Which laboratory result would be a priority for the nurse to report to the provider for a female client who has hypovolemia?

Potassium 5.8 mEq/L (3.5 to 5 mEq/L) Signup and view all the answers

Which recommendation should the nurse make to a client who reports difficulty falling asleep?

Maintain a consistent time to wake up each day. Signup and view all the answers

What precaution should the nurse take for a client with a latex allergy?

Wrap monitoring cords with stockinette and tape them in place. Signup and view all the answers

What action should the nurse take for a client refusing a blood transfusion for religious reasons?

Withhold the blood transfusion. Signup and view all the answers

What action should the nurse take regarding a client who has a new prescription for wrist restraints?

Pad the client's wrist before applying the restraints. Signup and view all the answers

After confirming the presence of a fire reported by a nonambulatory client, which action should the nurse take next?

Evacuate the client. Signup and view all the answers

What type of dressing should the nurse use for a stage 2 pressure injury?

Hydrocolloid Signup and view all the answers

How many mL/hr should the nurse set the infusion pump to deliver when administering 0.9% sodium chloride 750 mL IV over 7 hr?

107 mL/hr Signup and view all the answers

What actions should the nurse take for a client with tuberculosis? (Select all that apply)

Place the client in a room with negative-pressure airflow. Signup and view all the answers

Which physical assessment technique should the nurse use when assessing adult clients?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. Signup and view all the answers

What should the nurse do for a client showing signs of hemorrhagic shock?

Notify the nursing manager. Signup and view all the answers

What should the nurse say when caring for a client with a terminal diagnosis who requests information about advance directives?

We can talk about advance directives, and I can also give you some brochures about them. Signup and view all the answers

What intervention should the nurse take first for a client with difficulty breathing?

Assist the client to an upright position. Signup and view all the answers

Which observation indicates proper safety protocols for a client receiving supplemental oxygen?

The client identifies the location of a fire extinguisher. Signup and view all the answers

When should the nurse initiate discharge planning for a client with an exacerbation of heart failure?

During the admission process Signup and view all the answers

Which statement should the nurse identify as indicating that the client understands the preoperative teaching they received about pain management?

It might help me to listen to music while I'm lying in bed. Signup and view all the answers

What action should the nurse take to prevent skin breakdown in a client with limited mobility?

Have the client use a trapeze bar when changing position. Signup and view all the answers

Which statement indicates a client's readiness to learn about insulin self-administration?

I would like to learn how to do it myself. Signup and view all the answers

Which of the following findings should the nurse expect when completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days?

Rapid heart rate Signup and view all the answers

Which action should the nurse take first when caring for a client with a nasogastric (NG) tube receiving intermittent feedings?

Tell the client to keep the head of the bed elevated at least 30°. Signup and view all the answers

Which intervention should the nurse include in the plan of care for an adolescent who is postoperative following a lumbar laminectomy?

Allow the adolescent to make decisions regarding their daily routine. Signup and view all the answers

Which finding indicates that a client with an indwelling urinary catheter requires irrigation?

Bladder scan shows 525 mL of urine. Signup and view all the answers

Study Notes

Fluid Volume Deficit Management

Successful treatment of fluid volume deficit is indicated by a decrease in heart rate, as tachycardia is a symptom of this condition.
Hematocrit levels may initially rise due to fluid loss but should decrease with treatment, contrary to heart rate improvement.
Respiratory rate and capillary refill time should normalize with effective treatment.

Communication with Families

Therapeutic communication is facilitated by engaging family members in discussions about client care, rather than dismissing or defending against their concerns.

Laboratory Value Prioritization

A potassium level of 5.8 mEq/L requires urgent attention as it poses a risk for dysrhythmias, while other values like BUN and creatinine, although abnormal, are non-urgent.

Sleep Improvement Techniques

Maintaining a consistent wake-up time each day promotes better sleep patterns, while caffeine consumption and late exercise can disrupt sleep quality.

Restraint Protocols

Proper care for clients with wrist restraints includes padding to prevent injury, evaluating circulation every 15 minutes, and ensuring restraints are easily removable for repositioning and hygiene.

Fire Safety Response

The RACE mnemonic outlines priority actions during a fire: Rescue clients first (evacuate), then Alarm (activate the fire alarm), Contain (close doors/windows), and Extinguish the fire if safe.

IV Infusion Calculation

To infuse 750 mL of 0.9% sodium chloride over 7 hours, set the infusion pump to deliver 107 mL/hr.

Adult Client Assessment Techniques

Proper blood pressure cuff use requires the bladder to encircle 80% of the arm for accurate readings; age-appropriate pain scales and the correct location for auscultation are crucial for accurate assessments.

Advance Directives Discussion

When discussing advance directives, offering resources while directly addressing the client's needs fosters trust and connection, as opposed to postponing the conversation or shifting the responsibility.

Discharge Planning

Initiate discharge planning during the admission process to ensure comprehensive care and meet client needs throughout their hospital stay.

Postoperative Pain Management

Understanding that mild pain (2 on a scale of 0-10) can be effectively managed through non-pharmacological methods demonstrates patient knowledge of pain management techniques.

Expected Findings with Fluid Loss

Rapid heart rate is a common indicator of fluid volume deficit, while findings like neck vein distention are associated with fluid excess.

NG Tube Care Priorities

Keeping the head of the bed elevated at least 30 degrees is critical to prevent aspiration during enteral feeding.

Adolescent Independence in Care

Allowing adolescents to make decisions regarding their care promotes independence, which is essential during recovery from surgery.

Indications for Urinary Catheter Irrigation

A bladder scan revealing 525 mL of urine necessitates irrigation to prevent blockage and ensure proper urine flow.

