A.T.I Fundamental, Complete Questions & Answers, Rated 100%-List four (4) examples of a primary skin lesion including description and example of each.
... [Show More] Provide an example of appropriate documentation of the integumentary system.
• Macule- nonpalpable, skin color change, smaller than 1 cm i.e freckle, petechia
• Papule- palpable circumscribed, solid skin smaller than 1cm i.e elevated nevus
• Nodule-palpable, circumscribed, deep, firm, 1 to 2 cm i.e wart
• Vesicle- serous fluid-filled smaller than 1cm I.e blisters herpes simplex varicella
• Appropriate documentation would be to include the size color elevation location distribution configuration tenderness fluid and drainage, measure the height width and depth of lesions.
Observe a lesion for any odor, exudate the amount and consistency of the exudate and document.
List three (3) actions to take during the analysis or data collection step.
• Observe
• Interviews
• Documentation
• Listening
• Measure
• interprete
A nurse is caring for an older adult client with dementia. What preventative measures should the nurse institute to reduce the risk of falls?
• Complete a fall risk assessment to the patient and at regular intervals
• Encourage the use of call light and be sure the resident knows how to use it.
• Respond to call light in a timely manner.
• Use a color-coded wrist band to indicate fall risk.
• Provide regular toileting and orientation.
• Remove rugs on the hallways and clear of clutter and make clear paths.
• Provide adequate light I,e night light
• Lace the client at risk for fall near nurses’ station
• Provide hourly rounding
• Make sure bedside tables, frequent use items like telephone water, facial tissue are within reach.
• Keep bed in low position and lock brakes
• Provide nonskid footwear and nonskid bathmats for use in tubs and showers
• Use electronic safety monitoring devices.
A nurse is providing discharge education to a client regarding home wound care. What manifestations of wound infection should the nurse include in this education?
• Pain around the wound
• Swelling around the wound
• Tenderness greenish yellow wound drainage
• Redness around the wound
• High fever and hotness around the wound.
A client has been diagnosed with Varicella. What type of tier transmission precaution is required? What protective equipment will be required for prevention of transmission?
• Airborne precautions
• Require private room, mask for respiratory protection for care givers and visitors, gloves mask gown googles if there is splashing or spraying, negative pressure air flow, and client should wear
mask out of room.
List at least five (5) priority considerations when performing a sterile dressing change.
• Identify latex allergies and use items that use items that are latex free
• Always use hand hygiene, wash hands with antimicrobial or plain soap and water
• Use ppe like mask, gloves, gowns and protective eyewear to help control the contact and spread of micro organism
• Avoid coughing, sneezing and talking directly over sterile field.
• Advise clients to avoid sudden movements or refrain from toucing supplies, drape or the nurses gloves and gown [Show Less]