ATI Fundamentals Proctored Exam Review

Practice Question: A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. “I will determine the most important client problems that we should address.” B. “I will review the past medical history on the client’s record to get more information.” C. “I will go carry out the new prescriptions from the provider.” D. “I will ask the client if his nausea has resolved.” Practice Question: By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain Medical and Surgical Sepsis- ATI Fundamentals Ch. 10 Hand Hygiene  PRIMARY BEHAVIOR!!!!!! 3 essential components (at least 15 seconds and up to 2 minutes if more soiled) ▪ Soap ▪ Water ▪ Friction Must perform hand hygiene with either soap and water or alcohol-based product Alcohol based amount- usually 3-5mLs (rub until completely dry) If visible soiled= soap and water (2 min) Perform hand hygiene using recommended antiseptic solutions for immunocompromised or multi-drug resistant micro-organisms Personal Protective Equipment (PPE): ▪ Put on (or Don): Gown  Mask  Googles  Gloves ▪ Take off (or Doff): Gloves  Googles  Gown  Mask Physical Environment: ▪ Do not place items on the floor (even soiled laundry) ▪ Do not shake linens  can spread microorganisms in the air • Keep from touch clothing  keep away from you ▪ Clean LEAST soiled areas FIRST ▪ Use plastic bags for moist, soiled items ▪ Place specimens in biohazard containers Maintaining a Sterile Field: ▪ Prolonged exposure to airborne micro-organisms can make sterile items nonsterile. • Avoid coughing, sneezing, and talking directly over a sterile field. • Ask patients to refrain from touching supplies ▪ Only sterile items may be in a sterile field. • The outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile. • Touch sterile materials only with sterile gloves ▪ Microbes can move by gravity from nonsterile item to a sterile item. • Do not reach across or above a sterile field. • Do not turn your back on a sterile field. • Hold items to add to a sterile field at a minimum of 6 inches above the field. ▪ Any sterile, non-waterproof wrapper that encounters moisture becomes nonsterile • Keep all surfaces dry. • Discard any sterile packages that are torn, punctured, or wet. Sterile Filed set up: ▪ First  open flap or wrapper of packaging AWAY from you ▪ Next  open SIDE flaps ▪ Last  open last flap TOWARD your body Practice Question: A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. a bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand Infection Control- ATI Fundamentals Ch. 11 Modes of transmission ▪ Contact • Direct contact- person to person • Indirect contact- inanimate object to person • Fecal-oral transmission- handling food without washing hands after using a restroom and failing to wash hands ▪ Droplet • Sneezing, coughing, and talking ▪ Airborne • Sneezing and coughing ▪ Vector-borne • Animal or insects (such as ticks with Lyme disease, mosquitos with West Nile Virus and Malaria) Chain of Infection ▪ Causative Agent  Reservoir  Portal of Exit  Mode of Transmission  Portal of entry  Susceptible host Stages of Infection ▪ Incubation  interval b/w pathogen entering the body and presentations of first finding ▪ Prodromal  interval of onset of general findings to more distinct findings; pathogen multiplies ▪ Illness  interval when findings specific to the infection occur ▪ Convalescence  recovery Isolation Precautions ▪ Change PPE after contact with each client and between procedures with the same client Standard Precautions (Tier 1) ▪ Applies to all body fluids (except sweat), non-intact skin, and mucous membranes ▪ Perform hand hygiene ALWAYS!!!! Transmission Precautions (Tier 2) ▪ Airborne precautions • Private room, masks and respiratory devices, negative pressure airflow exchange • T- N95 or high-efficiency particulate air (HEPA) respirator • Wear mask while outside of room ◆ Measles, Varicella, TB ▪ Droplet precautions • Droplets larger than 5 mcg and travel 3-6 ft ◆ Haemophilus influenzae B, Rubella, Pertussis, Scarlet fever, mumps, mycoplasma pneumonia, sepsis • Private room with client with same infection • Masks for providers and visitors • Wear mask outside of room ▪ Contact precautions • Within 3 ft of client against direct and environmental contact • RSV, Shigella, Herpes simplex, impetigo, Scabies, multi-drug resistant organisms-MRSA, enteric organisms- C-Diff (From GI) • Private room with other clients with same infection • Gloves and gown worn by caregivers and visitors ▪ Protective precautions • To protect clients who are immunocompromised: stem cell transplant, chemo • Private room • Positive airflow 12 or more air exchanges/hr. • HEPA filter for incoming air • Mask for when patient is out of the room Multidrug-resistant Infection: ▪ Methicillin- resistant Staphylococcus aureus- MRSA • Resistant to many antimicrobials • Vancomycin and linezolid are used to treat MRSA ▪ Vancomycin-resistant Staphylococcus aureus- VRSA • Resistant to Vancomycin • Other antimicrobials will work based on the specific strain Herpes Zoster (Shingles) ▪ Viral Infection ▪ Initially produced by chicken pox after which the virus remains dormant ▪ Re-activated as Shingles later in life ▪ Has a prodromal period: • Pain- unilateral and extends horizontally along a dermatome • Tingling • Burning ▪ Shingles may be very debilitating and painful ▪ Older adults are more susceptible to herpes zoster ▪ Nursing Care: • Assess pain, lesions, presence of fever, neuro. complications, signs of infection • Use air mattress or bed cradle for pain prevention to affected areas • Isolate the client until the vesicles have crusted over • Maintain strict wound care precautions • Avoid exposing client to infants, pregnant women who have not had chicken pox, immunocompromised clients • Anyone who has not had chicken pox and have not been vaccinated is at risk • Administer analgesics- NSAIDS, narcotics ▪ Administer antiviral agents- acyclovir can shorten the course ▪ Monitor for complications of Postherpetic neuralgia- pain lasting longer than 1 month Isolation Guidelines- ATI Fundamentals Ch. 11 Isolation guidelines are a group of actions that include hand hygiene and the use of barrier precautions Must be used whenever there is anticipation of contacting infectious material Change PPE: ▪ After contact with each client ▪ In between procedures with the same client ▪ If in contact with large amounts of blood and body fluids Clients in isolation are at higher risk for depression and loneliness- provide sensory stimulation Health Care Associated Infections- ATI Fundamentals Ch. 11 HAI’s are infections acquired while receiving care in the health care setting. Formerly called “Nosocomial Infections” Often occurs in the ICU Best way to prevent HAIs is frequent and effective handwashing Common sites: ▪ UTI- E-Coli, Staph aureus, enterococci ▪ Surgical wounds ▪ Respiratory tract ▪ Blood stream Practice Question: A client is 2 days postoperative following an appendectomy. While changing the linens on the client’s bed, the nurse notes drainage from an infected wound has soiled the bed sheet. The appropriate nursing action is to: A. carefully place the soiled sheet in a moisture-resistant plastic bag B. Spray the soiled sheet with a bleach solution C. Roll up the soiled sheet and toss it directly into the laundry chute D. Discard the sheet in an impervious trash bag Safe Medication Administration and Error Reduction- ATI Fundamentals Ch. 47 Providers Responsibilities: ▪ Obtain pt. medical history ▪ Perform physical exam ▪ Diagnosing ▪ Prescribe medication ▪ Monitor response to therapy ▪ Modify medication prescription to therapy Nomenclature: ▪ Chemical Name  chemical composition ▪ Generic Name  official or nonproprietary name ▪ Trade Name  brand name Unsafe prescription Appropriate/ priority actions following a medication error Routes of administration- intradermal, Z-track, TB test: ▪ IV Intermittent IV bolus IV catheter insertion: ▪ Selecting an IV site Medication reconciliation Manifestations of allergic reactions Mixing insulin Evaluating appropriate use of herbal supplements Priority action for handling defective equipment Client Safety – ATI Fundamentals Ch. 12 Fall precautions: ▪ Complete fall risk assessment on admission and regular intervals ▪ Adequate lighting ..............................................................................................CONTINUE