Preview Extract
Practice Quizzes Fundamentals 1 40
preguntas
Fundamentals 1 VERSION 6
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. the nurse auscultates a high-pitched scratching sound during both
systole and diastole with diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
Answer: Pericardial friction rub
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
Answer: Place the bladder of the cuff over the posterior aspect of the thigh
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
Answer: Confirm unresponsiveness
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported
for the procedure, which of the following actions should the nurse take first?
Answer: Identify the client using two identifiers
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
Answer: Administer analgesics to the child on a routine schedule throughout the day and
night.
A nurse is providing teaching to a client who has heart failure about how to reduce his daily
intake of sodium. Which of the following factors is the most important in determining the
client's ability to learn new dietary habits?
Answer: The involvement of the client in planning the change
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?
Answer: Obtaining cotton balls for the tracheostomy care
A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take?
Answer: Raise the level of the bed
A nurse is witnessing a client sign an informed consent form for surgery. Which of the
following describes what the nurse is affirming by this action?
Answer: The signature on the preoperative consent form is the client's
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
Answer: Perform hand hygiene
A nurse is caring for an older adult client who becomes agitated when the nurse requests that
the client's dentures be removed prior to surgery. Which of the following responses should the
nurse make?
Answer: "What worries you about being without your teeth?"
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
Answer: "I keep having nightmares about my upcoming surgery."
A nurse on a medical-surgical unit is caring for a client. Which of the following actions
should the nurse take first when using the nursing process?
Answer: Obtain client information
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV
lines. The provider prescribes soft wrist restraints. Which of the following actions should the
nurse take while the client is in restraints?
Answer: Remove the restraints one at a time
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse
reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min,
a soft contender abdomen, and census overdue by 2 days. Which of the following findings
should be the nurse's priority?
Answer: Temperature
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand.
The client has no documented bloodstream infection. Which of the following actions should
the nurse take?
Answer: Carefully remove the gloves and follow with hand hygiene
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the
following abdominal assessments should the nurse expect?
Answer: Absent bowel sounds with distention
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning selfinjection of insulin. Which of the following statements should the nurse make?
Answer: "Tell me what I can do to help you overcome your fear of giving yourself
injections."
A nurse is receiving a client from the PACU who is postoperative following abdominal
surgery. Which of the following actions should the nurse take to transfer the client from
stretcher to the bed?
Answer: Lock the wheels on the bed and stretcher
A nurse is caring for a client who is in terminal stage of cancer. Which of the following
actions should the nurse take when she observes the client crying?
Answer: Sit and hold the client's hand
A nurse in an emergency department is assessing a client who reports diarrhea and decreased
urination for 4 days. Which of the following actions should the nurse take to assess the
client's skin turgor?
Answer: Grasp a skin fold on the chest under the clavicle, release it, and note whether it
springs back
A nurse is caring for a client who has a terminal illness. The client asks several questions
about the nurse's religious beliefs related to death and dying. Which of the following actions
should the nurse take?
Answer: Encourage the client to express his thoughts about death and dying
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes
by an electronic blood pressure machine. The nurse notices the machine begins to measure
the blood pressure at varied intervals and the readings are inconsistent. Which of the
following actions should the nurse take?
Answer: Discontinue the machine, and measure the blood pressure manually every 15 min.
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from
bed to a wheelchair. Which of the following techniques should the nurse use?
Answer: Place the wheelchair at a 45-degree angle to the bed
A nurse is performing an abdominal assessment for an adult client. Identify the correct
sequence of steps for this assessment.
Answer: Inspect, Auscultate, Percuss, Palpate
A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating
room when the client states she no longer wants to have surgery. Which of the following
actions should the nurse take?
Answer: Notify the provider about the client's decision
A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical
handwashing technique?
Answer: The nurse washes with her hands held higher than her elbows
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the
next month that might require a blood transfusion. The client expresses concern about the risk
of acquiring an infection from the blood transfusion. Which of the following statements
should the nurse make to the client?
