Quizlet
ATI RN Fundamentals Proctored Focus
Terms in this set (105)
Always correct You've answered all of these correctly!
1. Home safety: Teaching an older adult client about home safety
Answer:
• remove items that could cause the client to trip (rugs, cords, carpets)
• place electrical/extension cords against a wall behind furniture
• monitor gait/balance, provide aids PRN
• make sure steps/sidewalks are in good condition
• grab bars near toilet, tub, shower
• stool riser, toilet cushion
• non-skid bath mats/shower mats
• shower chair or bedside commode PRN
• ensure adequate lighting
• water heater 120
• no smoking if on oxygen, cotton stuff only, no heating oil or nail polish remover
• cook meat and fish fully, handle properly
2. Safe Medication Administration & Error Reduction: Appropriate Actions Following a
Medication Error
Answer:
• assess client
• inform charge nurse
• complete incident report
3. Normal level for WBC's
Answer: 4,500-11,000
4. Normal lab values for Hbg male
Answer: 13.5-17.5 g/dL
5. Normal lab values for Hbg female
Answer: 12-16 g/dL
6. Normal lab values for Na
Answer: 135-145 mEq/L
7. Normal lab values for K
Answer: 3.5-5 mEq/L
8. Normal lab values for Cl
Answer: 95-105 mEq/L
9. Normal lab values for HCO3
Answer: 22-29 mEq/L
10. Normal BUN lab values
Answer: 7-18 mg/dL
11. Normal Creatine lab values
Answer: 0.6-1.2 mg/dL
12. Normal Glucose lab values
Answer: 70-110 mg/dL
13. Normal Calcium lab values
Answer: 8.5-10.5 mg/dL
14. Normal total protein lab values
Answer: 6-8 g/dL
15. Normal Alb lab values
Answer: 3.5-6 g/dL
16. Normal total Bili
Answer: 0-1 mg/dL
17. How many grams are in 1 oz
Answer: 28.35
18. How many mL are in 1 oz
Answer: 29.57
19. How many oz are in 1 cup?
Answer: 8 oz
20. How many liters are in 1 gallon?
Answer: 3.8
21. What are normal values of pH for ABG
Answer: 7.35-7.45
22. What are normal values of PaCO2?
Answer: 35-45 mmHg
23. What are normal values of PaO2?
Answer: 80-100 mmHg
24. What are normal values of HCO3
Answer: 24-30 mEq/L
25. What are the steps in removing an artificial eye?
Answer:
• pull down the lower lip with index finger & exert slight pressure, allowing to slide over
lower lid and grab with free hand
• store artificial eye in labeled container filled with tap water or saline
26. What are the steps in inserting an artificial eye?
Answer: lift upper and lower lid to insert and blink until sets
27. How do you wash an artificial eye?
Answer: Wash with warm, normal saline, with soft gauze or clean tap water
28. How do you properly irrigate an ear
Answer:
• Have pt sit or lie on side with the affected ear UP.
• Using a bulb-irrigating syringe or Walter Pik set on No 2, gently wash ear with warm
solution, directing flow toward the superior aspect of the ear canal.
29. Non-blanchable erythema indicates the skin has been damaged by what?
Answer: Pressure
30. Explain what is happening in the S1 sound
Answer: "Lub" sound-tricuspid and mitral valves snap shut @ beginning of systole. It is
loudest at the apex of the heart.
31. Explain what is happening in the S2 sound
Answer: "Dub" sound-Aortic and Pulmonic valves shut at beginning of diastole. This is
heard best at the base of the 3.
32. What does a split S2 mean?
Answer: Electrical conduction may be delayed on one side so ventricles might not close at
the same time - may sound like a "stutter"
33. S3 is heard in pt's with what?
Answer: CHF. It follows S2
34. S4 is heard in pt's with what?
Answer: HTN, CAD, MI.
35. What is a murmur?
Answer: occurs between S1 and S2. It should be silent there, but with a murmur there is a
whooshing sound ..... this typically happens if a valve isn't open wide enough (Stenotic) or if
a valve doesn't close tightly enough and blood leaks back
36. Grade 1 murmurs are typically ____ to hear
Answer: difficult
37. Grade 6 murmurs are typically ___ to hear
Answer: easy to hear
38. Grade 4 and above murmurs are considered ____ and are accompanied by a _____
Answer: loud murmurs. palpable thrill
39. Pericardial friction rub
Answer: pericardium (membrane around the heart) becomes inflamed. It causes high pitched,
scratchy sound. It is loaded at apex
40. What is the Valsalva maneuver?
Answer: holding breath and bearing down. Usually done to check for hernia's
41. When suctioning a trach, do you apply suction before or after insertion? Do you use a
rotation method?
