ATI proctored final exam
How can an RN delegate surgical aesepsis responsibilities to UAP's? - ✅✅ -As the
circulating nurse, the RN can have UAPs under her supervision involved in activities
requiring surgical asepsis. On the unit, situations requiring surgical asepsis are not
delegated to UAP.
✅✅
How can an RN delegate transmission-based precaution responsibilities to UAP's? -
-The RN can delegate care of a client requiring precautions to UAP. The nurse
cannot delegate the assessment of need for precautions, evaluation of effectiveness
of client compliance with precautions, or teaching of client & family member's
precaution techniques. The nurse delegating care of an isolated client should be
sure the UAP knows appropriate procedures.
✅✅
When should traditional hand washing be used instead of using alcohol-based
sanitizer? - -When hands are visibly soiled
After touching bodily fluids
Before and after applying sterile gloves
After using sanitizer 10 or more times
Contradictions of good hand hygiene - ✅✅-Nail polish
Long nails
Using lotions
Wearing jewelry
Which of the following is a potential route of entry into the body for bloodborne
pathogens:
a. Mucous membranes
b. Puncture wounds
c. Burns on hands
✅✅
d. Blood
e. All of the above - -E. All of the above
✅✅
Personal Protective Equipment is the single most effective way to prevent the
transmission of infection. (TRUE or FALSE) - -True
Two potential sites for nosocomial infections: - ✅✅-1. A hospital
2. Homecare
Potential causes of nosocomial infections: - ✅✅ -1. Pt has suppressed immune
system
2. Failure to follow isolation precautions or aseptic technique
3. Hospital error
,You are assisting in the evaluation of a pt with acute onset of severe headache, fever
and some confusion. The physician is preparing to perform a lumbar puncture. The
✅✅
suspected diagnosis is bacterial meningitis. What type of precaution is needed? -
-Standard precautions
A 70 y. male develops new diarrhea and a high WBC while in the hospital recovering
from MV Replacement surgery which was complicated by a CVA. He is bed bound
✅✅
and incontinent of stool. What do you suspect is the cause for his diarrhea? -
-A bacterial, nosocomial infection
Medical abbreviation: CBR, BR - ✅✅-complete bedrest, bedrest
✅✅
T/F: Frequent bathing for the older client is necessary to prevent skin breakdown. -
-False
✅✅
A ____ bath can be helpful in soaking a client's pelvic area in warm water to
decrease inflammation. - -sitz
✅✅
List at least three guidelines for providing patient-centered care when addressing a
client's hygiene needs - -Be respectful to cultural values.
Ask the pt in what order they would like to complete their hygiene routine.
Provide hygienic care as often as necessary (but not too often) and as gently as
necessary.
What should be included in documentation of a bath? - ✅✅-Date and time
Type of bath
Abnormal findings/pt reaction
When might the RN need to collaborate a colleague for personal care? - ✅✅-If a
patient is not ambulatory and is too heavy to be moved alone
✅✅
What are the components of the Braden scale?
Is a high score good or bad? - -Sensory perception, moisture, activity, mobility,
nutrition, friction & shear
High score indicates low risk.
Trochanter roll -✅✅-Keeps hips in a neutral position
Hemiparesis - ✅✅-Weakness on one sign of the body
Hemiplegia - ✅✅-Paralysis on one side of the body
Prone position - ✅✅-Lying on the abdomen
, Sim's position -✅✅-Lying on left side w/ left leg straight and right knee bent
Foot drop - ✅✅-Gait w/ drop of the forefoot
Fracture pan - ✅✅-A bedpan used for someone w/ a hip fracture
Fecal impaction - ✅✅-Dry, hard stool stuck in the rectum
Hand roll - ✅✅-Hand placed in the palm to prevent fractures
Medical abbreviation: WNL - ✅✅-Within normal limits
Medical abbreviation: BRP - ✅✅-bathroom privileges
Medical abbreviation: BUS - ✅✅-Bladder ultrasonic scanner
Factors to consider when delegating to UAP - ✅✅-Scope of practice
Facility, state regulations
Level of experience
Pt safety
Hazards of immobility on CV system & interventions - ✅✅-DVT: elastic stockings,
SCD's
Orthostatic BP: give pt time btwn position changes
Hazards of immobility on pulmonary system & interventions - ✅✅ -PE: TED host
Inadequate expansion of the chest: place pt in orthopneic position
Pneumonia: clean/sterile technique, pneumovax
Intervention for each: early and frequent ambulation
Hazards of immobility on renal system & interventions - ✅✅ -UTI, problems with
continence, altered BP: monitor I/O's, assist w/ voiding as needed
Hazards of immobility on integumentary system & interventions - ✅✅ -Skin
breakdown: repositioning, monitor nutrition status, reduce mositure, provide hygiene
care
Hazards of immobility on musculoskeletal system & interventions - ✅✅-Stiff joints:
ROMs/ambulation
Muscle atrophy: ROMs/ambulation
Ca2+ imbalance: nutrition measures
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