RN ATI Capstone Fundamentals 2019
ABC(DE) framework - -Airway: necessary for breathing
-Breathing: necessary for oxygenation of the blood to occur
-Circulation: necessary for oxygenated blood to reach the body's tissues
-Disability
-Exposure
cane instructions - -maintain two points of support on the ground at all times
-keep the cane on the stronger side of the body
-support body weight on both legs
-move the cane forward 15-25 cm
-move the weaker leg forward toward the cane
-advance the stronger leg past the cane
dehydration vital signs - -hypothermia (hypovolemia) or hyperthermia (dehydration)
-tachycardia
-thready pulse
-hypotension
-orthostatic hypotension
-decreased central venous pressure
-tachypnea (increased respirations)
-hypoxia
hypovolemia vital signs - -hypothermia
-tachycardia (attempting to maintain normal BP)
-thready pulse
-hypotension
-orthostatic hypotension
-decreased central venous pressure
-tachypnea (increased respirations to compensate for lack of fluid volume within the
body)
-hypoxia
implementation - -nurses base the care they provide on assessment data, analyses,
and the plan of care they developed in the previous steps of the nursing process
-therapeutic interventions also include measures nurses take to minimize risk
-nurses use evidence based-rationale for the selection and implementation of all
therapeutic interventions
-during implementation, nurses perform nursing actions, delegate tasks, supervise other
health care staff, and document the care and clients' responses
IV extravasation - the leak of a vesicant solution which can damage the tissues; prior to
regular treatment, the nurse must withdraw the solution from the client's IV access and
might need to administer an antidote prior to d/c'ing the IV access. Findings include
pallor, local swelling at the site, decreased skin temperature around the site, damp
dressing, or slowed rate of infusion
,RN ATI Capstone Fundamentals 2019
IV infiltration - the leak of a non-vesicant into the SC tissue
oxygen safety nursing actions - -post "no smoking" or "oxygen in use" signs to alert
others of the fire hazard
-know where to find the closest fire extinguisher
-educate about the fire hazard of smoking with oxygen use
-have clients wear a cotton gown because synthetic or wool fabrics can generate static
electricity
-ensure that all electric devices are working well
-make sure all electric machinery is grounded
-do not use volatile, flammable materials near clients receiving oxygen
pain assessment in clients with communication difficulties - -behaviors complement self-
report and assist in pain assessment of nonverbal clients
-facial expressions (grimacing, wrinkled forehead), body movements (restlessness,
pacing, guarding)
-moaning, crying
-decreased attention span
seizure positioning - maintain the pt in a side-lying position to prevent aspiration and to
facilitate drainage of oral secretions
sterility and moisture - -any sterile, non-waterproof wrapper that comes in contact with
moisture becomes non-sterile
-keep all surfaces dry
-discard any sterile packages that are torn, punctured, or wet
a charge nurse is assisting a newly licensed nurse with the preoperative assessment of
a 2 year old child who has a Wilm's tumor, what actions by the newly licensed nurse
requires intervention from the charge nurse - anspalpating the child's abdomen
a home health nurse is providing teaching about post-seizure management to the
parents of a school-age child who has epilepsy, what should be included - ansrecord
the length and character of the child's postictal period following a seizure
call for emergency medical services if the size of the child's pupils are unequal after the
seizure
a nurse in a pediatric clinic is discussing the physiology of Reye syndrome with a newly
licensed nurse, what statements by the newly licensed nurse indicates an
understanding of the disorder - ansReye's syndrome causes fatty changes in the liver
a nurse in a pediatric clinic is performing a history and physical for a toddler who is
going to receive a MMR immunization, what indicates that it should be withheld -
ansreceiving prednisone for nephrotic syndrome
, RN ATI Capstone Fundamentals 2019
a nurse in the ED is creating a plan of care for a child who has an acute head injury
following a fall from playground equipment, what interventions should the nurse include
- ansinitiate seizure precautions for the child
a nurse in the emergency department is caring for a preschooler who has epiglottitis ,
what action should the nurse take - ansinitiate droplet precautions for the child
a nurse is admitting a child who has bacterial meningitis, what actions should the nurse
take first - ansinitiate antibiotic therapy for the child
a nurse is assessing a 12m old infant who is immediately postop hernia repair surgery,
what pain measurement tools should the nurse use to determine if the infant is
experiencing pain - ansFLACC
a nurse is assessing a 3yr old preschooler at a well-child visit, what developmental
tasks should be expected - ansuses primarily two word phrases
a nurse is assessing a 5 month year old infant during a well-child visit, what finding
should the nurse report to the provider - ansthe infant does not make consonant sounds
when babbling
a nurse is assessing a 6 month old infant during a well-child visit, what finings should
the nurse report to the provider - ansthe infant does not roll over from his abdomen to
his back
a nurse is assessing a child who has acute renal failure, what clinical manifestations are
expected - ansedema
a nurse is assessing a child who has received the first 50 mL of a blood transfusion,
what findings indicates the child may be experiencing an air embolism - anssharp pain
in the middle of the chest
a nurse is assessing a child who has sickle cell anemia and is experiencing a
vasoocclusive crisis, what manifestations should the nurse expect - anspain
a nurse is assessing a toddler who has infective endocarditis, what findings should the
nurse expect - ansnew heart murmur
a nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5/101.3,
what findings should the nurse suspect a UTI - ansincontinence
a nurse is assessing an infant who has hydrocephalus, what clinical manifestations
should the nurse expect - ansseparated cranial sutures
a nurse is assessing an infant who has intussusception, what manifestation is expected
