ATI Fundamentals Notes—Questions I got wrong on practice tests
Red flag for abuse caregiver remaining in the room
People in middle adulthood often find satisfaction in nurturing/guiding
young ppl
If N/V for 3 days, expect rapid HR – tachycardia = fluid volume deficit s/s
When descending stairs, pt should first shift weight on R leg (L in cast,
using crutches)
ENEMA ADMIN
sPut pt in left side-lying position with R knee flexed
sAdmin cleansing enema if prescribed
sAuscultate bowel sounds
sPerform a manual digital exam of rectum
Isometric exercises have no weight bearing, for pt at risk for osteoporosis,
tell them to first walk briskly weight bearing exercises are essential for
maintain bone mass, which helps prevent osteoporosis
When preparing for suctioning secretions for pt who has a new trach,
select a suction cath that is half the size of the lumen
Pneumonia
sPlace on droplet precaution
sApply 2 L/min O2 via nasal cannula (o2 sat = 91%)
sAsk for antipyretic (101.4)
sRemain 3 feet from pt
S/S of malnourishment
sCachectic (lack of energy) with flaccid muscle tone and wasting
appearance
sSkin dry/scaly with bruises
sPulse rate 118/min – tachycardia can be an indication of malnutrition
sAbdomen distention
sBMI 17
Inflate cuff 30 mm Hg beyond point at which nurse was last able to
palpate pulse
For pressure ulcer report
sTemp, WBC, prealbumin, pain, odor (look at shit)
RACE for fire
sResponse to fire- ptrescue
sActivate alarm
sContain fire by closing all doors
sExtinguish fire
IV fluid assessment use ABC’s
sAuscultate lung sounds as fluid volume excess can produce moist
crackles in lung fields, dyspnea, SOB
Injecting 5 units of regular insulin and 10 units of NPH insulin to mix
together
sInject air into vial of NPH without touching needle to solution
sInject air into regular insulin and withdraw correct amount
sInsert needle into NPH insulin
sFollow these steps to prevent contaminating regular insulin with NPH
insulin
Colorectal cancer screenings for pt at average risk beings at 50 – should
get fecal occult blood test every year
With NG tube/intermittent feeding via open system – keep HOB elevated
at least 30
Single dose Rx – gently shake before admin
Ethics
sAdvocacy ensure pts safety, health, rights
sAccountability – nurse can explain actions
sFidelity – follow through with promises
sJustice – fairness in care/deliver/distribution of resources
sVeracity – tell truth at all times
sAutonomy – rec pts wishes/right to refuse/enforcing DNR
sFidelity – keeping promises
For strep
sRequest abx
sDroplet precautions
sWear mask within 3 ft of pt
sApply mask on pt when they leave room
Fluid volume excess
sNVD, edema, tachycardia, crackles, dyspnea, bounding pulse, BP
increase
Weber test = tuning fork
Heart sounds
sNarrowed arterial lumen = blowing (bruit)
sImpaired ventricular contraction = S3/S4
sAsynchronous closure of aortic/pulmonic vavles
Two dub sounds
For tb
sNeg-pressure airflow
sWear gloves
sUse antimicrobial hand sanitizer
DIPTHERIA = DROPLET
PRECAUTIONS
sDROPLET
RUBELLA, MENINGOCOCCAL PNEUMONIA, STRETOCOCCAL
PHARYNGITIS
sCONTACT
VANCO RESISTANT ENTEROCOCCI, HERPES
sAIRBORNE
VAIRCELLA, TB, MEASELS
N95
sPROTECTIVE
12 air exchanges/hr
Make sure pt wears mask when outside room if there is
construction in the area
Positive pressure airflow/private room
Don’t need to wear N95
Fall risk assessment
sPupil clarity, visual fields, visual acuity
Thigh-length sequential compression sleeves
sMake sure 2 fingers fit under
EBP for O2 admin
sRegulate O2 via nasal cannula at a flow rate of no more than 6 L/min
sRegulate flow by aligning rate on flow meter with the middle of the
silver ball inside the meter