Symptoms of Hyponatremia

Abdominal cramping is a common manifestation of low sodium levels, while symptoms like bradycardia and numbness are indicative of different electrolyte imbalances.

Understanding Herbal Supplements

Echinacea is recognized for its immune-boosting properties; other herbs serve different purposes but misconceptions about their effects should be clarified to ensure proper use.### Catheter Irrigation
For catheter irrigation, subtract the amount of irrigant used from the client's total urinary output to maintain accurate fluid balance.
Position the client in a supine or dorsal recumbent position for optimal access during irrigation procedures.

Role-Performance Stress in Caregivers

Role overload occurs when a caregiver has more responsibilities than they can manage, often leading to frustration.
Role ambiguity involves unclear expectations, while the sick role pertains to those with health alterations, and role conflict surfaces when multiple roles have opposing expectations.

Caring for Clients with Vision Loss

Arrange food in a consistent pattern on the plate to facilitate self-feeding for clients with vision loss.
Use large-handled, adaptive utensils rather than small ones to improve grip and independence.

PCA Pump Management

Educate family to avoid pushing the PCA button for a sleeping client, minimizing overdose risks.
Regular vital sign monitoring is essential within 1 to 2 hours, rather than every 8 hours.

Latex Allergy Precautions

Cover monitoring cords with stockinette to prevent contact with latex, essential for clients with latex allergies.
Avoid using latex gloves, even if hypoallergenic, due to potential allergic reactions.

Autonomy in Medical Treatment

Respect a client’s autonomy by withholding treatment they refuse, even if family members disagree.
No need to involve the ethics committee as a competent client has the right to refuse treatment.

Dressing for Pressure Injuries

Hydrocolloid dressings are most suitable for healing stage 2 pressure injuries by maintaining a moist environment.
Alginate dressings are intended for more severe injuries due to their drainage absorption capabilities.

Tuberculosis Precautions

Utilize negative-pressure rooms and ensure proper hand hygiene with antimicrobial sanitizers when caring for clients with tuberculosis.
N95 respirators are necessary for nurses, while gloves are required for personal care.

Hemorrhagic Shock Nursing Actions

Notify the nursing manager to ensure immediate action for a client in hemorrhagic shock before documenting or filling incident reports.

Client Positioning for Breathing Difficulties

Sit clients upright to maximize oxygen delivery and facilitate breathing effectiveness.

Home Safety for Oxygen Use

Clients should identify fire extinguisher locations; however, do not use wool blankets due to static electricity risks.
Store extra oxygen tanks upright to prevent hazards.

Skin Breakdown Prevention

Encourage using a trapeze bar to minimize friction during repositioning to reduce skin breakdown risks.
Maintain balanced nutrition, focusing on protein intake to support tissue repair.

Client Readiness to Learn

Indicate willingness to learn by expressing optimal learning times; the client’s discomfort with inadequate tools or reluctance suggests unpreparedness.

Clostridium Difficile Infection Protocol

Ensure that family members wear protective gowns and gloves to prevent the transmission of spores; thorough hand hygiene with soap and water is essential.

24-Hour Urine Collection Instructions

Correct procedure involves discarding the first void and retaining all urine thereafter; immediate collection ensures accuracy in the 24-hour test.

Middle Adult Client's Emotional State

Address feelings of uselessness following children's independence with supportive, empathetic communication to validate their emotions.### Developmental Stages and Client Care
Middle adulthood is characterized by the psychosocial task of generativity versus self-absorption, as described by Erik Erikson.
Generativity includes nurturing others, particularly through mentoring and voluntary support.
Common misconceptions include the belief that parents should automatically be happy when children leave home, while feelings of being unneeded may arise need exploring.

Infection Control Precautions

Clients with rubella require droplet precautions due to transmission via larger droplet nuclei.
Airborne infections (like tuberculosis) and contact infections (like MRSA) require different precautions.
Protective environments are necessary for immunocompromised patients, not those with droplet-transmissible infections.

Health Recommendations for Older Adults

Older adults should receive the pneumococcal vaccine at age 65.
Routine eye examinations should occur annually, not every two years.
Tetanus boosters should be given every 10 years, and shingles vaccines at 60 years, not 70.

Client Care and Delegation

Assistive personnel (AP) can be delegated lower-risk activities like partial bed baths and vital signs measurement.
Tasks like evaluating swallowing or irrigating indwelling catheters are outside the AP's scope due to the need for clinical assessment.

Post-Mortem Care

Upon a client’s death, the first steps are to obtain the pronouncement of death and remove tubes and lines.
After cleansing the body, the family can be offered a chance to view the remains, followed by placing a name tag on the body.

Seizure Management

Blanket wrapping around the bed can help protect clients from injury during tonic-clonic seizures.
Restraints are contraindicated as they can increase the risk of injury, and inserting objects in the mouth is unsafe.

Documentation Best Practices

Accurate documentation should focus on objective observations, such as "Client found lying on the floor," avoiding subjective interpretations.
Proper abbreviations and complete names of medications are critical to avoid misinterpretation and medication errors.

Identifying Fluid Volume Status

Distended neck veins indicate fluid volume excess, while a weak pulse and hypotension suggest volume deficit.
Common indicators of excess include crackles in lungs and edema.

NG Tube Placement Confirmation

Correct placement of an NG tube is confirmed by an x-ray showing the tube positioned above the pylorus.
Gastric aspirate pH should be 5 or less; a pH of 7 suggests inappropriate placement.

Assessing Pain Quality

When assessing pain, open-ended questions should encourage clients to describe their pain quality, providing insight for tailored intervention.

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Test your knowledge on fluid volume deficit and postoperative care with these ATI RN fundamentals flashcards. This quiz provides crucial insights related to patient care, vital signs, and nursing interventions. It's essential for nursing students preparing for the RN exam.