ATI Fundamentals Exam Questions and Answers
Save
Terms in this set (244)
1. Snellen
- Stand 20 ft away
Eye Charts
2. Rosenbaum
- Stand 14 inches away
- Age
SAFTEY IS BIG ON THIS - Mobility
ATI! - Cognitive and sensory awareness
Factors that affect the - Emotional state
patient's ability to protect - Ability to communicate
themselves - Lifestyle
- Safety Awareness
- Decreased visual acuity
- Generalized weakness
- Urinary frequency
Fall Risk - Gait and balance problems (Cerebral palsy, MS,
Parkinsons)
- Cognitive dysfunction
- Medication side effects
, - 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
Seizure precautions
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.
- Avoid getting up to quickly
How would you help
- Sit on the side of the bed for a few seconds prior to
prevent falls for a patient
standing
with orthostatic
- Stand at the side of the bed a few seconds prior to
hypotension?
walking
- When everything else fails (orientation to
environment, family member, sitter, diversional
activities, electronic devices) is when you use
Seclusion and Restraints
restraints.
- Provider must prescribe after seeing the patient face
to face
- Reason for restraints
- Type of restraints
- Location of restraints
Provider prescription for - How long to use restraints
restraints must include - Type of behavior that warrants restraints
what?
- Prescription only last 4 hours for an adult.
Providers may renew these prescriptions with a
maximum of 24 consecutive hours.
, - When there is an immediate risk to the patient or
others, nurses may place restraints on patient.
Restraints in an
emergency situation
- The nurse must then obtain a prescription from the
provider ASAP, usually within 1 hour.
- 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
Nursing Responsibilities
- Offer range of motion exercises of extremities.
for patients in restraints
- 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.
Save
Terms in this set (244)
1. Snellen
- Stand 20 ft away
Eye Charts
2. Rosenbaum
- Stand 14 inches away
- Age
SAFTEY IS BIG ON THIS - Mobility
ATI! - Cognitive and sensory awareness
Factors that affect the - Emotional state
patient's ability to protect - Ability to communicate
themselves - Lifestyle
- Safety Awareness
- Decreased visual acuity
- Generalized weakness
- Urinary frequency
Fall Risk - Gait and balance problems (Cerebral palsy, MS,
Parkinsons)
- Cognitive dysfunction
- Medication side effects
, - 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
Seizure precautions
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.
- Avoid getting up to quickly
How would you help
- Sit on the side of the bed for a few seconds prior to
prevent falls for a patient
standing
with orthostatic
- Stand at the side of the bed a few seconds prior to
hypotension?
walking
- When everything else fails (orientation to
environment, family member, sitter, diversional
activities, electronic devices) is when you use
Seclusion and Restraints
restraints.
- Provider must prescribe after seeing the patient face
to face
- Reason for restraints
- Type of restraints
- Location of restraints
Provider prescription for - How long to use restraints
restraints must include - Type of behavior that warrants restraints
what?
- Prescription only last 4 hours for an adult.
Providers may renew these prescriptions with a
maximum of 24 consecutive hours.
, - When there is an immediate risk to the patient or
others, nurses may place restraints on patient.
Restraints in an
emergency situation
- The nurse must then obtain a prescription from the
provider ASAP, usually within 1 hour.
- 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
Nursing Responsibilities
- Offer range of motion exercises of extremities.
for patients in restraints
- 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.