Answer: After insertion. Yes
42. Do not insert ____ ___ into artificial airway because it increases the risk of infection
Answer: normal saline.
43. insert artificial airway until ____
Answer: feel resistance or patient starts coughing.
44. If pt needs more suctioning, repeat procedure only ______ more times & wait at least
____ minute
Answer: 1-2. 1
45. To rinse catheter, use ________ mL of ________
Answer: 5-10 mL. Normal saline
46. Elderly people and children need a _____ gauge for IV's
Answer: larger #
47. Every time access port you should _____
Answer: clean it
48. NEVER infuse _______
Answer: potassium chloride
49. Change IV sites every ______
Answer: 72 hours
50. Change tubing every ______
Answer: 96 hours
51. Fluids should not hang more than _______
Answer: 24 hours
52. Infiltration in IV
Answer: Fluid goes into interstitial skin and pt's extremities look cool and swollen
53. Phlebitis
Answer: inflammation of vein. Pt is red and warm near site
54. Signs and symptoms of fluid overload are ___
Answer: SOB, crackles in lung, increased urine output
55. Steps for inserting an IV
Answer:
• place pt in dependent position
• apply tourniquet above the antecubital fossa or approximately 4-6 inches from anticipated
site
56. if pt has fragile skin or excessive hair where do you place the tourniquet?
Answer: over sleeve of gown to protect skin
57. If a pt has fragile skin and the tourniquet is not
available, use ________, Inflate just below pt's normal ____ _____.
Answer: blood pressure cuff. Diastolic pressure
58. If you are having trouble finding a well dilated vein, what do you do?
Answer: stroke the extremity below intended IV site from distal to proximal or place a warm
blanket/towel over extremity for a couple of minutes. AVOID rubbing vigorously or flicking
vein as it can cause vein to constrict or a hematoma
59. If pt is not receiving a continuous infusion, what do you initiate?
Answer: A saline lock.
60. Saline locks must be flushed with what and when?
Answer: They must be flushed with 1-3 mL of normal saline before and after you administer
each medication
61. What do you clean site with prior to initiating IV access?
Answer: Chlorhexidine 2%
62. IV insertions on older adults
Answer:
• Use tourniquet sparingly to avoid tearing or bruising of the skin
• be sure to pull skill below the insertion site taut to stabilize the vein
• use lower angle of insertion to avoid puncturing posterior wall of vein
• to secure, use minimal tape-use mesh dressing instead
63. Hypertonic solutions
Answer:
• used for pt's who have severe hyponatremia .... cardiac or renal disease.
• most risky,
• pull fluid into vascular space by osmosis resulting in an increased vascular vL that can
result in pulmonary edema
64. Discharge teaching for a client with diabetes mellitus:
Answer:
DIET:
• limit calories & decrease total fat intake to 30% of total calories/day
• eat omega 3 fatty acids and fiber
• low sat fats
• use artificial sweetners
WHEN SICK:
• monitor glucose Q 3-4 hr
• take DM meds as prescribed
• increase fluids
• test urine for ketones
• encourage rest
• report persistent fever above 101, confusion, rapid breathing, persistent N/V, etc.
