Examen
ATI | HESI Fundamental Study Guide
ATI | HESI Fundamental Study Guide GET YOUR BOOK DIRECTLY AFTER PAYMENT
[Montrer plus]
Aperçu du contenu
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
Les avantages d'acheter des résumés chez Stuvia:
Qualité garantie par les avis des clients
Les clients de Stuvia ont évalués plus de 700 000 résumés. C'est comme ça que vous savez que vous achetez les meilleurs documents.
L’achat facile et rapide
Vous pouvez payer rapidement avec iDeal, carte de crédit ou Stuvia-crédit pour les résumés. Il n'y a pas d'adhésion nécessaire.
Focus sur l’essentiel
Vos camarades écrivent eux-mêmes les notes d’étude, c’est pourquoi les documents sont toujours fiables et à jour. Cela garantit que vous arrivez rapidement au coeur du matériel.
Foire aux questions
Qu'est-ce que j'obtiens en achetant ce document ?
Vous obtenez un PDF, disponible immédiatement après votre achat. Le document acheté est accessible à tout moment, n'importe où et indéfiniment via votre profil.
Garantie de remboursement : comment ça marche ?
Notre garantie de satisfaction garantit que vous trouverez toujours un document d'étude qui vous convient. Vous remplissez un formulaire et notre équipe du service client s'occupe du reste.
Auprès de qui est-ce que j'achète ce résumé ?
Stuvia est une place de marché. Alors, vous n'achetez donc pas ce document chez nous, mais auprès du vendeur carla05. Stuvia facilite les paiements au vendeur.
Est-ce que j'aurai un abonnement?
Non, vous n'achetez ce résumé que pour 18,49 €. Vous n'êtes lié à rien après votre achat.
Peut-on faire confiance à Stuvia ?
4.6 étoiles sur Google & Trustpilot (+1000 avis)
85443 résumés ont été vendus ces 30 derniers jours
Fondée en 2010, la référence pour acheter des résumés depuis déjà 14 ans