Fundamentals Pre-Assessment ATI Flashcards
A client is prescribed antibiotic “A” 50 mg IV. The mixed IV solution contains 100 mL. The nurse is to administer the medication over ½ hour. The drip factor of the available IV tubing is 15gtt/mL. What is the drip rate in drops per minute? (Round to nearest whole number and enter only the number in the answer box).
50
A nurse is providing education to a client with a fractured femur who will need to use crutches for the next 6 weeks. Identify if the following directions provided by the nurse for walking up stairs using crutches are true or false.
- Hold to rail with one hand and crutches with the other hand.
- Push down on the stair rail and the crutches and step up with the ‘unaffected’ leg.
- If not allowed to place weight on the ‘affected’ leg, hop up with the ‘unaffected’ leg.
- Bring the ‘affected’ leg and the crutches up beside the ‘unaffected’ leg.
- Remember, the ‘unaffected’ leg goes up first and the crutches move with the ‘affected’ leg.
True
Match the development tasks with the correct age group.
Develop sense of personal identity that family expectations influence. Peer relationships develop as support system. Concerned with body images that media portray.
Adolescents 12-20 years
Match the development tasks with the correct age group
Develop sense of industry through advances in learning. Strive to develop healthy self- respect by finding out in what areas they excel. Peer groups play important role in social development.
School-age children 6-12 years
Match the development tasks with the correct age group
Take on new experiences and when unable to accomplish task may feel guilty or misbehave. Generally do not exhibit stranger anxiety. Understand behavior in terms of what is socially acceptable.
Pre-schoolers 3-6 years
Match the development tasks with the correct age group
Personalize values and beliefs and base reasoning on ethical fairness principles. Establish close relationships. Have influences that help with formation of healthy self-concept, such family and friends.
Young adults 20-35 years
Droplet precautions:
A private room or a room with other clients with the same infectious disease.
Masks for providers and visitors.
Pertussis
Contact precautions:
A private room or a room with other clients with the same infection.
Gloves and gowns worn by the caregivers and visitors.
Vancomycin resistant enterococcus (VRE)
Airborne precautions:
A private room.
Masks or respiratory protection devices for caregivers and visitors.
An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known or suspected to have tuberculosis.
Negative pressure airflow exchange in the room of at least six exchanges per hour.
Measles
Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material).
Stage 4
Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage.
Stage 2
Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
Stage 3
Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.
Stage 1
What is the name of a legal document that instructs health care providers and family members about what, if any, life-sustaining treatment an individual wants if at some time the individual is unable to make decisions?
Living will
A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been prescribed a high calorie, low protein diet. Which of the following meal selections is appropriate for this client?
Chicken breast, mashed potatoes, spinach.
(This option meets the prescribed diet. It is high in calories and while chicken does provide protein it is a low-fat source and can be eaten in moderation on a low-protein diet. Spinach will provide additional vitamin K for this client at risk for bleeding due to liver failure)
A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client’s risk for falls?
Hourly rounding by the nurse.
(In the health care environment, hourly rounding by nurses significantly reduces the occurrence of client falls, as well as reducing call light usage and increasing client satisfaction.)
A nurse is caring for a client with a closed head injury. When pressure is applied to the client’s nail beds, the client’s eyes open and adduction of the arms with flexion of the elbows and wrists is noted. The client also moans with stimulation. What is this client’s Glasgow Coma Score?
7
A nurse is caring for several clients prescribed heat/cold therapies. Which of the following clients are at risk of injury from these therapies? Select all that apply.
c. A client with diabetes prescribed cold therapy for a fractured toe. (Clients who have impaired sensory perception such as those with diabetes may not feel pain or burning.)
e. A cognitively impaired older adult prescribed alternating heat and cold therapy. (This client is at risk. Cognitively impaired, older adult clients are at risk for injury related to heat and cold therapies due to decreased perception.)
a. A fair-skinned, school age client prescribed heat therapy after a soccer injury.
d. An older adult client prescribed heat therapy for hip pain.