• assess support systems
• assess ability to self-admin insulin
• check glucose before meals and at bedtime
• return demonstrations on self admin
• store test strips in dry closed container
• hand hygiene
• continuous pump needles need to be changed Q 2-3 days
• rotate injection sites
• record I&Os and daily weights
• hypoglycemia warrants immediate evaluation of glucose
FOOT CARE:
• inspect feet daily, wash with mild soap & warm water-test temp first
• avoid lotions
• use mild foot powders
• NO home corn/callous remedies
• nail care after bath/shower
• avoid open toe or open heel shoes
• leather shoes better
• no barefoot
• cotton or wool socks
• water heater should be no more than 120
65. Client safety: fall risk precautions
Answer:
• complete fall risk assessment upon admission
• show client how to use call light, make sure it is within reach
• ensure adequate lighting
• orient the client to the setting, make sure they know how to use all assistive devices
• place fall risk clients near nurses station
• bedside tables, overbed tables, and frequently used items should be within reach
• bed in lowest position
• sedated/unconscious clients bed rails up, bed in lowest position
• avoid use of full side bed rails for clients who get out of bed or attempt to without
assistance
• non-skid footwear & non-skid bathmats
• keep floor free from clutter (no rugs, cords, furniture)
• educate family & client on fall risk status/prevention
• lock wheels on beds, wheelchairs, & carts
• use chair & bed sensors
66. Client safety: alternatives to restraints for a client who is confused
Answer:
• one to one care
• keep close to nurse's station
• low to the floor beds with mattress on the floors
• bed alarms
• rocking chair in the room
• relaxation techniques
• family stay with the patient
67. Hygiene: Bathing a client who has dementia
Answer:
• assess client's ability to help
• collect equipment & explain procedure, reassure, maintain their dignity
• apply gloves
• lock wheels on beds
• wash face first
• keep them covered
• shave in direction of hair
• brush teeth and hair often and gently
• do not need to bathe daily as their skin cannot take it
• reorient often
68. thorax, heart, and abdomen: appropriate technique for abdominal assessment:
Answer:
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
• urinate before Abd assessment
• supine, knees slightly bent
69. Self-concept and sexuality: Providing client support following a mastectomy:
Answer:
• monitor anger, emotions
• encourage client to participate in care
• arrange support group or visit from someone in similar situation
• counseling
• discuss alternative means of sexual expression (hugging, cuddling)
• therapeutic communication
70. Mobility & Immobility: Appropriate use of crutches:
Answer:
• do not alter crutches after fitting
• follow prescribed crutch gait
• support body weight at the hand grips with the elbows flexed at 30 degrees
• position crutches on the unaffected side when sitting or rising from a chair
• keep crutches 6 inches to the front and to the side of client when walking
• don't let crutches fit under the armpit - allow some space to avoid damage to skin or nerves
in axillae
71. Urinary elimination: preventing skin breakdown
Answer:
• keep skin dry and clean
• assess for signs of breakdown
• apply protective barrier creams
• implement bladder retraining programs
72. Mobility & Immobility: Preventing thrombus formation:
Answer:
• avoid pillows under knees or lower extremities
• avoid crossing legs
• avoid wearing tight clothes
• avoid sitting for long periods of time
• avoid massaging the legs
• use elastic stockings
• use compression devices (SCD, IPC)
• increase fluid intake
• avoid valsalva maneuver
• change positions often
• encourage ROM & leg exercises
73. Fluid imbalances: hypersomolar imbalance
Answer:
• aka dehydration
• fluids: isotonic solutions such as LR or 0.9% sodium chloride NaCl
• blood transfusions
• encourage oral rehydration as tolerated this results in:
• increased Hct
• increased serum elecs
• increased urine specific gravity
• antidiuretic hormone release
• aldosterone release
• increased thirst
74. Nasogastric Intubation & Enteral feedings: Unexpected findings
Answer:
• excoriation of nares & stomach
• coffee-ground or blood streaked drainage
• distention (caused by occlusion of tube)
• gastric residual exceeds 250 ml for each of two consecutive assessments
• diarrhea 3 or more times in 24 hrs
• N/V
• aspiration of formula
• skin irritation around site
75. Nutrition & Oral Hydration: Calculating intake
Answer:
1. 1oz = 30mL
2. 1 cup = 240mL
3. 1 tsp = 5mL
4. 1 tbsp = 15mL
5. CONVERT to mL then add
76. Rest & Sleep: Interventions to promote sleep:
Answer:
• establish routine
• limit waking during the night
