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Summary SAMMARRY NOTES FOR ATI FUNDAMENTALS CREATED BY DOCTOR FINDRANTEZ
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SAMMARRY NOTES FOR ATI FUNDAMENTALS CREATED BY DOCTOR FINDRANTEZ
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SAMMARRY NOTES FOR ATI FUNDAMENTALS CREATEDBY DOCTOR FINDRANTEZ
Providing oral care for an unconscious client requires careful attention to ensure safety and prevent
complications such as aspiration. Here are the steps a nurse should take:
1. **Prepare the Supplies**
- Gather all necessary supplies: oral swabs, toothbrush, toothpaste, a cup of water, a suction machine
with suction catheter or Yankauer suction tip, a towel, and a basin.
2. **Ensure Proper Positioning**
- Position the client on their side with their head turned to the side. This helps to prevent aspiration by
allowing fluids to drain out of the mouth.
- If the client cannot be turned on their side, raise the head of the bed to at least 30 degrees.
3. **Protect the Client's Clothing and Bedding**
- Place a towel or waterproof pad under the client’s head and neck to protect the bedding.
4. **Perform Hand Hygiene and Wear Gloves**
- Wash your hands thoroughly and put on gloves to maintain asepsis.
5. **Check the Client’s Mouth**
- Gently open the client’s mouth using a padded tongue blade if necessary.
- Inspect the mouth for any sores, dryness, or other abnormalities.
6. **Clean the Mouth**
- Moisten an oral swab with water or an appropriate solution (avoid alcohol-based solutions as they
can be drying).
- Gently clean the teeth, gums, and tongue using the swab.
, - Use a toothbrush with a small amount of toothpaste to brush the teeth if possible, being careful to
avoid stimulating the gag reflex.
7. **Suctioning to Prevent Aspiration**
- Use the suction machine to gently remove excess saliva and secretions from the mouth. Ensure the
suction catheter or Yankauer tip is used carefully to avoid causing trauma.
- Suction as needed throughout the procedure to keep the mouth clear of fluids.
8. **Moisturize the Lips and Mouth**
- Apply a water-soluble lubricant to the client’s lips to prevent dryness and cracking.
- If the mouth is very dry, you can also apply a moisturizing gel or solution to the mucous membranes
inside the mouth.
9. **Reposition the Client and Clean Up**
- Once the oral care is completed, ensure the client is comfortable and reposition them as necessary.
- Dispose of the used supplies properly, remove gloves, and perform hand hygiene.
10. **Document the Procedure**
- Record the oral care provided, including any findings such as sores or abnormalities, and the client's
response to the care.
Following these steps helps to ensure the safety and comfort of the unconscious client while providing
effective oral hygiene.
Using restraints, especially on a client, is a serious intervention that should be approached with caution
and in accordance with institutional policies and legal regulations. Here's what the nurse should do:
1. **Assess the Situation:** Before applying restraints, assess the client's behavior and the need for
restraints. Ensure that all other measures to prevent the client from pulling out the NG tube have been
exhausted.
,2. **Obtain Informed Consent:** If possible, obtain informed consent from the client or their legal
representative before applying restraints. Explain the reason for using restraints, the type of restraint
being used, and how it will be applied.
3. **Choose the Least Restrictive Option:** Select the least restrictive type of restraint necessary to
ensure the safety of the client and prevent harm. In this case, wrist restraints may be appropriate since
the client is attempting to remove the NG tube.
4. **Apply Restraints Correctly:** Follow proper procedure for applying restraints, ensuring they are
applied securely but not too tightly to avoid compromising circulation or causing injury. Position the
restraints so that the client is unable to reach the NG tube but can still move within reason.
5. **Monitor the Client Closely:** Once the restraints are applied, monitor the client closely for signs of
discomfort, circulation impairment, or emotional distress. Check the client's skin integrity frequently and
provide care for any areas of irritation.
6. **Document Carefully:** Document the use of restraints, including the reason for their use, the type
of restraint applied, the time they were applied, and ongoing assessments of the client's condition and
response to restraint use.
7. **Reassess and Remove Restraints Promptly:** Continuously reassess the need for restraints. As
soon as the client no longer requires them for safety, remove the restraints promptly and document
their removal.
8. **Provide Alternative Interventions:** Alongside restraints, implement alternative interventions to
address the client's behavior and needs, such as distraction techniques, therapeutic communication, or
adjusting the environment to promote comfort and safety.
Remember, the use of restraints should be a last resort and used only when absolutely necessary to
ensure the safety of the client or others. Always prioritize the client's dignity, autonomy, and well-being
when considering the use of restraints.
A nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate to
an assistive personnel?
a. Changing the dressing for a client who has a stage 3 pressure injury
b. Determining a client's response to a diuretic
, c. Comparing radial pulses for a client who is postoperative d.Providing postmortem care to a client -
ANSWER-d
A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the
following statements by the client indicates an understanding of the use of the supplements?
A. I take ginkgo biloba for a headache
B. I take echinacea to control my cholesterol
C. I use ginger when I get car sick
D. I use garlic for my menopausal symptoms - ANSWER-c
A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following
actions should the nurse take to prevent the spread of infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room.
D. Place the client in a negative airflow room. - ANSWER-a
A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which
of the following actions should the nurse take?
A. Attach the restraints securely to the side rails of the client's bed.
B. Apply the restraints to allow as little movement as possible
C.Allow room for two fingers to fit between the clients skin and the restraints
d. remove the restraints every 4 hours - ANSWER-c
A nurse is admitting a client who has tuberculosis. Which of the following types of transmission
precautions should the nurse plan to initiate?
A. Droplet
B. Airbornes
c. protective environment
d. contact - ANSWER-b
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