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 Nursing Process- ATI Fundamentals Ch. 7  Assessment/ Data Collection  Pt. interview  Medical history  Physical assessment  Lab reports  S/S, feelings  Objective data  VS  Analysis  ID pt. health status  Recognize trends and patterns  Planning  ...

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  • June 27, 2022
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  • 2021/2022
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ATI Fundamentals Proctored Exam Review


 Nursing Process- ATI Fundamentals Ch. 7
 Assessment/ Data Collection
 Pt. interview
 Medical history
 Physical assessment
 Lab reports
 S/S, feelings
 Objective data  VS
 Analysis
 ID pt. health status
 Recognize trends and patterns
 Planning
 Nurse initiated/Independent Interventions
 Provider-Initiated/Dependent interventions
 Collaborative interventions
 Establish priorities
 Implementation
 Base care according to data and plan of care
 Use problem-solving and critical thinking
 Minimize risks
 Implement nursing action based on delegation
 Evaluation
 Evaluate client responses to interventions for form clinical judgement
 See if goals are met
 Determine effectiveness of nursing care plan

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

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