ATI - Predictor Study Notes (updated 2020) – Rasmussen College | ATI - Predictor Study Notes (updated 2020)

ATI - Predictor Study Notes (updated 2020) – Rasmussen College 
 ATI – NCLEX Predictor Remediation Study Notes Renal Calculi - Pain: Flank pain → Kidney or Ureter (if pain radiates → stones in ureter or bladder) ...

ATI - Predictor Study Notes (updated 2020) – Rasmussen College 
 ATI – NCLEX Predictor Remediation Study Notes Renal Calculi - Pain: Flank pain → Kidney or Ureter (if pain radiates → stones in ureter or bladder) Performing Ear Irrigation: Sterile technique, warm meds, pull up & back, tilt toward affected ear Thrombolytic Therapy (Stroke): Reteplase recombinant (rTPA – clot buster) w/ in 4.5 hours of initial symptoms Trach care: Dressing ∆, inner cannula ½ hydrogen peroxide, & stoma □ knot Head injury (changes in LOC): Length of time unconscious & GCS General anesthesia (post-op): ABC’s – full body assessment, Vitals every 15 minutes, Lateral position (if unresponsive or unconscious - monitor LOC), Fluids/Electrolytes Superficial Burns: Painful, pink, red, mild edema (3-6 day healing), damage to epidermis Dialysis (reporting unexpected findings): Temp of 100 degrees, ↓ BP, bleeding, 1 L of fluid = 1Kg, clotting, H/A, Nausea, Disequilibrium syndrome (rapid ↓ BUN & Fluid volume), anemia, peritonitis, ↑ BG, ↑ cholesterol Pacemaker (complications): Infection, hematoma, pneumothorax, hemo-thorax, arrhythmias, pacer spikes before P or QRS, hiccups / muscle twitching Magnesium (Mg) Sulfate → Increase Mg+ > 1.3 Mg/dL
 ↑ Mg foods = (Dairy, dark leafy greens veges)
 ↓ Mg causes → Hyperactive deep tendon reflexes * Paresthesia’s, muscle tetany, positive chvostek’s & Trousseau’s sign, hypoactive bowels, constipation, abdominal distention, paralytic Ileus. TPN Admin: (Total parenteral nutrition) -feeding that bypasses the GI tract. Fluids are given into a vein to provide most of the nutrients the body needs. Given when person cannot/ should not receive feedings or fluids by mouth.
 Hypertonic (20-50% dextrose), Used in chronic pain, peritonitis, burns, Infection, etc No more than 10% hourly, ↑ in rate for body adjustment, check BG Hyperglycemia, hypoglycemia, vitamin deficiencies, air embolism (clamp, place in Trendelenburg pos., O2)
 Fluid imbalance → Fluid volume excess Wound Culture specimen: Sterile field, press / rotate over wound surface inside the wound (center) in drainage Diabetes Mellitus (Nephropathy): Kidney damage d/t prolonged ↑ BG & dehydration Monitor I & O, Creatinine, BP Avoid Soda, alcohol, acetaminophen/NSAIDS / 2 – 3 L fluid from food / beverages Kidney Biopsy (Post op): Monitor VS → Client receives sedation Assess dressings & urinary output (hematuria-blood in urine) Labs: HgB & Hct values, Admin PRN pain meds, Complications hemorrhage / infection Thyroidectomy (Post Op): Needs Thyroid hormone replacement Client in high fowler’s position, Respiratory (trach supplies) present, Check for laryngeal nerve damage Pain management, Hypocalcemia / Tetany can occur Prioritization: Apply knowledge to Standards to determine priority action
 Systemic before Local – “Life before Limb” Acute before Chronic Actual Problems before Potential Future Listen carefully to clients & Don’t Assume Recognize & Respond - Trends vs. Transient findings Recognize indications - Emergencies vs. Expected
 Delegate to LPN: Monitoring Findings, Reinforcing teaching, performing trach care, suctioning, checking NG tube patency, administer tube feedings, inserting urinary catheter, administering meds (No IV) Delegate to AP: ADLs, Bathing, Grooming, Dressing, toileting, Ambulating, feeding w/out swallowing precautions, positioning, routine tasks, bed making, specimen collection, I & O, VS for stable clients, monitoring clinical manifestations after initial RN assess/eval. Paracentesis (prep) - take out fluid from belly (peritoneal fluid) Have client VOID Bariatric Surgery: (weight loss surgery) – Semi fowlers, 6 small meals/day, liquid/pureed food for first 6 weeks (not to exceed 1cup), Vitamin / mineral supplements, & 2 servings of protein daily. Ostomy (in small intestine) Avoid odorous & gas foods (dark green veges, dairy, fish, eggs, beans, corn), yogurt ↓ gas Avoid ↑ fiber foods for first 2 months, ↑ fluid intake Dumping Syndrome: Happens within 15mins of eating.
