Ati fundamental

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Ati fundamental List three (3) actions to take during the analysis or data collection step. 1. Use therapeutic communication techniques 2. Reduce environmental noises 3. Introduce yourself and ass... essment parts A nurse is caring for an older adult client with dementia. What preventative measures should the nurse institute to reduce the risk of falls? 1. Make sure that the client knows how to use the call light (call belt) and that is within it reach 2. Encourage the client to use the call light (call belt) 3. Respond to the call in a timely manner 4. Place the client who are risk of falls near the nursing station 5. Ensure that. Client’s item is within its reach to prevent falls 6. Maintain bed in low position 7. If patient is sedated, unconscious bed rail should keep up and bed should be in low position 8. Provide nonskid footwear 9. Keep floor free of clutter with clear path to the bathroom 10. Lock wheels of beds, wheelchair and carts 11. Use chair or bed alarm A client has been diagnosed with Varicella. What type of tier transmission precaution is required? What protective equipment will be required for prevention of transmission? 1. Airborne 2. Tier two precautions 3. N95 mask List at least five (5) priority considerations when performing a sterile dressing change. 1. Hand hygiene 2. Avoid coughing, sneezing and talking over the sterile field 3. Only sterile items should be in the sterile field 4. Discard and sterile package that are torn punctured or wet 5. Select a clean area above waist level Identify three (3) priority teaching points to include when educating a client to use a cane. 1. Stand with a firm grip on your cane 2. At the same time that you step forward with you weaker leg, swing with your weaker leg 3. Swing the cane the same at the same distance in front of you 4. The tip of the cane and your forward foot should be even 5. Take some of the pressure off your weaker led by placing pressure on the cane 6. Step past the cane with your strong leg A nurse is caring for a client receiving oxygen therapy. What is the expected reference range when obtaining oxygen saturation level? Identify four (4) reasons the reference range may be lower. 1. The expeted reference is 95-100% 2. COPD 3. Pneumonia 4. Pulmonary edema 5. Asthma Describe the motor, cognitive and psychosocial development during infancy.  Motor 1. First month: grasp reflex and head lag 2. Second month: lift there head off the mattress and hold their hands in an open position 3. Third month: they can raise head and shoulders off the mattress and no grasp reflex 4. Fourth month: they can roll from front to side and they start placing object in their mouth 5. First month: roll from front to back and use of palmar grasp 6. Six months: roll from back to front and can hold bottle 7. Seven months: bear full weight on feet and can move objects from one hand to the other 8. Eight months: they can sit without support and begin use of pincer grasp 9. Nine months: pull to stand position 10. Ten months: change from prone position to sitting position and grasp a rattler by its handle 11. Eleven months: walk by holding to something and can place object into a container 12. One year: they should be able to sit down from standing position and attempt to build a two-block tower  Cognitive 1. Separation 2. Object permanence 3. Mental representation all occur  Psychosocial: trust vs mistrust; infant begin to bond with his parents within the first month. Separation anxiety begin to develop between 4 and 8 months of age and stranger fears become evident between age 6 and 8 months. A 36-year-old client is in the psychosocial development phase of generativity vs. stagnation. Identify four (4) psychosocial development tasks specific to the middle-aged adult. List five (5) expected assessment findings for the older adult due to the physical changes during aging. 1. Loss of muscle tissue 2. Vision change 3. Skin less elastic which shows wrinkles and age spots 4. Hearing loss 5. Decrease of length of sleep What are nursing interventions to promote/encourage client's coping in stressful situations? 1. Encourage client to verbalize feelings 2. Identify the client’s family strength and abilities 3. Encourage client’s autonomy with decision making 4. Discuss client’s and family’s abilities to deal with the current situation 5. Encourage the client to describe coping skills effectively in the past A nurse is caring for an elderly client with constipation. What are three (3) complications to monitor for during care of this client? 1. Fecal impaction 2. Hemorrhoid 3. Bradycardia, hypotension, syncope associated with the Valsalva maneuver How should the nurse respond when the client requests information about meditation? The nurse should tell the patient that mediation used rhythmic breathing through though and focusing to calm the mind and body. The nurse could educate the client that mediation can help decrease stress, anxiety and relax. A client is at risk for a deep vein thrombosis. What is the priority assessment for this client? Describe the procedure to use when applying elastic stockings (TEDS). 1. Perform hand hygiene 2. Assess skin and circulation in the legs 3. Measure the calf 4. Turn the stocking inside the hells 5. Put the stocking on the foot 6. Pull the remainder of the stocking over the hell and up the leg 7. Smooth any creases or wrinkles 8. Remove the stocking and reapply them at least twice a day 9. Be sure that the stocking is clean and dry 10. Document the application and removal of the stocking A client reports difficulty falling asleep. What are nursing interventions to promote sleep? 1. Stablish a bedtime routine, 2. Exercise two hours before going to sleep 3. Limit alcohol and nicotine and caffeine 4 hours before going to sleep 4. Limits fluid 2-4 hours before bedtime 5. Use muscle relaxation [Show More]

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