ATI focus Areas: SAFETY, (client, home, medication administration), assessment

(vitals), diets, asepsis, skin integrity (pressure ulcers, wounds), infection (indwelling
catheters), Precautions Hx of falls is major assessment for fall risk).. ABCs
1. Two questions on dosage calculations. Necessary conversion: 1 kg = 2.2 kg
2. Client as greatest risk for pressure ulcer, client who has been sitting up in chair for
4 hours (605)
3. client at risk for ulcer, client lying on greater trochanter (hip)
4. Client do not understand surgery, appropriate nursing action is to contact provider
(p 27)
5. Inmate bleeding, guard asks client if client has HIV, most appropriate action for
nurse is to inform the client to use standard precaution when in contact with all
inmates, personnel
6. Client is being combative, nurse apply restraints. Nurse fail to get a doctors
order. Which tort is violated? I chose battery instead of false imprisonment
because a battery is the wrongful physical contact with a person that involves an
injury or offensive contact (restraining a client). I did not chose false
imprisonment because the nurse did not restrain the client due to client wanting to
leave or refuse treatment. (p23) I could be wrong though.
7. Client at risk for hospital acquired infection is a client with an indwelling catheter
(93)
8. Which of the following indicate a client understanding of home safety. I will have
a fire plan in place in case of fire. (117)
9. Delegated task to AP: oral care to client who is NPO, tube (endotracheal). Tasks
that cannot be delegated is assessment, initial vital signs, teaching, medication
administration (p47)
10. Nurse walks into room and notices work IV bag hanging. After changing bag IV
to proper medication, what should the nurse do? Never chart this in medical
record. Never refer to incident report in medical record. I put report this incident
to the supervisor by stating the nurse who was responsible (489)
11. Proper technique to cleanse wound
12. Aortic valve, right sternum, 2nd intercostals

13. Blood pressure should be taken at (not above) heart level. Apply cuff 1 inch above
antecubital fossa. The bladder should surround 80 % of the arm circumference
(243)
14. Parent concerned about her child eating on certain foods, eat what she want to eat.
What is the appropriate response? You seemed concerned about you childs
eating habits. You want t acknowledge the persons feeling and have them
reflect.
15. What information to include when transferring client to a long-term care
facility It includes assessments that the client will need within the next few
hours. Client needs to see a physical therapist. Annual flu shot does not have to be
in the next few hours (p 76)
16. Proper way to wash hands is 15 sec, do not use hot water, do not dry from upper
arm to hands. (84)
17. Hand washing is most effective for reducing infections (83)
18. Full liquid diet
19. Puree diet
20. Pour sterile solution: holding the bottle with the label in the palm of the hand so
that the solution does not rundown the label (86)
21. Sterile gloves: pick up glove by grasping the folded edge of cuff. put on dominate
hand first.(87)
22. TB client are put on airborne precautions.(96)
23. Clients with MRSA are put in a private room (97)
24. Which client will you use a mask on droplets, contact with secretions
25. Mask: When moist, client should discard and get new mask because moist mask is
not effective anymore because organisms can penetrate. Also masks are single use
only. Mask should fit snugly around face.
26. Client who gets out of bed have a bed monitoring device
27. Nursing responsibilities regarding restraints include remove and replace restraints
at least every 2 hours to ensure circulation and allow for full range of motion; use
of a quick tie know (not a square not), ensure that there is room to fit 2 fingers
between the device and client (not three). p 105-6

28. To prevent ulcer from forming, place pillow under heel of foot (a pressure point)
29. Home safety p 116
30. Client who is sleep deprived judgment will be impaired
31. Health promotion: frequency of exams and screening. Clinical breast exams
yearly, annual vision/hearing screening (143)
32. Client acceptance of loss, I dread therapy but I am learning to live with my
prosthetic leg
33. Mother provides complete care for teenage son. Teenager complains to the nurse
that his mom does every thing. The appropriate action is to tell the mom to
provide privacy while her son clean his perineal area (Autonomy,
independence, 407)
34. Psychomotor learning: insulin injections
35. 9 month Baby able to grasp cereal
36. Z track method for iron used to prevent skin irritation
37. Client with dementia
38. Abnormal assessment data: thyroid gland is normally not visible (p257)
39. When taking temp whats appropriate, assess to see if client was smoking in the
past 30 min., b/c interfere with accuracy (234)
40. Pain: cultural variations of pain
41. Nursing interventions for client hearing impaired, selected all that apply. All of
the above except speak loudly to client.
42. The anterioposterior diameter should be half of the transverse not 1:1 Apical
pulse is (PMI) point of maximal impulse
43. Smoking cessation: (steps) assess what kind of tobacco client smokes. Inform
client of harmful effect. Develop cessation plan. Evaluate plan.
44. Foot care
45. Insomnia
46. Mobility and immobility (402-406)
47. Assess client with nonblanchable, redness; because of risk for advancement of
pressure ulcer.
48. Fecal impaction: sign diarrhea fluid leakage around impacted stool (441)

49. Do not put catheter drainage bag on floor.

50. Proper suctioning
51. Nurse realizes that dose for child is too high. Priority is to check to see what was
transcribed because there may be an error. You cant rely on client, checking with
pharmacy is not priority.
52. Give regular insulin first
53. Nurse walks in and realizes that IV solution bag is empty. What should the nurse
do? Assess vital signs first, and then adjust the rate. (p 533)
54. Specimen (sputum)
55. Suctioning (573)
56. Communicating with client who have trache, picture cards
57. Herbs
58. Test gag reflex when performing oral care