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ATI | HESI Fundamental Study Guide
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Fundamentals- Rest and sleep: interventions to promote sleep
o Establish a routine bedtime
o Limit waking clients during the night
o Help with personal hygiene needs or a back rub prior to sleep to increase comfort
o Instruct client to:
Exercise regularly at least 2 hours before bedtime
Arrange the sleep environment for comfort
Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.
Limit fluids 2-4 hr before bedtime
- Pharmacokinetics and routes of administration: selecting intramuscular site
o Ventrogluteal, dorsogluteal, deltoid, and vastuc lateralis (pediatric)
1-3 mL otherwise it needs to be divided into separate syringes.
- NG intubation and enteral feedings: evaluating proper function of NG tube
o Aspirate and x-ray
o pH up to 4.5
- Mobility and immobility: appropriate use of crutches
o Do not alter crutches after fitting
o Follow the prescribed crutch gait
o Support body weight at the hand grips with the elbows flexed at 30*
o Position the crutches on the unaffected side when sitting or rising from a chair
- Urinary elimination: performing closed intermittent irrigation
o 50 cc sterile solution
- Nutrition and oral hydration: findings to report
o Nausea, vomiting, diarrhea, constipation
o Flaccid muscles
o Mental status changes
o Loss of appetite
o Change in bowel pattern
o Spleen, liver enlargement
o Dry, brittle hair
o Loss of subcutaneous fat
o Dry, scaly skin
o Inflammation, bleeding of gums
o Poor dental health
o Dry, dull eyes
o Enlarged thyroid
o Poor posture
- Pressure ulcers, wounds, and wound management: preventing delays in healing
o Encourage intake of 2,000 to 3,000 mL of fluids/day
o Provide education about good resource of protein
, o Lack of protein increases the risk for a delay in wound healing and infection
o Provide nutritional support
o Clean wounds from least contaminated towards the most contaminated
o Use gentle friction when cleansing or applying solution to the skin
o Use a piston syringe or a sterile straight cath for deep wounds with small openings 30-
60 mL syringe with a 19 gauge needle.
- Nursing Process – Family Concerns
- Infection Control: Contact Precautions
o Person to person, object to person, fecal oral route
o Protect visitors and caregivers when they are within 3 ft of the client (Respiratory
synctytial virus, shigella, wounds, herpes simplex, impetigo, scabies.
o Private room or a room with other client with the same infection.
o Gloves and gowns
o Infectious dressing material into a single, nonporous bag without touching the outside
bag
- Mobility and Immobility: benefits of applying ice to extremity
o Decreases inflammation
o Prevents swelling
o Reduces bleeding
o Reduces fever
o Diminishes muscle spasms
o Decrease pain
o Assess every 5-10 minutes
- Vital Signs – Calculating pulse pressure
o Systolic – Diastolic
- Thorax, heart, abdomen: auscultating closure to the Aortic Valve
o Beginning of ventricular diastole and produces the S2 sound (Dub). Place the diaphragm
of the stethoscope at the aortic area.
Adult Med-Surg
- Cancer treatment options: Discharge teaching for myelosuppression
o Monitor the client’s temperature and WBC
o Fever greater than 100*F (37.8*C) should be immediately reported to the provider.
o If WBC drops below 1000/mm3, place client in a private room and initiate neutropenic
precautions.
o Place mask during transport
o Protect client from possible sources of infection.
o Frequent hand hygiene, have no ill visitors
o Avoid invasive procedures that can cause a break in tissue unless necessary (rectal
temp, injections are a no no)
o Avoid crowds
, o Avoid yard work, gardening, or changing a pet’s litter box
o Avoid fresh fruits
o Wash toothbrush daily in dishwasher or rinse in bleach solution
o Avoid fluids that have been sitting out for over 1 hr
- Meningitis: appropriate actions for bacterial meningitis
o Isolate the client as soon meningitis is suspected.
o Droplet precautions which requires a private room or a room with cohorts, wearing of a
surgical mask when within 3 feet of the client, appropriate hand hygiene, and the use of
designated equipment, such as blood pressure cuff and thermometer. Continue until
antibiotics have been administered for 24 hrs.
o Implement fever-reduction measures, such as cooling blanket.
o Report to the public health department.
o Decrease stimuli
o Maintain bedrest w/ head elevated at 30*
o Seizure precautions
o Replace fluid and electrolytes
- Hepatitis and cirrhosis: evaluating nutritional needs for hepatic encephalopathy
o Encourage high calorie and high carb with supplemental vitamins, folic acid, and iron.
Low protein!
- Posterior Pituitary Disorder: complications following a hypophysectomy
o Monitor glucose levels as drop can be caused by abrupt drop in cortisol
o Check weight
o ADH and oxytocin is secreted by posterior pituitary
o Secondary addisons’s and hyperlipidemia can occur.
- Electrocardiography and dysthymic monitoring: Sinus tachy
- Inflammatory Disorders: Pericarditis
o Inflammation of pericardium
o Follows respiratory infection
, o Findings include chest pressure/pain, friction rub auscultated in the lungs, shortness of
breath, and pain relieved when sitting and learning forward
o ECG done
o Auscultate for murmurs and friction rub
o Cardiac enzymes can be elevated with pericarditis
- Cancer treatment options – providing client teaching for radiation therapy
o Do not eat any red meat
o Instruct the client about the administration of antiemetics and schedule them prior to
meals.
o Suggest that the client select foods that are served cold and do not require cooking,
which can emit odors that stimulate nausea.
o Encourage high protein, high calorie, nutrients-dense foods and avoidance of low- or
empty-calorie foods. Use meal supplements as needed.
o Encourage the use of plastic eating utensils, sucking on hard candy.
o Fatigue is common
o Wash the irradiated area with mild soap and water. Try the area using patting motions.
o Do not remove tattoos
o Do not apply powders, ointments, lotions, or perfumes to the irradiated skin.
o Wear soft clothing over the irradiated skin and avoid tight or constricting clothes.
o Do not expose it to sunlight.
- Electrocardiograpghy and dysrhythmia monitoring: indicators for use of cardioversion
o Given to those with atrial dysrhythmias, supraventricular tachycardia, and ventricular
tachycardia with pulse. They are alive and but are dropping fast! De fib is pulseless.
- Fractures: Interventions for Sprain
- Bacterial, Viral, Fungal, and Parasitic Infections: Caring for a client who has clostridium difficile
o Contact isolation
o Wash hands with soap with water
- HIV/AIDS: Caring for a client who has neutropenia
o Assess skin integrity
o Monitor vital signs (especially temperature)
o Monitor labs (CBC,WBC, LFT)
o Instruct client to practice good hygiene and frequent hand hygiene to reduce the risk of
infection
o Encourage the client to avoid raw foods, such as vegetables and meat.
- Diabetes Mellitus Management: Clinical Manifestations of Hyperglycemia
o Hot, dry skin, and fruity breath
- Chest Tube insertion and monitoring: Identifying complications
o Air leaks
Monitor water seal chamber for continuous bubbling (bad)
Suction control
- Heart failure and pulmonary edema: Decreased cardiac output
o Left sided heart failure
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