ATI FUNDAMENTALS REMEDIATION COMPLTE SOLUTION: LATEST-2021, COMPLETE GUIDE

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List the pertinent information that should be included in a transfer report. • Medical diagnosis and care providers • Demographic information • Overview of health status, plan of care, recent ... progress • Alterations that can precipitate an immediate concern • Notification of assessments/care essential within the next few hours • Most recent vital signs and medications, including PRN • Allergies • Diet/activity orders • Specific equipment/adaptive devices (oxygen, suction, wheelchair) • Advance directives/emergency code status • Family involvement in care and health care proxy A nurse is caring for an older adult client with dementia. What preventative measures should the nurse institute to reduce the risk of falls? • Complete fall-risk assessment • Be sure client knows how to use the call light, it is in reach, and encourage them to use it • Respond to call in timely manner • Use fall-risk alerts (color-coded wristbands) • Provide regular toileting and orientation of clients who have cognitive impairment • Adequate lighting • Orient clients to the setting to make sure they know how to use all assistive devices (grab bars) • Place clients at risk for falls near the nurses’ station • Hourly rounding • Make sure bedside tables, overbed tables and frequent-use items (phone, water, tissues) are within reach • Bed in lowest position and lock brakes • Clients that are sedated, unconscious, or compromised, keep side rails up • Avoid use of full side rails for clients who het out of bed or attempt to get out of bed without assistance • Non-skid footwear and nonskid bath mats in tubs/showers • Use gait belts when moving clients • Keep floor clean, dry, and free of clutter with a clear path to the bathroom (NO scatter rugs, cords, furniture) • Keep assistive devices nearby after validation of safe use (eyeglasses, walkers, transfer devices) The nurse is discharging a client home with instructions on proper crutch use. Identify three (3) priority teaching points to include in the discharge instructions. • Do not alter crutches after fitting • Support body weight at the hand grips with elbows flexed at 30° • Position crutches on the unaffected side when sitting or rising from a chair The nurse is screening a client who has a family history of colorectal cancer. Identify three (3) modifiable risk factors for colorectal cancer to discuss with the client. • Smoking • Lack of exercise • Diet deficiencies (too much red meat/processed meat in diet) What are nursing interventions to promote/encourage client's coping in stressful situations? • Encourage health promotion strategies, including regular exercise, optimal nutrition, and adequate sleep and rest • Assist with time management, and determine priority tasks • Encourage appropriate relaxation techniques, including breathing exercises, massage, imagery, yoga, and meditation • Listen attentively, and take the time to understand the client’s perspective • Control the environment to reduce the number of external stressors, including noise and breaks in continuity of care • Identify available support systems • Use effective communication techniques to foster the expression of feelings A nurse is caring for an elderly client with constipation. What are three (3) complications to monitor for during care of this client? • Fecal impaction • Hemorrhoids/rectal fissures • Bradycardia, hypotension, syncope How should the nurse respond when the client requests information about meditation? • Understand the varieties of therapies available and any safety precautions associated with their use • Be receptive to learning about clients’ alternative health beliefs and practices (home remedies, cultural practices, vitamin use, modification of prescription) • Identify clients’ needs for complementary or alternative therapies, along with the client’s values and treatment preferences • Incorporate complementary or alternative therapies into clients’ care plans • Evaluate client’s responses to CAM interventions • Assist with evaluating the safety of herbal and natural products the client may be using. Provide the client with reliable information, and determine possible interactions with prescription medicines and therapies The nurse is caring for a client who has been diagnosed as hypovolemic and has been ordered fluid replacement therapy. What lab values would indicate hypovolemia due to dehydration and why? • Increased Hct • Increased serum osmolarity (greater than 295 mOsm/kg) • Increased protein, BUN, electrolytes, glucose • Increased urine specific gravity (greater than 1.030) • Increased serum sodium (greater than 145 mEq/L) 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). • Calf circumference measurements, respiratory/cardiac changes/trends, peripheral pulses, and pain, warmth, and/or edema in extremities • First, perform hand hygiene, next assess peripheral circulation, calf circumference with a tape measure on both legs, skin, and presence of edema. Turn the stockings inside to the heel, insert the foot, tune the remainder of the stocking over the heel and up the leg. Smooth creases/wrinkles. Remove and reassess every 8 hours. Make sure stockings are clean, dry and not too light over the toes. Perform proper documentation of application, removal and assessments. [Show More]

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