ATI CMS FUNDAMENTALS FINAL PAPER
QUESTIONS AND CORRECT ANSWERS FULL
REVIEW GUIDE
●● 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
●● 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.
QUESTIONS AND CORRECT ANSWERS FULL
REVIEW GUIDE
●● 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
●● 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.
