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
Written for
ATI Fundamentals
All documents for this subject (4357)
Seller
Follow
NURSEREP
Reviews received
Content preview
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
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller NURSEREP. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $16.49. You're not tied to anything after your purchase.
