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Fundamentals II FINAL-Standardized ATI Exam Questions and Answers
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Fundamentals II FINAL-Standardized ATI Exam Questions and Answers
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Fundamentals II FINAL-Standardized ATIImmobility-
Major objective, assessment items and NI for Integumentary
*teaching - Answer-assessment: pallor/redness in fair-skinned, blue/purple in dark, bony prominences,
skin turgor, assess every 2 hrs, oserve for incontinence
interventions: position w/corrective devices (pillows, splints, rolls, boots), teach independent client to
*turn every 15 min, limit sitting in chair to 1 hr, teach clients to shift weight everyr 15 while sitting*
Immobility-
Major objective, assessment items and NI for Respiratory *teaching - Answer--maintain airway, optimal
lung expansion, mobilize airway secretions
-assess every 2 hr: wall movement for symmetry, lung auscultation, observe for productive cough
-reposition every 1-2 hr, teach turning, coughing, deep breathing every 1-2hr while awake, teach
*yawn* every hour, incentive spirometer, remove abdominal binders every 2 hrs, use suction if unable
to expectorate secretions
Immobility-
,Major objectives, assessment items for cardiovascular
*teaching - Answer--maintain function, increase activity tolerance, prevent thrombus formation
-measure BP and assess for dizziness, palpate pulses, auscultate heart at *apex for S3 (early heart
failure)*, palpate for edema, warmth, tenderness, measure circumference of calves and thighs to
compare (*DVT* risk)
Immobility-
NIs for cardiovascular
*teaching *pharm - Answer--increase activity ASAP, dangle feet/transfer to chair
-isometric exercises
-teach to *avoid Valsalva*-stool softener prevents straining
-antiembolic exercises (*ankle, foot, knee*)
-*AVOID* pillows under knees, crossing legs, tight clothes, sitting for a long time, massaging legs
-use elastic stockings
-use sequential compression devices or intermittent pneumatic compression
-increase fluid intake
-low dose *heparin or enoxaparin* prophylactically
Immobility- major objectives, assessment, NIs for metabolic - Answer--reduce skin injury/maintain
metabolism
-record measurements of height weiht skinfolds
-I&O
-assess healing
-auscultate bowel sounds
-provide high calorie high protein diet with vitamin B and C supplements
,Immobility- NIs for elimination - Answer-maintain elimination
-fruits and veggies high in fiber
-stool softener, laxative, enema
-perineal care
-teach bladder and bowel training
-catheter
Immobility- NIs for musculoskeletal - Answer--change position in bed every 2 hr shifts weight in
wheelchair every 15 min
-cluster care to promote sleep-wake cycle
Immobility- instructions to using a cane - Answer-maintain 2 points of support on ground
keep cane on stronger side of body
support body weight on both legs
FIRST move cane forward 15 cm (6-10 inches) THEN move weaker leg forward toward cane NEXT
advance stronger leg past cane
Immobility-instructions on using crutches - Answer-don't alter after fitting
support body weight at hand grips elbows flexed 30 degrees
position crutches on unaffected side when sitting or rising from a chair
Immobility-older adults - Answer--balance, coordination, gait, functional status, level of independence,
social isolation
-plan care with clients and families to increase independence
-provide stimuli (clock newspaper calendar weather)
encourage families to visit
, plan staff to spend time talking and listening to clients
Immobility- ITherapeutic effects of applying heat and cold - Answer-Heat:
^ blood flow
^tissue metabolism
relaxes muscles
eases joint stiffness and pain
Cold:
decreases inflammation
prevents swelling
reduces bleeding
reduces fever
diminishes muscle spasms
decreases pain by decreasing velocity of nerve conduction
Immobility-risk considerations about applying heat and cold - Answer-caution w/very young, very old
immobile might not be able to move away from application
impaired sensory perception
avoid long applications
*do NOT use cold for ppl with vascular insufficiency, open wounds etc*
Immobility-heat - Answer--bony prominences are more sensitive to heat applications
-avoid heat application over metal device
-do not use heat during first 24hr after traumatic injury, for active bleeding, for non inflammatory
edema
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