ATI Fundamentals and CMS Practice Assessment Comprehensive Study Guide

Clinical Nutrition and Assessment of Malnutrition

• Findings Indicating Malnutrition:     * Clinical Appearance: The client appears cachectic with flaccid muscle tone.     * Integumentary System: Skin is described as dry, scaly, and pale; presence of bruises on the extremities is noted.     * Vital Signs and Physical Findings: Pulse rate of $118/min$ and a distended abdomen.     * Anthropometric Data: Body Mass Index (BMI) of $17$.

• Dietary Modifications for Chronic Kidney Disease (CKD):     * Clients with CKD often require a low-potassium diet.     * An appropriate food choice demonstrating understanding of this diet is $1\text{ cup of applesauce}$.

Fluid, Electrolyte, and Acid-Base Balance

• Fluid Volume Deficit (Dehydration) Manifestations:     * Cool extremities.     * Orthostatic hypotension.     * Flat neck veins.

• Fluid Volume Excess Manifestations:     * A laboratory finding of Blood Urea Nitrogen (BUN) of $8\,mg/dL$ (reference range is typically $10\text{ to }20\,mg/dL$) indicates fluid volume excess (dilutional effect).

• Electrolyte Imbalances:     * Hypomagnesemia: Indicated by a positive Chvostek's sign (facial twitching in response to tapping the facial nerve).

• Infiltration Findings during IV Therapy:     * Edematous site, taut skin surrounding the catheter, blanched skin, and skin that is cool to the touch. The IV fluid will cease to infuse.     * Nurse Actions for Infiltration:         1. Stop the IV infusion.         2. Elevate the client's affected arm.         3. Apply heat (some protocols may specify cold depending on the infusate, but the transcript indicates heat for this specific scenario).

Safety, Infection Control, and Hygiene

• Hand Hygiene Protocols:     * The faucet should be turned off using a clean paper towel after drying the hands.     * Clostridium difficile (C. diff) Infection: Sanitizing with alcohol-based gel is insufficient; nurses must use mild soap and water to perform hand hygiene.     * General Prevention of Healthcare-Associated Infections (HAIs):         * Wash hands immediately after removing gloves.         * Use antimicrobial hand gel after refilling a client's water pitcher.         * Clean the stethoscope with an antimicrobial wipe after each use for vital signs.

• Isolation Precautions:     * Airborne Precautions: Required for clients who have measles or active tuberculosis (requires a negative-pressure airflow room).     * Droplet Precautions: Required for streptococci infections and pertussis.         * The nurse should wear a mask when within $1\,m$ ($3\text{ feet}$) of the client.         * The client must wear a surgical mask during transportation throughout the facility.

• Fire Safety (RACE Sequence):     1. Evacuate clients from the immediate area.     2. Alarm: Pull the lever on the fire alarm box.     3. Contain: Close the fire doors on the unit.     4. Extinguish: Use a fire extinguisher to put out the fire.

• Fall Prevention:     * Ensure the client is wearing nonskid slippers.     * Place the client in a room near the nurses' station.     * Reinforce teaching about how to use the call bell.

• Home Safety for Sensory Deficits:     * For clients with partial hearing loss, a priority modification is the installation of a flashing smoke alarm.

Medical Surgical Procedures and Maintenance

• Nasogastric (NG) Tube Management:     * Verification of Placement: The nurse should check the pH of the gastric aspirate.     * Potential Complication (Hypomagnesemia): Can occur when a tube is set to low intermittent suction.     * Continuous Enteral Feeding Concerns: The charge nurse should be notified if gastric residual exceeds reaching $520\,mL$, if the client develops an intermittent non-productive cough, or if bilateral breath sounds reveal fine crackles in the bases (indicating potential aspiration).     * Bowel Sounds: If a client receiving continuous feedings has specific bowel sound presentations (indicated by audio in the assessment), the nurse should decrease the rate of the feeding.

• Urinary Catheterization and Care:     * Prior to intermittent catheterization, the nurse should first perform a bladder scan.     * To prevent Urinary Tract Infections (UTIs) with an indwelling catheter, the nurse should drain urine from the tubing before ambulation.

• Wound Care and Irrigation:     * Preparation: Administer an analgesic $30\text{ min}$ before starting irrigation for a large wound.     * Healing by Secondary Intention: Example includes a Stage 3 pressure injury on the coccyx.     * Negative Pressure Wound Therapy Improvements: Indicated by granulation tissue covering the wound bed, lack of odor, decrease in wound size (e.g., from $10\,cm$ to $8.75\,cm$), and decrease in tunneling depth.

• Post-Mortem Care:     * Documentation should include a release of personal belongings form.     * Ensure soiled areas of the body are cleaned prior to family viewing.

• Ostomy Care:     * A purple-colored stoma is an abnormal finding that must be reported to the provider (indicates ischemia).

• Blood Transfusion Reactions:     * Manifestations of an allergic reaction include itching (pruritus), hives (urticaria), anxiety, and a flushed face.

Ethical and Legal Principles

• Ethical Principles:     * Beneficence: Taking positive actions to help others, such as breaking a large potassium pill into smaller pieces for a client who has difficulty swallowing.     * Autonomy: Allowing a client to make their own decisions about treatment.     * Ethical Dilemma: A situation where there is a conflict between competing values, such as a client admitting to taking a partner's oxycodone without the doctor's knowledge.