Answer: Donate autologous blood before the surgery
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the
following statements by the AP indicates an understanding of the teaching?
Answer: "There are times I should use soap and water rather than alcohol-based hand rub to
clean my hands."
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of
the following actions should the nurse take?
Answer: Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a
regular size cuff for a client who is obese. Which of the following explanations should the
nurse give the AP?
Answer: "Using a cuff that is too small will result in an inaccurately high reading."
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who
will have emergency surgery for appendicitis. Which of the following statements indicates a
lack of readiness to learn by the client?
Answer: The client reports severe pain
A nurse is providing teaching to an older adult client who has constipation. Which of the
following statements should the nurse include in the teaching?
Answer: "Sit on the toilet 30 minutes after eating a meal."
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea
and who might have a right ear infection. Which of the following routes should the nurse use
to obtain the temperature?
Answer: Temporal
A community health nurse is preparing a campaign about seasonal influenza. Which of the
following plans should the nurse include as a secondary prevention?
Answer: Screening groups of older adults in nursing care facilities for early influenza
manifestations
A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
Answer: Evaluate pedal pulses
A nurse on a medical-surgical unit is admitting a client. Which of the following information
should the nurse document in the client's record first?
Answer: Assessment
A nurse is teaching a group of older adults about expected changes of aging. Which of the
following statements by a group member indicates that the teaching has been effective?
Answer: "I should expect my heart rate to take longer to return to normal after excessive as I
get older."
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the
following actions by the nurse will improve the client's commitment to a long-term goal of
weight loss?
Answer: Attempt to increase the client's self-motivation
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve?
Answer: Second intercostal space to the right of the sternum
Version 7 Topics
to Look Over
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Nursing ethical principles
o Autonomy
o Beneficence
o Fidelity
o Justice
o Nonmaleficience
o Veracity
Intentional torts
o Assault
o Battery
o False imprisonment
Unintentional torts (didn’t intend to harm patient but you did)
o Negligence- forgetting to set the bed alarm for a fall risk patient
o Malpractice- medication error occurs that harms a patient
Informed Consent
o Responsibility of the provider
▪ Purpose and complete description of procedure in patient’s
primary language
▪ Risks vs. benefits
▪ Describe alternatives
o Responsibility of the nurse
▪ Make sure provider did give all info needed
▪ Patient is competent
▪ Patient sign consent document
• If pt has further questions call provider and have them come
back and explain things further BEFORE they sign
the form
Advance Directives
o Living will
o Durable power of attorney (health care proxy)
o Provider’s orders- for DNR AND (allow natural death)
o Mandatory Reporting—must report suspicion of abuse
▪ Don’t wait just report it right away
▪ Report communicable disease to local and state departments
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• Mandated by the state
Nursing Documentation
o Recording objective data
▪ Don’t include opinions and interpretations
o Recording subjective data
▪ Patient statement
o Legal guidelines for documentation
▪ Don’t leave blank spaces
▪ Never use correction tape or fluid or scratch out or black out words
▪ Include name and title on documentation
Incident reports
o When accident occurs (falls or med error)
▪ Used for quality improvement for facility (for hospital)
o Not part of the patients records and should not be referenced in the
patients record
▪ Need to document the incident and patient’s reaction and incidence
report is for the hospital not for the patient’s medical record
Telephone Orders