- ansgelatinous red stool
ABC(DE) framework - -Airway: necessary for breathing
-Breathing: necessary for oxygenation of the blood to occur
-Circulation: necessary for oxygenated blood to reach the body's tissues
-Disability
-Exposure
cane instructions - -maintain two points of support on the ground at all times
-keep the cane on the stronger side of the body
-support body weight on both legs
-move the cane forward 15-25 cm
-move the weaker leg forward toward the cane
-advance the stronger leg past the cane
dehydration vital signs - -hypothermia (hypovolemia) or hyperthermia (dehydration)
-tachycardia
-thready pulse
-hypotension
-orthostatic hypotension
-decreased central venous pressure
-tachypnea (increased respirations)
-hypoxia
hypovolemia vital signs - -hypothermia
-tachycardia (attempting to maintain normal BP)
-thready pulse
-hypotension
-orthostatic hypotension
-decreased central venous pressure
-tachypnea (increased respirations to compensate for lack of fluid volume within the
body)
-hypoxia
implementation - -nurses base the care they provide on assessment data, analyses,
and the plan of care they developed in the previous steps of the nursing process
-therapeutic interventions also include measures nurses take to minimize risk
-nurses use evidence based-rationale for the selection and implementation of all
therapeutic interventions
-during implementation, nurses perform nursing actions, delegate tasks, supervise other
health care staff, and document the care and clients' responses
IV extravasation - the leak of a vesicant solution which can damage the tissues; prior to
regular treatment, the nurse must withdraw the solution from the client's IV access and
might need to administer an antidote prior to d/c'ing the IV access. Findings include
pallor, local swelling at the site, decreased skin temperature around the site, damp
dressing, or slowed rate of infusion
,RN ATI Capstone Fundamentals 2019
IV infiltration - the leak of a non-vesicant into the SC tissue
oxygen safety nursing actions - -post "no smoking" or "oxygen in use" signs to alert
others of the fire hazard
-know where to find the closest fire extinguisher
-educate about the fire hazard of smoking with oxygen use
-have clients wear a cotton gown because synthetic or wool fabrics can generate static
electricity
-ensure that all electric devices are working well
-make sure all electric machinery is grounded
-do not use volatile, flammable materials near clients receiving oxygen
pain assessment in clients with communication difficulties - -behaviors complement self-
report and assist in pain assessment of nonverbal clients
-facial expressions (grimacing, wrinkled forehead), body movements (restlessness,
pacing, guarding)
-moaning, crying
-decreased attention span
seizure positioning - maintain the pt in a side-lying position to prevent aspiration and to
facilitate drainage of oral secretions
sterility and moisture - -any sterile, non-waterproof wrapper that comes in contact with
moisture becomes non-sterile
-keep all surfaces dry
-discard any sterile packages that are torn, punctured, or wet
a charge nurse is assisting a newly licensed nurse with the preoperative assessment of
a 2 year old child who has a Wilm's tumor, what actions by the newly licensed nurse
requires intervention from the charge nurse - anspalpating the child's abdomen
a home health nurse is providing teaching about post-seizure management to the
parents of a school-age child who has epilepsy, what should be included - ansrecord
the length and character of the child's postictal period following a seizure
call for emergency medical services if the size of the child's pupils are unequal after the
seizure
a nurse in a pediatric clinic is discussing the physiology of Reye syndrome with a newly
licensed nurse, what statements by the newly licensed nurse indicates an
understanding of the disorder - ansReye's syndrome causes fatty changes in the liver
a nurse in a pediatric clinic is performing a history and physical for a toddler who is
going to receive a MMR immunization, what indicates that it should be withheld -
ansreceiving prednisone for nephrotic syndrome
, RN ATI Capstone Fundamentals 2019
a nurse in the ED is creating a plan of care for a child who has an acute head injury
following a fall from playground equipment, what interventions should the nurse include
- ansinitiate seizure precautions for the child
a nurse in the emergency department is caring for a preschooler who has epiglottitis ,
what action should the nurse take - ansinitiate droplet precautions for the child
a nurse is admitting a child who has bacterial meningitis, what actions should the nurse
take first - ansinitiate antibiotic therapy for the child
a nurse is assessing a 12m old infant who is immediately postop hernia repair surgery,
what pain measurement tools should the nurse use to determine if the infant is
experiencing pain - ansFLACC
a nurse is assessing a 3yr old preschooler at a well-child visit, what developmental
tasks should be expected - ansuses primarily two word phrases
a nurse is assessing a 5 month year old infant during a well-child visit, what finding
should the nurse report to the provider - ansthe infant does not make consonant sounds
when babbling
a nurse is assessing a 6 month old infant during a well-child visit, what finings should
the nurse report to the provider - ansthe infant does not roll over from his abdomen to
his back
a nurse is assessing a child who has acute renal failure, what clinical manifestations are
expected - ansedema
a nurse is assessing a child who has received the first 50 mL of a blood transfusion,
what findings indicates the child may be experiencing an air embolism - anssharp pain
in the middle of the chest
a nurse is assessing a child who has sickle cell anemia and is experiencing a
vasoocclusive crisis, what manifestations should the nurse expect - anspain
a nurse is assessing a toddler who has infective endocarditis, what findings should the
nurse expect - ansnew heart murmur
a nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5/101.3,
what findings should the nurse suspect a UTI - ansincontinence
a nurse is assessing an infant who has hydrocephalus, what clinical manifestations
should the nurse expect - ansseparated cranial sutures
a nurse is assessing an infant who has intussusception, what manifestation is expected
- ansgelatinous red stool