• help with personal hygiene needs or a back rub prior to sleep to increase comfort
• exercise regularly at least 2 hr before bedtime
• limit fluids 2-4 hr before bed
• engage in muscle relaxation techniques
• pharm agents
77. Pharmacokinetics & Routes of Admin: Administering Intradermal Tuberculin Test
Answer:
• use small amounts of solution (0.01 to 0.1 mL) in a tuberculin syringe
• fine-gauge needle (26-27 gauge)
• inject in lightly pigmented, thin-skinned, hairless sites (inner surface of mid-forearm or
scapular area of the back)
• 10 to 15 degree angle
78. Pharmacokinetics & Routes of Admin: Enteral Administration of Medications
Answer:
Contraindications include:
• vomiting
• decreased GI motility
• absence of gag reflex
• difficulty swallowing
• decreased LOC
• have client seated at 90 degree angle
• admin irritating meds with small amounts of food
• do not mix with large amounts of food or beverages in case the client is unable to consume
the entire quantity
• avoid grapefruit juice or milk with iron etc
• admin oral meds on an empty stomach (30-1 hr before meals or 2 hr after meals)
• enteric-coated meds or time-release must be swallowed whole
• use a liquid form of med to facilitate swallowing whenever possible
79. Intravenous therapy: catheter insertion procedure
Answer:
• don't use tourniquet on older adults, use BP cuff
• cleanse the skin prior with betadine or alcohol-wait to dry, inward then moving out
• pull skin taut and hold it
• warn client of sharp stick
• insert at 10-30 degree angle with bevel up
• advance catheter, look for flashback of blood
• thread catheter in vein about 0.25 in
• retract needle
• stabilize catheter with hand and release tourniquet
• attach tubing and stabilize with tape/dressing
• document
80. Intravenous therapy: Initiating IV therapy for an older adult client
Answer:
• don't use tie, use BP cuff (4-6 inches above proposed site)
• do not slap the extremity to visualize veins
• avoid rigorous friction while cleaning the site
• assess for allergies prior
• assess for bleeding disorders prior
81. Airway management: Monitoring oxygen saturation
Answer:
• pulse ox (normal 95-100%)
• acceptable levels range from 91-100%, some illness states may even allow 85-89%
• readings below 90% reflect hypoxemia
• readings can be impaired in older clients, darker skinned clients, clients with hypothermia,
edema, and nail polish
• place client in semi-fowler's or fowlers
• encourage deep breathing
82. Nasogastric intubation & enteral feedings: preparing to administer feeding
Answer:
1. introduce, explain, establish signs to show distress, clean
2. set up equipment & provide privacy
• NG tube
• tape
• clean gloves
• water soluble lubricant
• cup of water & straw
• basin
• catheter tip syringe (30-60 mL)
• pH test strip or meter
• stethoscope
• towel
• clamp or plug
• suction
• gauze square
3. Auscultate bowel sounds, then palpate
• raise HOB
• high fowlers
• assess nares
4. check placement
• aspirate, test pH (4 or less is expected)
• confirm placement with x ray
• feed slowly
5. document
83. Sensory perception: Performing ear irrigation:
Answer:
MEDS:
• use medical aseptic technique
• sit upright or maintain side-lying
• straighten ear canal by pulling auricle upward & outward for adults
• down and back for children
• hold dropper 1 cm above the ear canal, instill med, then gently apply pressure with finger
to tragus of ear unless contraindicated due to pain
• do not press cotton ball into ear, place in outermost area if needed
• remain in side lying position if possible for 2-3 min after installation of ear drops
• use warm water
UP & BACK adults
DOWN & BACK kids
84. Sensory perception: Teaching about care of an artificial eye
Answer:
• wash hands before and after touching eye
• keep blood pressure, blood glucose, and cholesterol under control
• eat foods rich in antioxidants, such as leafy vegetables
• use warm water & mild non scented soap to wash it
REMOVAL:
• place towel below head in case it pops out
• pull down on lower lid until you can see edge
• put extractor under & pull gently out
85. Airway management: teaching incentive spirometry use
Answer:
• used to see total breath intake and output
• place lips around mouthpiece and make sure there is a good seal around it
• inhale as much as you can
• once you have inhaled enough, hold your breath for three seconds
• exhale normally
86. Airway management: performing Nasopharyngeal suctioning
Answer:
• don correct PPE
• semi or high fowlers
• encourage coughing & deep breathing
• hyperoxigenate prior
• obtain baselines prior
• use a flexible catheter & lubricate the distal 6-8 cm with water soluble lubricant
• suction pressure no higher than 120-150
• limit duration of 10-15 seconds, 2-3 attempts