o From provider: get a second RN on the call to listen also
o After provider says the order you FIRST want to read back the order to the
provider
▪ To ensure it is accurate
o Provider needs to sign off for order within 24 hours
Information security
o HIPAA
o Don’t use patient names on public display boards
o Private room or nursing station
o Password protect and don’t share passwords
o Log off or lock computer when you walk away
o Don’t share information with unauthorized people
▪ Find out if ppl in room are authorized to know information or if you
need, they to leave
o Code system can be used
▪ If pt doesn’t want to tell anyone they are at the hospital
Delegation (VERY IMPORTANT)
o What RN has to do
▪ Patient education
▪ Nursing judgement
▪ Assessment
▪ Blood transfusions
What a PN can do (LPN)
▪ Med admin
▪ Enteral feedings
▪ Urinary catheter insertion
▪ Suctioning
▪ Trach care
▪ Wound care
▪ Reinforce patient teaching you (RN) have already done
What a NAP/UAP/CNA
▪ Bathing
▪ Dressing
▪ Ambulating
▪ Toileting
▪ Feeding without swallowing precautions
▪ Positioning
▪ Vitals
▪ Specimens
▪ I+Os
▪ Basic CPR
o 5 Rights to Delegation
▪ Right task
• Repetitive noninvasive and not a lot of supervision
▪ Right circumstances
• Do not assign a patient who is unstable
▪ Right patient
• Competent and within their scope of practice
▪ Right direction and communication
• Specific details and timeline for completion and
expectation for reporting findings back to you
▪ Right supervision and evaluation
• May need to intervene
• Provide feedback
Nursing process
o Assessment and data collection
▪ Do assessment before action
o Analysis and data collection
▪ Cluster collected data
▪ Any patterns and trends
▪ Compare data you gathered from baseline
o Planning
▪ Measurable outcomes
o Implementation
▪ Nursing care
▪ Document patients’ responses
o Evaluation
▪ Compare actual results from planned outcomes
▪ If not met, work on a plan B
Patient admission
o Document patients
▪ Advanced directions ASAP
▪ Vital signs
▪ Allergies
▪ Height and weight
▪ Head to toe assessment
▪ Health history
▪ Spiritual or cultural considerations
o Assess their ability to swallow safely
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Give a little water and assess what the patient does
Any concern is NPO until swallow evaluation by speech language
pathologist
o Assess safety
▪ Risk for falls
o Patient belongings and inventory
▪ Valuables should be sent home with family if possible
o Medication reconciliation
▪ Very important
▪ Should compare
o Discharge planning
▪ AT ADMISSION!!!
Patient transfer (one unit to another)
o Use SBAR
▪ Hand off tool to use when giving report to next nurse
Discharging a Patient
o Patients diet and activity
o Detailed instructions for procedures to be done at Home
o List of meds
o SX of complications and when to call provider
o Follow up information and appointment
o Names and numbers of community resources or providers
Hand hygiene
o When to use soap and water:
▪ Hands are visibly soiled
▪ Before eating meals
▪ After using the restroom
▪ Contact with bodily fluids
o Alcohol-based products
▪ 3-5 mL of product
▪ Rub hands continuously until dry
Ways to Prevent Spread Infection
o Cover mouth or nose when sneezing or coughing
o Use tissues and proper disposal of tissues
o 3 ft away of ppl who are coughing or provide a mask
o Short nails and no artificial nails or gel nail polish
o Remove jewelry from hands and wrists
o Don’t shake linen
o Clean least soiled areas first and move towards more soiled
o Don’t put soiled items on the floor
Sterile Fields
o Setting up sterile field
o Maintain sterile field
▪ Position package with top flat facing away from you
▪ LAST FLAP COMES TOWARDS YOU
▪ BOTTLE CAP FACE UP ON NONSTERILE SURFACE
▪ LABEL IS AGAINST PALM
▪ DON’T TOUCH BOTTLE TO SITE
▪ DON’T COUGH OR TALK OVER FIELD
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Falls
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FULL 1-INCH EDGE OF FIELD IS NOT STERILE
BELOW WAIST OR ABOVE CHEST IS CONTAIMIATED
ADD OBJECTS TO STERILE FIELD ATLEAST 6-INCH ABOVE THE FIELD
DON’T TURN BACK ON STERILE FIELD OR REACH ACROSS
ANY STERILE ITEM THAT COMES IN CONTACT WITH MOISTURE
SHOULD BE CONSIDERED NONSTERILE
Preventing falls
▪ Orthostatic hypotension
• Tell pt to get up slowly
