ATI Fundamentals Protcored Exam Review.

 Nursing Process- ATI Fundamentals Ch. 7  Assessment/ Data Collection  Pt. interview  Medical history  Physical assessment  Lab reports  S/S, feelings  Objective data  VS  Analysis  ID pt. health stat ...

 Nursing Process- ATI Fundamentals Ch. 7  Assessment/ Data Collection  Pt. interview  Medical history  Physical assessment  Lab reports  S/S, feelings  Objective data  VS  Analysis  ID pt. health status  Recognize trends and patterns  Planning  Nurse initiated/Independent Interventions  Provider-Initiated/Dependent interventions  Collaborative interventions  Establish priorities  Implementation  Base care according to data and plan of care  Use problem-solving and critical thinking  Minimize risks  Implement nursing action based on delegation  Evaluation  Evaluate client responses to interventions for form clinical judgement  See if goals are met  Determine effectiveness of nursing care plan Practice Question: A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process?  A. “I will determine the most important client problems that we should address.”  B. “I will review the past medical history on the client’s record to get more information.”  C. “I will go carry out the new prescriptions from the provider.”  D. “I will ask the client if his nausea has resolved.” Practice Question: By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?  A. Reassess the client to determine the reasons for inadequate pain relief.  B. Wait to see whether the pain lessens during the next 24 hr.  C. Change the plan of care to provide different pain relief interventions.  D. Teach the client about the plan of care for managing his pain   Medical and Surgical Sepsis- ATI Fundamentals Ch. 10  Hand Hygiene  PRIMARY BEHAVIOR!!!!!!  3 essential components (at least 15 seconds and up to 2 minutes if more soiled)  Soap  Water  Friction  Must perform hand hygiene with either soap and water or alcohol-based product  Alcohol based amount- usually 3-5mLs (rub until completely dry)  If visible soiled= soap and water (2 min)  Perform hand hygiene using recommended antiseptic solutions for immunocompromised or multi-drug resistant micro-organisms  Personal Protective Equipment (PPE):  Put on (or Don): Gown  Mask  Googles  Gloves  Take off (or Doff): Gloves  Googles  Gown  Mask  Physical Environment:  Do not place items on the floor (even soiled laundry)  Do not shake linens  can spread microorganisms in the air  Keep from touch clothing  keep away from you  Clean LEAST soiled areas FIRST  Use plastic bags for moist, soiled items  Place specimens in biohazard containers  Maintaining a Sterile Field:  Prolonged exposure to airborne micro-organisms can make sterile items nonsterile.  Avoid coughing, sneezing, and talking directly over a sterile field.  Ask patients to refrain from touching supplies  Only sterile items may be in a sterile field.  The outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile.  Touch sterile materials only with sterile gloves  Microbes can move by gravity from nonsterile item to a sterile item.  Do not reach across or above a sterile field.  Do not turn your back on a sterile field.  Hold items to add to a sterile field at a minimum of 6 inches above the field.  Any sterile, non-waterproof wrapper that encounters moisture becomes nonsterile  Keep all surfaces dry.  Discard any sterile packages that are torn, punctured, or wet.  Sterile Filed set up:  First  open flap or wrapper of packaging AWAY from you  Next  open SIDE flaps  Last  open last flap TOWARD your body Practice Question: A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.)  A. a bottle containing a sterile solution  B. The edge of the sterile drape at the base of the field  C. The inner wrapping of an item on the sterile field  D. An irrigation syringe on the sterile field  E. One gloved hand with the other gloved hand  Infection Control- ATI Fundamentals Ch. 11  Modes of transmission  Contact  Direct contact- person to person  Indirect contact- inanimate object to person  Fecal-oral transmission- handling food without washing hands after using a restroom and failing to wash hands  Droplet  Sneezing, coughing, and talking  Airborne  Sneezing and coughing  Vector-borne  Animal or insects (such as ticks with Lyme disease, mosquitos with West Nile Virus and Malaria)  Chain of Infection  Causative Agent  Reservoir  Portal of Exit  Mode of Transmission  Portal of entry  Susceptible host  Stages of Infection  Incubation  interval b/w pathogen entering the body and presentations of first finding  Prodromal  interval of onset of general findings to more distinct findings; pathogen multiplies  Illness  interval when findings specific to the infection occur  Convalescence  recovery  Isolation Precautions  Change PPE after contact with each client and between procedures with the same client  Standard Precautions (Tier 1)  Applies to all body fluids (except sweat), non-intact skin, and mucous membranes  Perform hand hygiene ALWAYS!!!!  