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 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