▪ Regular toileting to pt who need assistance
▪ Skid proof socks
▪ Place patients at risk for falls near nursing stations
▪ Round on patients hourly
▪ Frequent used items are within reach
• Call button
• Water
• Phone
▪ Position bed in LOWEST position and lock bed and set bed alarm on
▪ Don’t put ALL 4 side rails up on the bed at once
Seizures
o Implement seizure precautions
o Padding siderails
o Suction and oxygen equipment available at bedside
o Turn patient on their side (FIRST)
o Clear area for safety
o Loosen restrictive clothing
o Don’t insert airway or anything into patients mouth
o Note onset and duration of seizure
o After seizure keep pt in position and do vitals and reorient patient and keep pt
NPO until fully awake and swallow reflex has returned
Restraints
o Physical or chemical
o Before we apply it
▪ Try alternatives FIRST
• Reorientation
• Supervision
• Diversions
o If they fail, then we can apply
o In emergency RN can apply but prescription is needed ASAP within 1 hour
o Provider must rewrite restraint orders every 24 hours and no PRN orders
o Apply padded portion to client’s wrist
o Perform neurovascular checks at least every 2 hours
o Assess pts skin integrity
o ROM exercises regularly
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Use least restrictive restraint that can help (mittens are better than wrist
restraints)
o Apply so 2 fingers can fit between restraint and patient
o Use a quick release knot (slip knot don’t use square knot)
o Movable portion of the bedframe NOT on siderails and NOT on an
unmovable part of the bedframe
o Always apply belt restraints over clothing or gowns
Fire safety
o RACE
▪ Horizontal then lateral evacuation
o PASS
Injury prevention
o Across all lifespans
Oxygen safety
o Combustion
o No smoking sign at front door
o Electrical equipment is grounded and in shape
o Cotton bedding and clothes NO SYNTHETIC OR WOOL FABRICS
o Flammable items away from oxygen (nail polish)
ATI Fundamental Proctored Study
Guide VERSION 8
Redness at coccyx and patient is immobile
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Assess for blanching
Patient has IV catheter for right mastectomy, which veins do you
select? -
Cephalic vein left distal forearm
Colorectal cancer prevention guidelines for patient teaching
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Reduce intake of red meat
Applying catheter to a patient who is uncircumcised
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Roll the foreskin down, apply condom and then and roll back up
afterwards
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Place adhesive tape directly on the top If patient have an Artificial eye
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Teach patient to apply pressure below the eye to apply traction to
retreat upper and lower lids to insert the artificial eye
If patient is on restraint
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Remove one restraint at a time
PPE for C-Diff
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59.
Gloves, glow, wash hands with soap and water
POINT GAIT
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Bear weight on both legs
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Elbows should be 30% flexed
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Client should move each leg alternatively with opposite crutch - How
to walk with it? the type of order
If you enter a client room and after securing the patient, you
want to? - Pull the alarm
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*RACE*
IF SOMEONE PUT IN EYE DROP
- Make sure they press in corner of the eye
1. a nurse is assessing a client who is immobile and notices a red area over the client’s
coccyx. Which of the following actions should the nurse take?
a. Change the clients position every 4 hours
b. Apply petroleum base ointment in the red area
c. Assess the red area for blanching
d. Use friction when cleansing the client’s skin
Answer: c. Assess the red area for blanching
Rationale:
The nurse should assess the red area for blanching, as this indicates whether the redness is
due to pressure and reduced blood flow, which could lead to a pressure injury. Blanching is
when the redness disappears temporarily when pressure is applied to the area, suggesting that
blood flow is compromised.