• no suction while inserting
• measure tube insertion correctly(end of nose, to ear, to sternum)
• apply intermittent suctioning by doing thumb on/off 10-15 seconds & rotating on slowly
removing
87. Pressure ulcers, wounds, and wound management: dressings for pressure ulcers
Answer:
• saline or occlusive for stage 2
• nonadherent for stage IV
• debridement & skin grafts for stage IV
• antimicrobials for stage 3
• clean from least contaminated to the most contaminated
• use gentle friction
• do not use cotton balls or other products that shed fibers
• document the location and type of wound and incision, the status of the wound, type of
dressing and materials, client teaching, and how the client handled the procedure
DO NOT USE:
• alcohol
• dakin's solution
• acetic acid
• providone-iodine
• hydrogen peroxide
• cytotoxic cleansers
88. Legal responsibilities: completing an informed consent
Answer:
• witness
• parents may sign for minors
• client must understand & have no further questions
• have them sign
• document the questions the
• client had, if used an interpreter reinforcement of teaching, etc
89. Medical & Surgical Asepsis: Planning care for a client who has a latex allergy
Answer:
• check before any procedure
• ensure latex free everything is used by staff, client, and team
90. Older Adult (65 & up): identify expected changes in development:
Answer: PHYSICAL:
• decrease in skin turgor
• decrease in subcutaneous fat & connective tissue
• thinning & graying of hair, sparser distribution
• thicker fingernails & toenails
• slower reaction time
• decrease in touch, smell, taste
• decline in vision
• decrease in muscle tone & height
• joint degeneration
• decrease in GI motility
• decalcification of bones
• decrease in bladder capacity
• decline in estrogen & testosterone
• dental problems
COGNITIVE:
• dementia, delirium, depression
PSYCHOSOCIAL:
• face death
• deal with family losses
• integrity vs despair
91. Urinary elimination: Effects of Aging on Urinary Infections
Answer:
• increasing risk of UTIs with age
• residual urine from insufficient bladder emptying
• poor tone from aging leads to frequency
92. Adverse Effects, Interactions, Contraindications: Priority Assessment Findings (pain
management)
Answer:
• decreased respirations (morphine, opioids)
• EPS symptoms
• seizures
• LOC changes
93. Specimen Collection for Glucose Monitoring: Obtaining a Capillary Blood Glucose
Sample
Answer:
• check meds, gather stuff
• outer edge of fingertip most common site
• alternate sites
• warm site prior
• cleanse with warm water & soap or an antiseptic swab
• pierce skin with lancet, hold perpendicular to skin
• wipe away first drop of blood
• milk finger if needed
• don't smear blood on strip
94. Intravenous therapy: Recognizing Phlebitis
Answer:
• edema
• throbbing
• burning
• pain at site
• erythema
• red line up the arm with a palpable band at the vein site
95. Breast self-examination
Answer:
• inspect in front of mirror
• palpate in the shower
• do it 2-3 days after period ends
• postpartum clients should do BSE on the same day each month
• areola should be darker than nipple & round or oval shaped
• nipples should be everted
• one slightly larger than other
96. Ergonomic principles: Safely Transferring a Client from the Bed to the Chair
Answer:
• use 2 or more people to help
• use assistive equipment
• assess client's ability to help
• avoid twisting or bending at the waist
97. caring for a client with c-diff
Answer:
• contact precautions
• wash hands with soap and water
• keep one stethoscope in room
• use PPE
98. Identifying an intentional tort:
Answer:
• assault (threatens to place catheter)
• battery (restrains client & admins med against will)
• false imprisonment (all side rails)
99. Performing Romberg assessment:
Answer:
• ask client to stand with his feet together, arms at side, eyes closed
• expected finding: minimal swaying for at least 5 seconds
100. Implementing isolation precautions:
Answer:
• change PPE after every client
• provide stimulation to client in isolation
• assist client & family in understanding why precautions are implemented
101. Young Adults (20-25): teaching appropriate health promotion guidelines:
Answer:
• immunizations (hep A & B, diptheria, tetanus, pertussis, MMR, influenza, HPV, &
pneumococcal & meningococcal)
• monitor calcium intake for women
• avoid drugs & alcohol
• car safety
• helmets
• smoke & carbon monoxide detectors
• securing firearms in safe location
102. Normal BP systolic
Answer:
Systolic = less than 120
Diastolic = less than 80
103. Pre-HTN BP
Answer:
Systolic = 120-139
Diastolic = 80-89
104. stage 1 HTN BP
Answer:
Systolic = 140-159
Diastolic = 90-99
105. stage 2 HTN BP
Answer:
Systolic = greater than 160
Diastolic = greater than 100