 Sx: cramps, diarrhea, tachycardia, dizziness, fatigue, hypoglycemia
 Interventions: small frequent meals, drink liquids 1hr b4/after 
Parkinson’s disease: Tremor, muscle rigidity, bradykinesia (slowness in movement), postural instability Stages: 1. Unilateral shaking / tremor of one limb 2. Bilateral limb involvement, difficulty walking/balance 3. Slowed physical movements 4. Akinesia & Rigidity make ADL’s difficult 5. Unable to stand/walk, dependent of cares, dementia Assault: threat Battery: touching Hypoglycemia Sx: Shakiness, confusion, sweating, tachycardia, diaphoresis, palpitations, H/A, lack of coordination, blurred vision, seizures, coma Oral Hypoglycemic Agents: promote insulin release from pancreas (Type2 DM) Glipizide (Glucotrol), Chlorpropamide (Diabines), Glyburide (Diabinese), Metformin (Glucophage). * Med for insulin overdose = Glucagon Radiation Adverse Effects: Skin changes, hair loss, debilitating fatigue, 30 minute visits / stays 6ft away / private room Infection control in clients home: good hygiene, avoid crowded areas, avoid raw foods (veges/meats), avoid cleaning litter boxes, clean home and avoid sick family. Client evacuation in response to fire: greatest good for the greatest amount of people Client in seclusion: 18 yo+ → 4 hours, 9 – 17 yo →2 hours, 8 yo & younger →1 hour Conduct Disorders: lack of remorse, bullies, threatens, low self-esteem, tempers, physical cruelty, destroys property, truant, and shoplifts Manic Phase: ↑ mood, irritable, lasts at least a week, euphoria, agitation, restless, ↑ in talking, flight of ideas, grandiose view of self, impulsive, manipulative, poor judgement, attention seeking. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Hazards of immobility on CV system & interventions DVT: elastic stockings, SCD's, Orthostatic BP: give pt time between position changes Hazards of immobility on pulmonary system & interventions PE: TED host, Inadequate expansion of the chest: place pt in orthopneic position Pneumonia: clean/sterile technique, pneumovax Intervention for each: early and frequent ambulation Hazards of immobility on renal system & interventions-UTI, problems with continence, altered BP: monitor I/O's, assist w/ voiding as needed Hazards of immobility on integumentary system & interventions Skin breakdown: repositioning, monitor nutrition status, reduce moisture, and provide hygiene care Hazards of immobility on musculoskeletal system & interventions Stiff joints: ROMs/ambulation Muscle atrophy: ROMs/ambulation Ca2+ imbalance: nutrition measures Risk factors for skin breakdown Poor nutrition, bedrest, obesity, using an SPM machine, increased friction and shear 4 areas prone to skin breakdown-Tailbone, Heels, Elbows, Hips Intervention most effective in preventing flaccidity in a hospitalized patient? Early ambulation after surgery After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation? Lower extremity circulatory status Components of Morse Fall Scale- History of falls, secondary diagnosis, ambulatory aid, IV/hep lock, gait/transferring, mental status Scores: 45+ = high risk 25-44 = moderate risk 0-24 = low risk TB Injection - Max amt: 0.1 cc, site: forearm, Angle: 15-20 degrees, Length: 1/4 - 1/2 in, Aspiration? No SQ injections - Max amt: 2 cc, Usual site: Upper arm, stomach, Angle: 45 degrees, Length: 1/2 - 1 in, Aspiration? Yes IM injections - Max amt: 5 cc Usual site: deltoid (1 cc), gluteus med/max or vastus lateralis (5 cc), Angle: 90 degrees, Length: 1 - 1.5 in, Aspiration? Yes
 What factors affect a BG result? Having fasted or eaten, time of day, level of activity, stress, illness, menstruation client most at risk for hypoglycemia? In the morning before breakfast Considerations for pt's on blood thinners such as warfarin, asprin, heparin, coumadin, etc? Monitor platelet levels (labs) Watch for bleeding/reduce risks of bleeding Monitor vitals (esp. BP) Assess skin Monitor mobility status benzodiazepines to older adults? No, benzo's increase the risk of accidents and mental deficits FUO - fever of unknown origin qhs - at bedtime ac - before meals Contraindications for opening capsules and mixing with food? EC: enteric coated & ER: extended release Rapid acting insulin Generic & brand names: Inslin aspart (NovoLog), insulin glulisine (Apidra), insulin lispro (Humalog) Onset: 15 min Peak: 30 - 90 min Duration: 3-5 hr Short acting insulin - Insulin regular (Humulin R, Novolin R) Onset: 30 - 60 min Peak: 2 - 4 hr Duration: 5 - 8 hr Intermediate-acting insulin- Insulin NPH (Humulin/Novolin N) Onset: 1 - 3 hr Peak: 8 hr Duration: 12 - 16 hr Long-acting insulin- insulin glargine (lantus), insulin detemir (levemir) Onset: 1 hr Peak: no clear peak Duration: 20 - 26 hr Signs of infiltration -Edema, pallor, decreased skin temperature around the site, and pain Signs of phlebitis - Pain, increased skin temperature, and redness along the vein Signs of extravasation (infiltration w/ dislodged IV catheter) - Pain, stinging or burning at the site, swelling, and redness Nursing interventions for infiltration, phlebitis, and extravasation Infiltration: D/C IV, elevate extremity, apply warm compress Phlebitis: D/C IV, apply warm/moist compress Extravasation: D/C IV, apply cool compress, administer antidote if needed, document degree of extravasation INT -intermittent (catheter) The 6 rights of medication administration 1. Right drug 2. Right dose 3. Right route 4. Right pt 5. Right time 6. Right documentation 3 nursing interventions r/t routine care of peripheral IV 1. Check insertion site frequently 2. Change tubing every 96 hr 3. Use good hand hygiene + standard precautions Factors to consider when choosing the best IV location Age, condition of veins, circulation status, length of IV therapy What is the smallest gauge IV catheter used to infuse blood? 20-22: RBS' might get crushed when using a smaller cath. 4 techniques to improve the chances of good IV access 1. Trim hair around the area 2. Gently stroke the area from the distal to proximal end 3. Place a warm blanket over the extremity 4. Palpate gently