2.a nurse is preparing to insert an iv catheter for a client following a right mastectomy. Which
of the following veins should the nurse select when initiating an IV therapy?
a. The radial vein on the left wrist
b. The cephalic vein in the left distal forearm
c. The basilic vein in the right antecubital fossa
d. The cephalic vein on the back of the right hand
Answer: b. The cephalic vein in the left distal forearm
Rationale:
The nurse should select a vein on the unaffected side for IV therapy following a right
mastectomy to avoid potential complications. The cephalic vein in the left distal forearm
would be a suitable option.
3. a nurse is teaching a client who had an enucleation about care of an artificial eye. Which of
the following information should the include in the teaching? (select all that apply)
a. Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation
b. remove from the artificial eye by retracting the upper eyelid
c. Apply pressure just below artificial eye to break the suction
d. Clear the artificial eye with hydrogen peroxide before storing
e. Retract the upper and lower lids to reinsert the artificial eye
Answer: c. Apply pressure just below artificial eye to break the suction
e. Retract the upper and lower lids to reinsert the artificial eye
Rationale:
Applying pressure just below the artificial eye breaks the suction, making it easier to remove.
Retracting both upper and lower lids helps to properly reinsert the artificial eye without
causing damage.
4. a nurse is preparing to insert an IV catheter for an older adult client who has fragile skin.
Which of the following actions should the nurse take?
a. Stabilize the vein by applying traction above the insertion site
b. Engorge the vein by placing the arm in the dependent position
c. Use friction at the insertion site to increase venous distention
d. Leave the tourniquet on for 30 to 60 seconds after initial insertion
Answer: b. Engorge the vein by placing the arm in the dependent position
Rationale:
Placing the arm in a dependent position helps to engorge the vein, making it easier to
visualize and insert the IV catheter, especially in older adults with fragile skin. This position
enhances venous distention and makes the vein more prominent, facilitating successful IV
catheter insertion
HEALTH CARE FINANCING MECHANISMS
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Medicare: For clients greater than 65 years of age or those with permanent
disabilities
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Medicaid: For clients who have low incomes
LEGAL RESPONSIBILITIES
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Advanced Directives purpose is to communicate a client’s wishes regarding end
of life care should the client be unable to do so
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Living will be a legal document that expresses the client’s wishes regarding med
treatment
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Durable power of attorney: in which client designate a healthcare proxy to make
healthcare decisions for them if they are unable to do so
DELEGATIONS
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5 Rights: Task, circumstance, person, direction and communication,
supervision
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Remember that LVN/CNA/UAP can’t EAT(Evaluate, assess and
teach)
TYPES OF PREVENTION
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Primary: Administering vaccine, help those who are healthy to prevent from
getting sick
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Secondary: Screening for disease
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Tertiary: Prevent a disease from getting worst or to help make patient get better
HAND HYGIENE
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Wash hands with soap and water or antimicrobial soap
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If hands are visibly soiled 2 min
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Scrub hands for at least 15 seconds and dry hand with towel before
you turn faucet off
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If using alcohol product, use 3-5 mL and rub hands until dry
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Cover mouth nose when sneezing and encourage patient to do so
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Hold hand above elbow when washing
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Stand at least 3 feet away from those that’s coughing
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Keep nails short, no gel polished or artificial nails
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Remove jewellery from hands
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Never shake linen
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Clean lease soiled area first and then move to dirtier area
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Never place items on floor
SETTING/MAINTAINING UP A STERILE FIELD
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Open flap away from body first
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Open right flap with right and left flap with left
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Hold bottle so label is against the palm
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Do not cough/sneeze or talk over sterile field
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Do not turn your back on a sterile field or reach across
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Outer 1 Inch is not sterile
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Object below waist or above chest should be considered contaminated
TYPES OF PRECAUTION
Standard
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Use for all patients regardless of infection or isolation