sReservoir bag should be 1/3 to ½ inflate with inspiration
sUse water soluble lubricant to keep pts skin from drying out from o2,
not petroleum jelly
Isolation precaution
sN95 mask, soiled linen container in room, neg airflow room,
DEAD PT PREP
sObtain death pronouncement
sRemove tubes
sClean
sAsk family members if they want to view body
sPlace a name tag on the body
IV insertion
sDependent position
s10-15 degrees
sDon’t shave arm
sDon’t use fragile veins (hand) in old ppl, can roll
CANE
sHold on stronger side
sMove at 15-30 cm (6-12 in) aat a time
sTop should be parallel to greater trochanter
sMove weaker limb forward with the cane
Infiltration
sStop IV, elevate arm, apply heat
WOUND DRESSINGS
sAlginate – stage ¾ pressure injuries
sGauze promotes healing in stage 4 or unstageable by causing
debridement and allowing granulation of the wound bed
sTransparent promote healing in stage 1 and prevent further friction
and shearing
sHydrocolloid dressing promote healing in stage 2 by creating
moistened wound bed
HF edu
sFurosemide – should increase potassium
sHF pt should maintain a sodium intake between 2-3 g daily
sPt should lay down and rest before meals cuz it takes energy to eat,
should eat frequent small meals rather than a large meal to help
relieve SOB/fatigue
sCall MD if weight gain of 3lbs or more in 2 days
TRACH CARE
sUse trach cover when outside
sNever remove outer cannula
sMedical asepsis to clean
sUse NS 0.9 irrigation to cleanse the site
SUB Q injection = 45-90 angle
Edu for runs
eat probiotic foods like yogurt, avoid booze/caffeine,
follow low-fiber diet
Irrigating urinary catheter
sPt in supine/dorsal recumbent
sInstill 30-40 mL of irrigation fluid
sCalculate fluid used for irrigation and subtract from output
sUse 30-50 mL syringe
To make sure otic rx gets in, press gently on targus of the ear
sMove auricle upward and back or up and out to straighten out ear
canal
sHold dropper 1cm (0.5) in above ear canal during admin
When performing nasotracheal suctioning
sInsert while pt is inhaling to avoid inserting it into esophagus
sApply intermittent suction when withdrawing
sDiscard suction catheter after use
sUse dominant hand with sterile glove
Pain
sAsking if constant or intermittent – determines onset, duration,
pattern
sAsking how youd rate it = intensity of pain
sRadiate = location of pain
Gastro tube for intermittent feeding – what could cause runs?
sNot cleaning out bag
Prepping suction – use suction catheter that is half the size of the
lumen to prevent hypoxemia and trauma to the mucosa
Behind the ear hearing aid
sAllow for fine tuning of the volume, useful for pt who have mild to
severe hearing loss
sPhysical activity can easily dislodge
sWhistling during insertion is a sign that it does not fit properly or if too
much ear wax
s
s
s
ss Should remove before showering
Wound irrigation
s
s
s
ss Use a 35 mL syringe to irrigate, syringe that holds 30-60 mL create
safe but effective amount of pressure for irrigation
Tachycardia is an expected finding for fluid volume deficit
If bladder scan shows high mL of urine irrigate catheter
If someone starts choking-observe closely, as long as pt is able to cough,
don’t need to do Heimlich
NG tube for gastric decompression
s
s
s
ss Provide oral hygiene frequently, measure amount of drainage every
shift, secure to pts gown
Atenolol can decrease pts heart rate, admin before admin allopurinol
(other nurse made an error)
Imminent death = cold extremities, first in feet then in hands, urinary
incontinence, hypotension, slow weak pulse
Transcutaneous electrical nerve stimulations (TENS) modulates
transmission of pain impulse
s