• Client Confidentiality and Privacy:     * Confidentiality is maintained when providing client information to another nurse during a change of shift report.     * Privacy is protected by speaking with a client about their condition only after visitors have left.     * Client information documented on paper during report should be disposed of by shredding it in a secure container.

• Informed Consent:     * A nurse acts as a witness for informed consent for procedures such as a paracentesis.     * An 18-year-old client with acute appendicitis is considered capable of providing informed consent.     * If a client scheduled for surgery expresses that they do not understand the procedure, the nurse must notify the charge nurse.

• Advance Directives:     * A living will directs medical care when the client is unable to make decisions for themselves.

Physical Mobility and Positioning

• Lifting and Turning:     * When turning a client in bed, the nurse should "tighten your stomach muscles" to stabilize the core.     * When moving a client up in bed with assistance, place feet apart with the foot nearest the head of the bed in front of the other foot.     * When lifting heavy objects, keep the object close to the body.

• Assistive Devices:     * Crutches: The client should keep crutch tips dry to prevent slipping and advance the unaffected leg first when climbing stairs.

• Musculoskeletal Injury Prevention:     * For a client with quadriplegia in the supine position, use a trochanter roll to internally rotate the hips.

• Thrombus Prevention:     * The application of thromboembolic (TED) stockings is a task that can be delegated to assistive personnel (AP).

• Elastic Bandages:     * Pedal pulses should be compared bilaterally every $4\,hr$ to ensure circulation is not compromised.

Vital Signs and Physical Assessment

• Pulse Assessment:     * Dorsalis Pedis: Located on the top of the foot.     * Pulse Deficit: Detected by counting the radial and apical pulses simultaneously with another nurse.     * Tachycardia: A pulse rate of $110/min$ in an adult requires further data collection.

• Edema Scoring:     * Edema measured at $6\,mm$ is documented as $3+$ pitting edema.

• Age-Related Changes in Older Adults:     * Circulation becomes less efficient.     * Urinary incontinence is a finding that should be reported to the provider (as it is not a normal part of aging).

• Oximetry:     * Nail polish should be removed from the client's fingernail before applying the oximetry probe.

Therapeutic Communication and Development

• Communication Strategies:     * Aphasia: Use close-ended questions (Yes/No) to assist with communication.     * Hearing Impairment: Interview the client in a private room to minimize background noise.     * Therapeutic Response to Fear: For a client afraid of dying in their sleep, the nurse should say, "Describe your concerns about sleeping to me."     * Spiritual Support: For a client asking about the afterlife, an appropriate response is, "Tell me what the afterlife means to you."     * Expressing Availability: For a client having difficulty talking about their illness, the nurse should say, "As your nurse, I am available and willing to listen."

• Erikson’s Theory of Psychosocial Development:     * An older adult client stating their life has no purpose is in the stage of Ego Integrity vs. Despair.

• Health Behavior Change:     * The first stage of health behavior change is Precontemplation.

Professional Responsibilities and Delegation

• Tasks for Assistive Personnel (AP):     * Applying thromboembolic stockings.     * Assisting a client to get out of bed after a breathing treatment.     * Transferring a client from a wheelchair to the bed.     * Measuring intake and output (I&O).     * Documenting vital signs.

• Nursing Priority Reporting:     * A urinary output of $60\,mL$ over a $3\,hr$ period ($20\,mL/hr$) or $200\,mL$ over an $8\,hr$ period ($25\,mL/hr$) is below the minimum threshold of $30\,mL/hr$ and must be reported.

• Medication Reconciliation:     * Upon admission, the nurse should compare the medications the provider has prescribed with the medications the client takes at home.

Cultural and Spiritual Considerations

• Islamic Faith:     * Dietary: Clients often do not consume pork products.     * End-of-Life: The client's face should be turned toward Mecca.

• Catholicism:     * The nurse should be prepared to discuss spiritual needs and the meaning of the afterlife if the client requests.

Calculations and Medical Math

• Weight Conversion (Pounds to Kilograms):     * Formula: $\text{Weight in kg} = \frac{\text{Weight in lb}}{2.2}$     * Example: For a child weighing $30\,lb$:     * $30 / 2.2 = 13.6363\,kg$     * Rounded to the nearest tenth: $13.6\,kg$

• Intake Calculation (8-Hour Period):     * Continuous IV infusion: $150\,mL/hr \times 8\,hr = 1200\,mL$     * Juice ($4\,oz$): $4\,oz \times 30\,mL/oz = 120\,mL$     * Water ($0.5\,L$): $500\,mL$     * Total Intake: $1200 + 120 + 500 = 1820\,mL$

Respiratory Interventions

• Preoperative Teaching:     * Turning, coughing, and deep breathing (TCDB) are taught to prevent pneumonia.

• Oxygen Delivery:     * A Nonrebreather mask is chosen to provide the highest concentration of oxygen to a client in severe respiratory distress.

Questions & Discussion

• Question regarding Client Confusion: In the Emergency Department, if a client is confused, the nurse should first obtain a prescription for the suspected cause of confusion and then use alternative methods (such as sitters or safety devices) to keep the client safe.

• Question regarding Fecal Impaction: The most important assessment question is, "Have you had small liquid stools?" (This often indicates seepage around an impaction).

• Question regarding Health Promotion for Young Adults: Young adults should receive a dental assessment every $6\,months$.