ATI fundamentals review
ethical responsibilities: resolution process for ethical dilemmas
- ID if the issue is an ethical dilemma - gather relevant info - reflect on your own values - state the ethical dilemma, including surrounding issues and individuals involved - list & analyze all possible options for resolving the dilemma, review the implications - select the option that is in concert with the principle that applies to this situation, the decision maker's belief and profession's values for client care - apply this decision to the dilemma and evaluate the outcomes
legal responsibilities: teaching about declining resuscitation
- living will is a legal doc that expresses the client's wishes regarding medical tx in the event the client becomes incapacitated and is facing end-of-life issues - most state laws include provisions that protect health care providers who follow a living will from liability
legal responsibilities: safety/risk reduction
- look first for a safety risk - findings that suggest airway obstruction, hypoxia, bleeding, infection, injury - next ask, "what's the risk to the client?" and "how significant is the risk compared to other posed risks?" - give priority to responding to whatever finding poses the greatest or most imminent risk to the client's well-being
nasal cannula
- tubing with two small prongs for insertion in the nares - delivers a fraction of inspired oxygen (FiO2) of 24% - 44% at a flow rate of 1-6L/min - assess the patency of the nares - ensure the prongs fit in the nares properly - use water-soluble gel to prevent dry nares - provide humidification for flow rates of 4L/min or more
pressure injury, wounds, and wound management
- woven gauze: absorbs exudate from the wound - non-adherent material: does not stick to wound bed - damp to damp: used to mechanically debride a wound; must keep moist at all times - self-adhesive, transparent film: a temporary "second skin" ideal for small, superficial wounds - hydrocolloid: occlusive dressing that swells in the presence of exudate, prevents evaporation of moisture - hydrogel: for infected, deep wounds, or necrotic tissue - alginates: supports debridements, pack wounds, conform to wound's shape - collagen: powders, pastes, granules, sheets, gels, pastes stop bleeding
A nurse is preparing to obtain a client's BP. Which of the following actions should the nurse plan to take? A. place the lower border of the cuff slightly over the antecubital space B. record the diastolic number as the last sound heard C. release the air from the cuff so the pressure decreases at 5mmHg per second D. use a BP cuff with a bladder that is 50% of the client's arm circumference
B. pressure as the fifth and final sound, considered phase 5 of the Korotkoff sounds, is recorded as DBP A. should place cuff above the AC space C. release air so pressure decreases at a rate of 2-3mmHg per second D. bladder that is 40% of the arm circumference
A nurse is teaching a client who requires the insertion of a feeding tube into the jejunum. Which of the following instructions should the nurse include in the teaching? A. You should tilt your head forward when the tube is first inserted into your nostril B. You will need an x-ray to check the location of the tube after it is inserted C. You should cough forcefully as the tube is passed through the back of your throat D. This tube will be placed in your large intestine
B. the client will need to have an x-ray to verify that the feeding tube has advanced into the jejunum A. the client should hyperextend their neck when the feeding tube is advanced toward the nasopharynx C. should tilt their head forward and swallow sips of water to facilitate the passage of the tube into the esophagus D. jejunum is in the small intestine
A nurse in a provider's clinic is teaching a female client about how to collect a clean-catch urine specimen at home. Which of the following information should the nurse include in the teaching? A. use sterile gloves when collecting your urine specimen B. you may refrigerate your urine specimen for up to 12hrs before bringing it to the laboratory C. collect your urine specimen as soon as you start your stream D. clean your vaginal area from the front to the back
D. clean the vaginal area using a front-to-back motion two to three times using a fresh towelette, cotton ball, or gauze pad each time A. can use clean gloves B. may refrigerate the specimen for no more than 2hr before bringing it to the lab C. first initiate the stream and then collect 30-60mL of urine
legal responsibilities: professional negligence/malpractice
failure of a person who has professional training to act in a reasonable and prudent manner: describe a person who has the avg. judgment, intelligence, foresight, and skill that a person with similar training and experience would have most suits prompted by failure to: - follow prof. and facility-established standards of care - use equip. in a responsible and knowledgeable manner - communicate effectively and thoroughly with clients - document the care provided - notify the provider of a change in the client's condition - complete a prescribed procedure