ATI - FUNDAMENTALS PRACTICE
QUIZ
SAFTEY IS BIG ON THIS ATI!
Factors that affect the patient's ability to protect
themselves - ANSWER-- Age
- Mobility
- Cognitive and sensory awareness
- Emotional state
- Ability to communicate
- Lifestyle
- Safety Awareness
Eye Charts - ANSWER-1. Snellen
- Stand 20 ft away
2. Rosenbaum
- Stand 14 inches away
,Fall Risk - ANSWER-- Decreased visual acuity
- Generalized weakness
- Urinary frequency
- Gait and balance problems (Cerebral palsy, MS,
Parkinsons)
- Cognitive dysfunction
- Medication side effects
Seizure precautions - ANSWER-- Have oxygen, suction,
oral airway at bedside
- Padded side rails
- Saline locked IV for immediate access (High risk
patients)
- Rapid intervention to maintain airway patency.
- Clutter free environment
- Make sure everyone (family too) knows that if pt. has a
seizure, to not put anything in their mouth during seizure.
*Only thing that would go in mouth during seizure is airway
for status epilepticus.
- During seizure do not restrain pt. Lower pt. to floor or bed
and protect pt. head. Remove nearby furniture. Put patient
on side with head flexed slightly forward if possible and
loosen his clothing.
How would you help prevent falls for a patient with
orthostatic hypotension? - ANSWER-- Avoid getting up to
quickly
- Sit on the side of the bed for a few seconds prior to
standing
- Stand at the side of the bed a few seconds prior to
walking
,Seclusion and Restraints - ANSWER-- When everything
else fails (orientation to environment, family member,
sitter, diversional activities, electronic devices) is when
you use restraints.
- Provider must prescribe after seeing the patient face to
face
Provider prescription for restraints must include what? -
ANSWER-- Reason for restraints
- Type of restraints
- Location of restraints
- How long to use restraints
- Type of behavior that warrants restraints
- *Prescription only last 4 hours for an adult. Providers
may renew these prescriptions with a maximum of 24
consecutive hours.*
Restraints in an emergency situation - ANSWER-- When
there is an immediate risk to the patient or others, nurses
may place restraints on patient.
- The nurse must then obtain a prescription from the
provider ASAP, usually within 1 hour.
Nursing Responsibilities for patients in restraints -
ANSWER-- Explain the need for restraints to pt. and
family. They are for safety and are temporary.
- Ask pt. or guardian to sign consent form.
, - Assess skin integrity and provide skin care according to
hospital protocol, usually Q2.
- Offer fluid and food.
- Provide means for hygiene and elimination.
- Monitor Vitals
- Offer range of motion exercises of extremities.
- Pad bony prominences to prevent skin breakdown.
- Use quick release knot to tie the restraints to the bed
frame where they will not tighten when raising or lowering
the bed.
- Fit 2 fingers b/w restraints and patient.
- Remove or replace restraints frequently to ensure good
circulation to the area and allow for full range of motion to
the limbs.
- Never leave pt. alone without restraints.
Fire Response - RACE - ANSWER-R - *Rescue* and
protect patients close to fire by moving them to a safer
location. Let patients who can walk, walk.
A - *Alarm* Activate alarm
QUIZ
SAFTEY IS BIG ON THIS ATI!
Factors that affect the patient's ability to protect
themselves - ANSWER-- Age
- Mobility
- Cognitive and sensory awareness
- Emotional state
- Ability to communicate
- Lifestyle
- Safety Awareness
Eye Charts - ANSWER-1. Snellen
- Stand 20 ft away
2. Rosenbaum
- Stand 14 inches away
,Fall Risk - ANSWER-- Decreased visual acuity
- Generalized weakness
- Urinary frequency
- Gait and balance problems (Cerebral palsy, MS,
Parkinsons)
- Cognitive dysfunction
- Medication side effects
Seizure precautions - ANSWER-- Have oxygen, suction,
oral airway at bedside
- Padded side rails
- Saline locked IV for immediate access (High risk
patients)
- Rapid intervention to maintain airway patency.
- Clutter free environment
- Make sure everyone (family too) knows that if pt. has a
seizure, to not put anything in their mouth during seizure.
*Only thing that would go in mouth during seizure is airway
for status epilepticus.
- During seizure do not restrain pt. Lower pt. to floor or bed
and protect pt. head. Remove nearby furniture. Put patient
on side with head flexed slightly forward if possible and
loosen his clothing.
How would you help prevent falls for a patient with
orthostatic hypotension? - ANSWER-- Avoid getting up to
quickly
- Sit on the side of the bed for a few seconds prior to
standing
- Stand at the side of the bed a few seconds prior to
walking
,Seclusion and Restraints - ANSWER-- When everything
else fails (orientation to environment, family member,
sitter, diversional activities, electronic devices) is when
you use restraints.
- Provider must prescribe after seeing the patient face to
face
Provider prescription for restraints must include what? -
ANSWER-- Reason for restraints
- Type of restraints
- Location of restraints
- How long to use restraints
- Type of behavior that warrants restraints
- *Prescription only last 4 hours for an adult. Providers
may renew these prescriptions with a maximum of 24
consecutive hours.*
Restraints in an emergency situation - ANSWER-- When
there is an immediate risk to the patient or others, nurses
may place restraints on patient.
- The nurse must then obtain a prescription from the
provider ASAP, usually within 1 hour.
Nursing Responsibilities for patients in restraints -
ANSWER-- Explain the need for restraints to pt. and
family. They are for safety and are temporary.
- Ask pt. or guardian to sign consent form.
, - Assess skin integrity and provide skin care according to
hospital protocol, usually Q2.
- Offer fluid and food.
- Provide means for hygiene and elimination.
- Monitor Vitals
- Offer range of motion exercises of extremities.
- Pad bony prominences to prevent skin breakdown.
- Use quick release knot to tie the restraints to the bed
frame where they will not tighten when raising or lowering
the bed.
- Fit 2 fingers b/w restraints and patient.
- Remove or replace restraints frequently to ensure good
circulation to the area and allow for full range of motion to
the limbs.
- Never leave pt. alone without restraints.
Fire Response - RACE - ANSWER-R - *Rescue* and
protect patients close to fire by moving them to a safer
location. Let patients who can walk, walk.
A - *Alarm* Activate alarm