Transmission Precautions (Tier 2)  Airborne precautions  Private room, masks and respiratory devices, negative pressure airflow exchange  T- N95 or high-efficiency particulate air (HEPA) respirator  Wear mask while outside of room  Measles, Varicella, TB  Droplet precautions  Droplets larger than 5 mcg and travel 3-6 ft  Haemophilus influenzae B, Rubella, Pertussis, Scarlet fever, mumps, mycoplasma pneumonia, sepsis  Private room with client with same infection  Masks for providers and visitors  Wear mask outside of room  Contact precautions  Within 3 ft of client against direct and environmental contact  RSV, Shigella, Herpes simplex, impetigo, Scabies, multi-drug resistant organisms-MRSA, enteric organisms- C-Diff (From GI)  Private room with other clients with same infection  Gloves and gown worn by caregivers and visitors  Protective precautions  To protect clients who are immunocompromised: stem cell transplant, chemo  Private room  Positive airflow 12 or more air exchanges/hr.  HEPA filter for incoming air  Mask for when patient is out of the room  Multidrug-resistant Infection:  Methicillin- resistant Staphylococcus aureus- MRSA  Resistant to many antimicrobials  Vancomycin and linezolid are used to treat MRSA  Vancomycin-resistant Staphylococcus aureus- VRSA  Resistant to Vancomycin  Other antimicrobials will work based on the specific strain  Herpes Zoster (Shingles)  Viral Infection  Initially produced by chicken pox after which the virus remains dormant  Re-activated as Shingles later in life  Has a prodromal period:  Pain- unilateral and extends horizontally along a dermatome  Tingling  Burning  Shingles may be very debilitating and painful  Older adults are more susceptible to herpes zoster  Nursing Care:  Assess pain, lesions, presence of fever, neuro. complications, signs of infection  Use air mattress or bed cradle for pain prevention to affected areas  Isolate the client until the vesicles have crusted over  Maintain strict wound care precautions  Avoid exposing client to infants, pregnant women who have not had chicken pox, immunocompromised clients  Anyone who has not had chicken pox and have not been vaccinated is at risk  Administer analgesics- NSAIDS, narcotics  Administer antiviral agents- acyclovir can shorten the course  Monitor for complications of Postherpetic neuralgia- pain lasting longer than 1 month  Isolation Guidelines- ATI Fundamentals Ch. 11  Isolation guidelines are a group of actions that include hand hygiene and the use of barrier precautions  Must be used whenever there is anticipation of contacting infectious material  Change PPE:  After contact with each client  In between procedures with the same client  If in contact with large amounts of blood and body fluids  Clients in isolation are at higher risk for depression and loneliness- provide sensory stimulation  Health Care Associated Infections- ATI Fundamentals Ch. 11  HAI’s are infections acquired while receiving care in the health care setting.  Formerly called “Nosocomial Infections”  Often occurs in the ICU  Best way to prevent HAIs is frequent and effective handwashing  Common sites:  UTI- E-Coli, Staph aureus, enterococci  Surgical wounds  Respiratory tract  Blood stream Practice Question: A client is 2 days postoperative following an appendectomy. While changing the linens on the client’s bed, the nurse notes drainage from an infected wound has soiled the bed sheet. The appropriate nursing action is to:  A. carefully place the soiled sheet in a moisture-resistant plastic bag  B. Spray the soiled sheet with a bleach solution  C. Roll up the soiled sheet and toss it directly into the laundry chute  D. Discard the sheet in an impervious trash bag  Safe Medication Administration and Error Reduction- ATI Fundamentals Ch. 47  Providers Responsibilities:  Obtain pt. medical history  Perform physical exam  Diagnosing  Prescribe medication  Monitor response to therapy  Modify medication prescription to therapy  Nomenclature:  Chemical Name  chemical composition  Generic Name  official or nonproprietary name  Trade Name  brand name  Unsafe prescription  Appropriate/ priority actions following a medication error  Routes of administration- intradermal, Z-track, TB test:  IV Intermittent IV bolus  IV catheter insertion:  Selecting an IV site  Medication reconciliation  Manifestations of allergic reactions  Mixing insulin  Evaluating appropriate use of herbal supplements  Priority action for handling defective equipment  Client Safety – ATI Fundamentals Ch. 12  Fall precautions:  Complete fall risk assessment on admission and regular intervals  Adequate lighting  Call light within reach  Assistive devices, if needed  Assign to nurses’ station  Hourly rounding  Frequently used item within reach  Bed in lowest position with brakes locked  Keep side rails up  Nonskid footwear and bathmats  Use gait belts  Keep clear path to bathroom  Seizure precautions:  Make sure equipment is at bedside  Maintain airway patency  Inspect environment and remove items that can harm patient  Assist with ambulation  DO NOT PUT ANYTHING IN CLIENTS MOUTH!!  