s
s
ss Applies low voltage electrical stimulation directly over a location of
pain at an acupressure point-modulates transmission of pain impulse
and can also cause a release of endorphins to assist with pain relief
Weight pt when they wake up, after pee, before breakfast, wear same
clothes on same scale – for volume status daily
Clarifying – “it sounds like your pain is intermittent” ensure understanding
of pts message
MRSA – contact, don gloves piror to entering room
When suctioning, if pt coughs, pull it back 1 cm (0.5) in – removes
catheter from mucosal wall of the trachea prior to suctioning
Antagonistic muslc group = movement of knee joint
Antigravity is responsible for stabilizing knee joint
Synergistic contracting in sync to cause same movements
Sit on toilet for 30 min after meal helps with bowel retraining
For TPN – check pts cap blood glucose level q4 hours due to pt risk of
hyperglycemia while receiving TPN
s
s
s
ss Dextrose concentration in TPN increases risk of hyperglycemia
Pt with impaired swallowing should consume tart/sour foods at the
beginning of meal to stimulate saliva production which aids in chewing
and swallowing
Stop teaching if pt says they’ve never been taught and check with the
surgeon about informed consent
To check for costovertebral tenderness angle, sitting position promotes
relaxation and allows access to the back for percussion of that region
(area where the spine and 12 rib intersect)
th
Ventrogluteal site is safest injection site for all adults because it contains
thick gluteal muscles and does not contain major nerves or blood vessels
Glaucoma – obstruction of flow of vitreous humor of the eye – obstruction
leads to increase in intraocular pressure, resulting in damage to the eye
LABS
s
s
s
ss Magnesium 1.3-2.1
s
s
s
ss Specific urine gravity 1.005-1.030
Elevated = hypovolemia
s
s
s
ss Hgb 12-16
s
s
s
ss Hct 37-47%
Elevated = hypovolemia
s
s
s
ss K+ 3.5-5
Hyper – numbness of extremities
s
s
s
ss Platelet 150-400
s
s
s
ss WBC 5000-10000
s
s
s
ss Prealbumin 15-36
s
s
s
ss BUN 10-20
Elevated = hypovolemia
s
s
s
ss Cr 0.5-1.1 for women 41-60, 0.6-1.3 for men 41-60
s
s
s
ss Na 136-145
Hyponatremia – abdominal cramping, weakness, confusion,
lethargy, HA, nausea, tachycardia
s
s
s
ss Hypomagnesemia and hypocalcemia – positive Chvostek sign
s
s
s
ss pH 7.35-7.45, indicating alkalosis, PaCO2 35-45 – if below,
indicates respiratory origin
5mL = 1 tsp
Hold moutpice 1-2 in front of mouth, tilt back head/open, depress
canister, hold breath for 10 sec
BRADEN SCALE
sNutrition, sensory perception, moisture, activity, mobility,
friction/shear
Rebreather bag is priority regarding O2 pts
ENEMA – L sims position
sLubricate 2 inches
Phyisical exam – objective, thorough systematic
Interview = subjective data
sROS is subjective data that nruse collects during interview about body
systems and mental status
Health history – subjective
Wound healing – vit C and zinc
1 lb of fat = 3500 cal/week
Pap age 30-65 3 years
Mammogram at 45 yearly, at 55 can do 2 years
Colonoscopy 10 years
Eye exam 2 years
Choose soft vein “bouncy”
Rom repeat 5 times
Remove restraints every 2 hours
Soak inner cannula of the trach tube in NS to loosen secretions
sSterile technique
s1-2 fingers under trach ties
sDon’t put gauze/cotton balls near, can aspirate
Infancy – Basic trust versus mistrust
Toddler – Autonomy versus shame and doubt
Preschool-age – Initiative versus guilt
School-age – Industry versus inferiority
Adolescence – Identity versus identity confusion
Young adulthood – Intimacy versus isolation
Middle age – Generativity versus stagnation
Older adulthood – Integrity versus despair