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Make sure to wash hands before going in and out of patient room
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Preferably alcohol unless hands are soiled, then use water+soap - Wear
gloves Contact
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Used for impetigo, scabies, MRSA, VER, c diff, RSV, enteric
infection/wound infection
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Private room
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Gowns/glove
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Dispose of linen
Droplet
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Used for influenza, pertussis, mumps, pneumonia, rubella and
meningitis
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Private room
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Mask
Airborne
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Used for Measles, varicella, TB
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Negative airflow
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N95 Mask
BREAST EXAMINATIONS
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As women get older
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Older patient tend to have more Barrel chest and decreased alveolar
along with kyphosis(increased curvature of the thoracic spine)
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Chest reflex, excursion or expansion will diminish
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Nipples no longer have erectile ability and can invert
PHYSICAL ASSESSMENT ON ABDOMEN
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Inspect, Auscultate, percuss, Palpate
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Left lower quadrant→ left Upper quadrant→ Right upper quadrant→ Right
lower quadrant
Hypoactive/Hyperactive bowel Sound:
Expected sound: High pitched click and gurgles 5-35 times/minute
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To determine absent bowel sound, you must hear no sounds after listening
for a full 5 min
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Tympany sound when percussing
Unexpected Sound: Loud, growling sounds(borborygmi) or no bowel sounds
*Make sure to Palpate tender area last
*Paralytic ileus: No bowel movement
*Flatulence: gas accumulation
PRESSURE ULCER STAGES/WOUND CARE
Stage 1: Non-blanchable erythema;
Stage 2: Partial thickness skin loss with bruising; used hydrocolloid
Stage 3: Full thickness skin loss with undermining/tunnelling;
Stage 4: Full thickness skin loss with exposed bone/tissue; use Calcium
alginate Unstageable: Use proteolytic enzyme
NURSING PRINCIPLES
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Fidelity: Promise with a client
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Autonomy: ensuring that the client has the right to make decisions
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Nonmaleficence: Doing no harm
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Justice: Treating everyone fairly
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Battery= Actually hurting someone
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Assault=Threatening
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Respite care: For caregiver who needs time to rest
WHEN ASSISTING A PATIENT DURING MEAL TIME
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Have patient sit in an upright position
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Have patient lean forward when eating
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Have patient tilt head forward
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Advise patient to tuck chin downward
CANE
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Client should keep 2 points of support on ground at all times
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Client should hold cane on stronger side/unaffected side
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Client should advance the cane first then the unaffected/stronger leg
CRUTCHES
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Place left foot on first step and transfer weight to left foot then the right
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Stance should be 15 cm in front and back
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Client should have his arms bear the weight of their body
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Keep the rubber crutch tips in place
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Make sure client slightly flexed elbow when ambulating
HEALTH CARE ROLES
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Speech pathologist: Examine/help with swallowing and dysphagia
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Social Worker: Assist with community services such as financial and
meal delivery
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Physical therapist: Evaluate the strength/weakness and mobility
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Occupational therapist: Help with ADL or patient who have
disabilities
WHEN INSERTING A URINARY CATHETER
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Have patient bear down
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Encourage patient to take slow, deep breaths
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Encourage patient to relax
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Place urinary catheter below the level of the bladder
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Tape the catheter to the inner thigh
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Use soap and water to clean the perineal area
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For male: Tape urinary catheter to the lower abdomen
WHEN COLLECTING A URINE SPECIMEN FOR PATIENT WITH AN
INDWELLING URINARY CATHETER
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Clamp the tubing below the collection port
