ATI Content Mastery Fundamentals Exam Q & A Verified 100% Correct!!

ATI Content Mastery Fundamentals Exam Q & A Verified 100% Correct!! Advance directives- teaching Communicates the client wishes regarding end of life care; are written before a client becomes ill Nurses role is to provide info about advance directives Document client's advance directive status Ensure advance directives reflects clients current decision Inform all members of the healthcare team of the client's advanced directives Culture (client who speaks a different language) Use an interpreter always; try to get someone around same age and gender as client Delegation to UAP Stable/chronic clients; post-mortem care; they cannot teach, assessed, or evaluate Ethical (client need for information about treatment) Provide client with truthful information so they can make an informed decision about their own health and well-being Discharge planning Determine ability to afford insulin and supplies Make sure he has transportation to follow up appointments Informed consent Nurses role is to witness the client signature and ensure that the provider has obtained the informed consent responsibly Greater than 18 years of age or if the mother or father is a teenage parent they have the right to sign the consent form Client inquiry about surgery Consult health care provider/surgeon for procedures/informed consent questions Telephone prescriptions are Must write the order down before reading it back to the provider Identify Improper documentation Documenting should be factual Subjective data documentation Quotes with quotation marks- what the client states to the nurse Objective data documentation What the nurses, smells, osculates do not use derogatory words, judgment, or opinions Intentional tort Doing harm (The act must be intentional, not merely reckless or careless) Assault, battery, false imprisonment, invasion of privacy, slander Interprofessional team member consult PT- consulted for mobility issues OT- assist clients to regain ADL skills ST- Deals with speech and language disorders Coordinated client care among healthcare team Social worker- Coordinates care and community resources Demonstrating client advocacy Nurses role is to provide support of the clients health, wellness, safety, and personal rights, including privacy Nursing role- client observation Share appropriate information among team members Prioritizing client care Follow ABC's (airway, breathing, circulation) Unstable are seen before stable clients Acute clients are seen before chronic clients Ethical dilemma Follow autonomy, beneficence, Fidelity, justice, nonmaleficence, and veracity principles Disposition of valuables (Admit/transfer/DC) Personal items include clothing, jewelry, money, credit cards, hearing aides, eyeglasses, dentures, etc Discourage the client from keeping valuables at bedside Document communication with the client related to items left within the room Valuables should be locked in the facilities safe Identify negligence Failure to provide care as defined by a standard Breach of duty Foreseeability of harm Caused harm Latex allergy Schedule first on the morning operating list (OR must be free from powdered latex gloves for at least 3 hours prior to surgery) Synthetic gloves must be used Furniture in operating room equipment must be washed down using synthetic gloves only Anything containing latex must be removed from the OR Seizure precautions Remember to maintain the airway and keep the client safe from harm Oral airway and oral suction equipment Oxygen supplies Padding for side rails IV access Client identifiers Name, date of birth, medical record number, photograph Home safety- teaching Nonskid footwear Adequate lighting Remove clutter/environmental hazards Keep devices nearby (walker, eyeglasses) Place cords next to walls or behind furniture Preparing sterile field Only touch 1 in border Only touch sterile field with sterile gloves Keep sterile field above the waist Do not reach across sterile field Do not turn your back to the sterile field Hold items to add to a sterile field and a minimum of 6 inches above the field When pouring sterile solution whole bottle with the label in the palm of the hand so the solution does not run down the label Multidrug resistant infections Private room Precautions positive airflow room with 12 or more exchanges per hour Mask for client went outside the room Culture prior to administering antibiotics Monitor antibiotic levels and ensure they are therapeutic Teach clients a complete full course of antibiotics Allergenic stem cell transplant teaching Place in a private room Use protective equipment Positive pressure room with 12 or more airflow changes per hour Caring for a client requiring a restraint Least restrictive Remove every 3 to 4 hours Secure with a quick release knot such as a slipknot Tie to bedframe (not bed rail) Assess client every 2 hours or per facility protocol for toileting/nutritional needs and skin assessment Regularly determine the need for continuing the restraints Remove as soon as client no longer requires being restrained If using a wrist restraints allow for two fingers to fit between skin and restraint Isolation precautions Private room Always remove gloves first when removing PPE If contact precautions positive airflow room with 12 or more exchanges per hour (shingles, wound infections, multi drug resistant organisms) Handling defective equipment Unplug and remove from clients room first Tag for repair Webers test Place a vibrating tuning fork on top of the clients head. Ask the client whether they can hear the sound best in the right or left ear, or both ears equally If the client hears the sound in both ears equally that this is a negative Weber test Common Abbreviations Okay to use: BRP- bathroom privileges NPO- nothing by mouth See page 280 in ATI fundamentals book For abbreviations not to use Priority action following missed provider order Ensure client is safe and without complications from missing order Notify supervisor and start an incident report Disposing biohazard waste Protect self and avoid contact with biohazardous waste Identify hazardous material Follow MSDS guidelines for disposal Wear PPE If skin is exposed to biohazard waste wash skin with copious amounts of water and antibacterial soap Remove any contaminated clothing Place all contaminated materials into a large plastic bag and seal them Situation requiring incident report Any incident that caused harm or can cause potential harm to a client; administering meds without order, giving incorrect medication, if using too much IV fluid, fall, treatment to incorrect client Caring for a client who is immunocompromised Use frequent hand hygiene before and after care Use aseptic technique and proper PPE Properly clean all equipment for client care Goal is to prevent infection Precautions for client with influenza Droplet precautions Private room Masks for providers and visitors TB precautions Airborne N-95 masks Negative pressure airflow At least 6-12 exchanges per hour Teaching home care oxygen use Place "no smoking" signs near front door and clients bedroom Inform client/caregivers of dangers of smoking when oxygen is in use