ATI Fundamentals Proctored 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 status
▪ Recognize trends and p...
ati fundamentals proctored exam review nursing process ati fundamentals ch 7 assessment data collection ▪ pt interview ▪ medical history ▪ physical assessment ▪ lab reports ▪ ss
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ATI Fundamentals Proctored 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 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
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