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Place specimen in a sterile specimen cup
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ADMINISTERING ENEMA
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Put patient in sims position
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Lubricate 2-3 inches of the tip of the rectal tube
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Hold enema 18 inches above the rectum
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Insert the tip of tubing 8 cm
WHEN CARING FOR PATIENT WITH DRESSING CHANGES
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Clean incision from top to bottom
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Apply sterile gloves after opening dressing package
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Pull the tape toward the wound
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Clean the drain from the centre to outer
CRANIAL NERVE
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Cranial Nerve X(Vagus) ask client to vocalize
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Cranial Nerve XII(Hypoglossal) Ask client to stick tongue out
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Cranial Nerve VIII(Vestibulo Ocular) Ask client if they can hear
whisper -
Cranial Nerve V(Trigeminal) Ask client to clench their
teeth
WHEN DISCHARGING A PATIENT WITH A NASAL CANNULA HOME FOR
OXYGEN
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Make sure equipment have no frayed wires
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Avoid use of oil
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Make sure all electronics are off the floor
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Wear Cotton clothes
TYPES OF POSITIONS
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Sims is used for rectal procedures
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Supine is used for assessment such as thoracic and abdominal
examinations
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Sitting is used for Costovertebral angle tenderness
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Lateral is used for auscultating heart/murmur
Braden Scale
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Measures the nutrition, Sensory perception, moisture, activity,
mobility and friction
WHEN A NURSE IS ASSISTING A PT. DURING MEALTIME AND SEES THEM
SUDDENLY GRAB THEIR NECK WITH BOTH HANDS AND APPEARS
FRIGHTENED, A NURSE SHOULD FIRST
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Determine whether the client is able to breathe
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Remember that you need to Assess first
MANIFESTATION OF HYPERCALCEMIA
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Depressed deep tendon reflexes
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Nausea
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Vomiting -
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Weakness
Bone pain -
Lethargy
REMOVING PPE
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Gloves-->goggles/face shield-->Gown--->Mask / respirator
*pH should be between 0 to 4 for gastric secretion
*When examining a patient’s thyroid gland, have them tilt head back and
swallow
*Romberg test examines the patient’s balance
*Weber test examines patient’s hearing
*Signs of infiltration for IV include edema and feeling of coolness
*Signs of phlebitis or infection for IV include Redness and warmth
*Patient with a Chvostek’s sign will have HYPO calcaemic
*When administering eye drop to client following surgery: Drop the eye medication in
the outer third of the lower conjunctival sac
*Ventrogluteal site is the safest injection site for adults
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Be aware that Ventrogluteal Site can also be described as: “ side hip
between the iliac crest and anterior iliac spine”
TRACH CARE
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Pull suction catheter back 1 cm if client start coughing
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Allow 1 minute rest between each suction
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Hyper oxygenate 100%
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Perform maximum of 3 suction with the suction catheter
NG TUBE INSERTION
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Coat tip with lab
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Ask client to swallow water while tube enters the throat
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Tell client to tilt head backward as insertion begins
*Unintentionally torts/delegation (Refer to Into to prof
nursing) *Study chapter 1-6 fundamental
CRANIAL NERVES
1. I Olfactory (Smell)
2. II Optic (Sight)
3. III Oculomotor (Moves eyelid and eyeball and adjusts the pupil and
lens of the eye)
4. IV Trochlear (Moves eyeballs)
5. V Trigeminal (Facial muscles incl. chewing; Facial sensations)
6. VI Abducens (Moves eyeballs)
7. VII Facial (Taste, tears, saliva, facial expressions)
8. VIII Vestibulocochlear (Auditory)
9. IX Glossopharyngeal (Swallowing, saliva, taste)
10. X Vagus (Control of PNS e.g. smooth muscles of GI tract) 11. XI
Accessory (Moving head & shoulders, swallowing)
12. XII Hypoglossal (Tongue muscles - speech & swallowing)
Cranial Nerve Names Mnemonic
Only Oranges On Tilting Towers Are Fun And Give Very Awkward Holes
Cranial Nerve Function Mnemonic:
**S=Sensory M=Motor B=Both
Some Say Marry Money But My Brother Says Big Brains Matter More
Breast Examination- must be performed yearly to check for cancer.
*Use the techniques of inspection and palpation to examine breast.
*Instruct clients who do not currently perform monthly BSE to inspect their breast in
front of a mirror and palpate them during a shower.
*Feel for lumps using the finger pads of your three middle fingers.