Do not restrain patient  Lower to floor, put them on one side with head flexed  Wrap a blanket on all 4 sides of patient’s bed  Stay with client and call for help  Administer medication  Determine mental status  Measure VS and oxygenation  Document seizure  Home safety hazards  Place “No Smoking” sign  No smoking near oxygen  Do it outside  Ensure electrical equipment is in good repair and well grounded  Keep oxygen 8 feet away from gas stove  Replace bedding that can generate static electricity w/ items made from cotton  Keep flammable materials away from oxygen  Ergonomics- prevention of injury when lifting  Avoid injury when turning patients  Needle disposal  Handling defective equipment  Home safety  Older adult  Teaching client about home safety  Evaluating client understanding of home safety  Seclusion and restraints- in general use seclusion or restraints for the shortest duration necessary and only if less restrictive measures are not sufficient  Possible complications include- pneumonia, incontinence and pressure ulcers  Fire safety  R (rescue client), A (Alarm), C (Contain Fire), E (Extinguish)  Fire Extinguishers:  P (pull the pin), A (aim), S (squeeze), S (Sweep)  Classes of fire extinguishers:  Class A: combustibles such as paper, wood- trash fires  Class B: for flammable liquids and gas fires  Class C: electrical fires  Seclusion/Restraints- ATI Fundamentals Ch. 12  Can be physical (vest, belt, etc.) or chemical (sedatives)  Use only if less restrictive measures are not effective  Inappropriate use of seclusion or restraints:  Convenience of staff  Client extremely physically or mentally unstable  Punishment for the client  Clients who cannot tolerate the decreased stimulation of a seclusion room  Restraints should:  Never interfere with treatment  Restrict movement as little as necessary  Fit properly and be discreet  Be easily removed or changed  Alternatives to restraints:  Orientation to the environment  Supervision of a family member or sitter  Diversional activities  Electronic devices  Planning care for a client with a prescription for restraints:  Provider must complete a face to face assessment  Order must include reason, type, location, how long to use, type of behavior needing the restraints.  4hr of restraints  Adult  2hr  9-17 years of age  1hr  < 9 years of age  May renew these orders with a MAXIMUM of 24 consecutive hours  CANNOT have a PRN restraint order  In an emergency, nurses may place restraints but MUST get an order from provider ASAPusually within 1 hr.  Nursing Responsibilities:  Explain the need to client  Aske client or guardian for consent  Assess skin integrity every 2 hr., offer food and fluid, hygiene, elimination, monitor vitals, offer range of motion of extremities  Pad bony prominences  prevent skin breakdown  QUICK-RELEASE knot to movable part of bed frame  Fit 2 fingers between restraints and client  Remove or replace restraints frequently to ensure good circulation  Ongoing evaluation for the need for restraints  Never leave the client alone without the restraints  Document all the above Practice Question: A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?  A. “I will place the client on his side.”  B. “I will go to the nurses’ station for assistance.”  C. “I will administer his medications.”  D. “I will prepare to insert an airway.” Practice Question: A nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.)  A. Place a belt restraint on the client when he is sitting on the bedside commode.  B. Keep the bed in its lowest position with all side rails up.  C. Make sure that the client’s call light is within reach.  D. Provide the client with nonskid footwear.  E. Complete a fall-risk assessment.  Home Safety- ATI Fundamentals Ch. 13  Infants and toddlers:  Aspiration  Keep small objects out of reach  Check toys/objects for loose or sharp edges  Do not feed infant hard candy, peanuts, popcorn, sliced pieces of hot dog  Do not place infant in supine position wile feeding  Pacifier should only be one piece (no string or ribbon attached)  Suffocation  Teach “back to sleep” mnemonic  Keep plastic bags out of reach  Make sure crib mattress fit snugly  Do not place anything in the crib with infant  Remove crib toys  Fence swimming pools, begin swim lessons  CPR/Heimlich training  Keep toilet lids down  Poisoning  Keep houseplant/cleaning agents out of reach  Inspect/remove sources of lead (paint chips)  Have poison control hotline number available  Place poisons, paint, gasoline in locked cabinet  Lock up medications using child-proof containers  Dispose expired meds  Falls  Keep crib/playpen rails up  Never leave infant unattended on high surfaces (changing tables)  Use gates on stairs, windows have screens  Place in low bed when toddler starts to climb  Motor vehicle injury  Place infants/toddlers in a rear-facing car seat until 2 y/o  Car seat should have a 5-point harness  Place car seat in the back seat of car (safest)  Burns  Test temperature of formula and bath water  Place pots on back burner, turn handle away  Supervise use of faucets  Keep matches/lighters out of reach  Cover electrical outlets  Apply sunscreen SPF 30 or higher or protective clothing  Preschoolers and school-age:  Drowning  Be sure child knows how to swim  Wear life jacket  Implement buddy system  Have locked fences around pools  Supervision near pools and water  Motor vehicle injury  Use booster seats for children who are < 4 ft  Air bag in passenger seat  < 12 y/o in back seat  Use seat belts  Wear protective equipment (riding a bike, sports)  Road safety  Play in safe areas  Firearms  Keep firearms unloaded, locked up, and out of reach  Teach to never touch and gun  Store bullets in different location