ATI PN Comprehensive Test 2017 Questions and Answers

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T/F the nurse should plug an NG tube and keep it above the level of the stomach when ambulating a client - ANSWER True. This prevents stomach contents from leaking into the pigtail T/F the nurse c... an NOT instil air into an NG pigtail but she can instil air IF there is leakage. - ANSWER True. If the nurse notes edema above the catheter insertion site, what is the best action of the nurse? - ANSWER This indicates infiltration. The nurse stop the IV infusion. THe presence of skin balancing indications infiltration as well. S/Sx of hypoglycemia: - ANSWER pale, sweaty skin, irritability, tachycardia, tremors and hungry S/Sx of hyperglycemia - ANSWER fruity breath, lethargy, weakness, thirst, polyuria, How can a pt decrease pain when replacing an ostomy pouch system - ANSWER Gently and gradually peeling the skin barrier away while *holding the skin taut* will minimize discomfort AND trauma to the peristomal skin If a pt does not meet goals or outcomes in the critical pathway due to an unexpected finding, or the nurse finds a need for additional interventions, what is the nurse's best action? - ANSWER document the findings as a variance as either a negative or positive variance. T/F Rifampin, for the tx of TB, can interact w/ and reduce the effectiveness of oral contraceptives, therefore the nurse should instruct the pt to use a secondary method to prevent pregnancy. - ANSWER True If a client taking Rifampin for the tx of TB complains of HA, fever, or muscle aches, what should the nurse's response be? - ANSWER Report the symptoms to HCP immediately as these indicate flu like symptoms and infection, which can lead to meningococcal meningitis A nurse in a providers office is reviewing pediculosis capitis management and prevention strategies w/ the parent of a school age child. What education should the nurse provide the parents with? - ANSWER Transmission of lice occurs via contact w/ personal items so store the childs clothing in a separate cubicle when at school. Do NOT use insecticides because they are a danger to young children and pets Boil brushes and combs in water for 10 minutes to kill lice and nits Dry bed linens and clothing in a HOT dryer for at least 20 minutes Contaminated non washable items should be sealed in a plastic bag for 14 days to kill the lice. Enoxaparin for the prevention of thrombosis should be administered how? - ANSWER SubQ Rotating injection sites A pt taking atorvastatin for hypercholesterolemia, experiences muscle pain, what does this indicate? - ANSWER This could be a manifestation of myopathy or muscle injury which is a potential serious adverse effect of statin drugs. Montelukast is a leukotriene modifier taken for asthma. Describe how it is appropriately used: - ANSWER Taken once daily for *maintenance* - it is NOT a rescue medication. How does the nurse appropriately obtain a blood draw? - ANSWER apply the tourniquet to find a vein *in the antecubital fossa*, then release the tourniquet cleanse the insertion site allow the site to dry reapply the tourniquet obtain blood draw Describe the first stool passed by a newborn: - ANSWER Meconium that develops in utero dark green to black and viscous contains components of amniotic fluid, cells, intestinal secretions and occult blood A nurse in contributing to a teaching plan for a group of male adolescents about the adverse effects of anabolic steroid use. What are the manifestations that the nurse should include: - ANSWER Reduced ht potential d/t premature epiphyseal closure reducing the full ht potential Liver disorders Hyperlipidemia Breast enlargement Acne Edema When a pt uses rationalization it is used as a means to what: - ANSWER justify unreasonable feelings, thoughts, or actions. ex. "I did not get a good grade because my teacher does not like me" When a pt uses denial, it is a means to what? - ANSWER Avoid unpleasant feelings, thoughts or needs by pretending they do not exist. ex. "I do not believe you because my mother cannot be gone" When a pt is compensating, the nurse would recognize this as what? - ANSWER The client is making up excuses for their negative behaviors. Ex. "When i've had a few drinks I feel much better about myself" What is suppression? - ANSWER The purposeful denial of an uncomfortable situation by putting it off until it is convenient for the client to address. ex. "I will call the doctor for my test results after I return from this vacation". A pt w/ a NG tube has continuous enteral feedings, what interventions should the nurse include: - ANSWER Aspirate gastric residual q 4 hrs Change enteral feeding bag and tubing q 24 hrs *W/hold feeding if more than 100ml to 250ml gastric residual volume is obtained* Measure the pH of gastric tube aspirate prior to administering nutrition, anything less than 5 indicates the tube resides in the stomach T/F sharing client information w/ the clients employer is a vilant of client confidentiality. The nurse should inform the employer he will need to speak directly with the client. - ANSWER True. A nurse is assisting w/ the care of a school age child immediately following surgery. The child weighs 21.8kg (48lbs) and has a chest tube applied to suction. What findings should the nurse report to the provider? - ANSWER Subcutaneous emphysema: this is an indication of an air leak under the clients skin. If there is more than 3mL/kg/hr of sanguineous drainage occurring for more than 2 to 3 consecutive hours following surgery this can indicate hemorrhaging and should be reported immediately. What are expected findings when a pt has a chest tube applied to suction: - ANSWER continuous bubbling in the suction control chamber - this is because it contains water and when suction is applied to the unit, continuous bubbling occurs. Fluctuation in the water seal chamber w/ inhalation returning to 2 cm - a higher level can impede the flow of air from the chest. T/F COPD causes respiratory stress that leads to hypermetabolism and wasting of the muscle mass. - ANSWER True. The client should drink high protein and high caloric nutritional supplements to maintain respiratory muscle fnx. Generalized petechiae over a newborn indicates what? - ANSWER Infection or a decreased platelet count and should be reported to the HCP immediately. Petechiae over the forehead, in a brow presentation of anywhere on the head of infants who had a nuchal cord, is an expected finding. A nurse is talking w/ a client who says the provider agreed to initiate a do not resuscitate prescription. After leaving the clients room what action should the nurse take? - ANSWER Check for documentation that the provider spoke with the client about the DNR Why should the nurse maintain a drainage flow rate, keeping the urine diluted to a reddish pink color on a pt w/ continuous bladder irrigation following a transurethral resection of teh prostate? - ANSWER This keeps the tubing free of clots and bleeding To maintain patency of a feeding tube and to ensure that a pt receives all their medication, what action is essential that the nurse perform? - ANSWER Flush the feeding tube w/ water before and after administration of medication. How often should the nurse check the neurovascular status of an affected extremity, postoperatively. - ANSWER Hourly for 24 hours Then q 2 to 4 hours How is the FLACC score determined? - ANSWER Five categories of behavior Facial expression Leg movement Activity Cry Consolability Why would a pregnancy place a vulnerable partner at risk for intimate partner violence? - ANSWER The perpetrator may selfishly view the pregnancy as a threat to the relationship and will likely envy the attention the child receives An orthodox judaism, following the death of a family member, likely would request what practice? - ANSWER That a family member can remain with the body of the loved one until burial. These individuals discourage or oppose autopsies, as well as cremation. Individuals who practice catholicism, following the death of a family member, likely would request what practice? - ANSWER That he/she will receive the last rites immediately after the death. [Show More]

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