*Compress the nipples carefully between your thumb and index finger to check for
discharge. UNEXPECTED FINDING:
Fibrocystic breast disease: tender cyst often more prominent during
menstruation. 3 techniques: circular pattern, wedge pattern, vertical strip pattern.
VERSION 9
ATI Fundamentals proctor exams
The following are some of the questions and answers on ATI FUNDEMENTAL PROCTOR
EXAMS.
1. An acute illness is;
a. Less than two weeks
b. Less than one month
c. Less than three months
d. Less than six months
Answer: c. Less than three months
Rationale:
An acute illness is defined as a health condition that lasts for a relatively short period, usually
less than three months.
2. Who defines health as “A state of complete physical, mental and social well-being, and not
merely the absence of disease or infirmity”?
a. W.H.O
b. A.N.A.
Answer: a. W.H.O
Rationale:
The World Health Organization (W.H.O) defines health as a state of complete physical,
mental, and social well-being, and not merely the absence of disease or infirmity.
3. Which of the following is a complete wellness diagnosis?
a. Readiness for spiritual well-being
b. Readiness for enhanced family coping
c. Possible social isolation
d. Risk for powerlessness
Answer: b. Readiness for enhanced family coping
Rationale:
A wellness diagnosis reflects a desire to move to a higher level of wellness in the individual,
family, or community. "Readiness for enhanced family coping" is an example of a complete
wellness diagnosis.
4. This is a diagnosis that is associated with a cluster of other diagnoses
a. Actual diagnosis
b. Possible nursing diagnosis
c. Risk nursing diagnosis
d. Syndrome diagnosis
Answer: d. Syndrome diagnosis
Rationale:
A syndrome diagnosis is a clinical judgment concerning with a cluster of actual or risk
nursing diagnoses that are predicted to be present because of a certain event or situation.
5. Which of the following is a correct PES formatted diagnostic statement?
a. Noncompliance (Diabetic Diet) related to unresolved anger about diagnosis as manifested
by weight gain of 5 kg
b. Noncompliance (Diabetic Diet) related to denial of having disease
c. Noncompliance (Diabetic Diet) due to unresolved anger about diagnosis as manifested by
weight gain of 5 kg
d. Situational low self-esteem r/t feelings of rejection by husband
Answer: a. Noncompliance (Diabetic Diet) related to unresolved anger about diagnosis as
manifested by weight gain of 5 kg
Rationale:
PES format stands for Problem (diagnosis), Etiology (related factor), and Signs/Symptoms
(as manifested by). The correct format is "Problem related to Etiology as manifested by
Signs/Symptoms." Option a is the only one that follows this format.
6. Which diagnostic statement(s) consist of a NANDA label only?
a. Possible nursing diagnosis
b. Syndrome diagnosis
c. Risk nursing diagnosis
d. Wellness diagnosis
Answer: d. Wellness diagnosis
Rationale:
Wellness diagnoses consist of a NANDA label only, as they focus on an individual, family, or
community transition to a higher level of wellness.
7. Which of the following is correct nursing diagnosis?
a. Risk for impaired skin Integrity related to decreased peripheral circulation secondary to
diabetes
b. Impaired skin integrity related to improper position
c. Impaired skin integrity related to ulceration of the sacral area
d. Risk for ineffective airway clearance related to emphysema
e. Impaired oral mucous membrane related to decreased salivation secondary to radiation of
the neck
Answer: c. Impaired skin integrity related to ulceration of the sacral area
Rationale:
This diagnosis follows the correct format: "Problem related to Etiology as manifested by
Signs/Symptoms." The other options are incorrect because they either miss the related factor
(etiology) or do not reflect a complete nursing diagnosis. Stabilizing the vein by applying
traction above the insertion site can help prevent vein movement and subsequent damage to
the fragile skin.
Using friction at the insertion site to increase venous distention can damage fragile skin.
Leaving the tourniquet on for 30 to 60 seconds after initial insertion can increase the risk of
venous stasis and tissue damage.
