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Advance directives- teaching - ✔✔✔-Communicates the client wishes regarding end of life care;
are written before a client becomes ill
Nurses role is to provide info about advance directives
Document client's advance directive status
Ensure advance directives reflects clients current decision
Inform all members of the healthcare team of the client's advanced directives
Advancing to a full liquid diet - ✔✔✔-All clear liquids plus liquid dairy products, all juices,
puréed vegetables, and yogurt
Adverse interaction priority assessment findings - ✔✔✔-These are undesirable and potentially
dangerous responses to a medication
Check client for allergies prior to administering
Follow client rights or medication administration
If adverse interaction occurs discontinue medication immediately
Follow airway breathing circulation prioritization
Make sure client is stable and safe
Report to provider
Complete incident report within 24 hours
Airway management collecting sputum culture - ✔✔✔-Wait 1 to 2 hours after a client eats to
obtain a specimen
Perform chest physiotherapy to help mobilize secretion
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Use a sterile specimen cup
Wear appropriate PPE- masks, gowns, gloves, goggles, hair covering
If client unable to produce specimen may need to perform endotracheal suctioning to obtain
specimen (Will need a doctors order)
Allergenic stem cell transplant teaching - ✔✔✔-Place in a private room
Use protective equipment
Positive pressure room with 12 or more airflow changes per hour
Aloe - ✔✔✔-Wound healing
Assessing psychosocial history - ✔✔✔-Assessment including the following information:
identifying the client, chief complaint, history of present illness, psychiatric history, medical or
surgical history, medication list, alcohol/drug use, cultural assessment, financial assessment,
coping skills, violence risk assessment, family/social history, occupational history, educational
history, legal history, developmental history, spiritual assessment, interests, abilities, mental
status examination
Assisting client to a fracture pan - ✔✔✔-Shallow end under the buttocks
ATI fundamentals stages of general adaption syndrome - ✔✔✔-Alarm- stressor upsets
homeostasis and the body prepares for an attack (fight or flight)
Resistance- body uses up a great amount of energy trying to adapt to the stressor
Exhaustion- body exhaustion and health problems due to the failing to adapt to the stressor
Bathing a client who has dementia - ✔✔✔-Allow to participate in care as much as possible
Give step by step instructions slowly
Limit choices of clothing to put on
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Calculating client fluid intake - ✔✔✔-All fluids going into the client (oral, tube feedings, IV,
medication, TPN, lipids, blood products, dialysis fluids, and flushes
Calculating diphenhydramine solution - ✔✔✔-Know dosage calculation for PO, IM, and IV
administration
Calculating dose of gentamycin - ✔✔✔-Know dosage calculations for IM and IV administration
Caring for a client requiring a restraint - ✔✔✔-Least restrictive
Remove every 3 to 4 hours
Secure with a quick release knot such as a slipknot
Tie to bedframe (not bed rail)
Assess client every 2 hours or per facility protocol for toileting/nutritional needs and skin
assessment
Regularly determine the need for continuing the restraints
Remove as soon as client no longer requires being restrained
If using a wrist restraints allow for two fingers to fit between skin and restraint
Caring for a client who has a high fever - ✔✔✔-Apply cooling blanket (make sure to apply a
bath blanket between the cooling blanket and client)
Keep hydrated
Administer antipyretics as ordered
Caring for a client who is immunocompromised - ✔✔✔-Use frequent hand hygiene before and
after care
Use aseptic technique and proper PPE