ATI RN Comp Predictor 2016 Retake 2 ALL SOLUTION 100% CORRECT GUARANTEED GRADE A+

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what is delegation? transferring the authority and responsibility to another team member to complete a task, while retaining accountability RN's can NOT delegate what to a PN or AP? nursing process ... , client education, or tasks that require clinical judgment. don't delegate anything you can E.A.T. (evaluate, assess, and treat) What tasks can RN's delegate to AP's? -activities of daily living (ADLs) -bathing, grooming, dressing -toileting, ambulating, positioning -feeding (without swallowing precautions) -bed making -specimen collection -Intake and output -vital signs (stable clients) what are the 5 rights of delegation? right task right circumstance right person right direction and communication right supervision and evaluation nurses transcribes medications onto what? medication administration record (MAR) what are the rights to safe medication administration? right client right medication right dose right time right route right documentation right client right to refuse Prioritizing multiple clients systemic before local (life over limb) ex: client in shock vs client with limb injury acute before chronic (client who has new injury/illness such as mental confusion, chest pain vs client with long-term chronic illness medical emergencies vs expected findings (client with increasing ICP who has a new diagnosis of a stroke vs the findings expected following a stroke) Priority setting framework ABC's and disability and exposure safe and secure environment love and belonging self-esteem self-actualization what is magnesium sulfate used for prevent seizures by depressing the CNS in clients who have eclampsia and severe preeclampsia maintain fluid restriction of 100-125 mL/hr signs for magnesium sulfate toxicity cardiac dysrhythmias output urine less than 30 mL/hr respiration less than 12 absent DTRs (hyporeflexia) LOC decreased (CORAL) antidote for magnesium sulfate calcium gluconate what is the nurses role in the informed consent witness the clients signature and that it has been appropriately obtained what is an ischemic stroke an embolus that travels from another part of the body to the cerebral artery blood to the brain is occluded causing neurological deficits or loss of consciousness how do you treat an ischemic stroke alteplase also known as TPA unless contraindicated due to active bleeding nutrition for client who experienced ischemic stroke -assess swallowing and gag reflexes. -use speech-language pathologist -have client sit upright and swallow with the head and neck flexed slightly forward -place food in back of mouth on the unaffected side -have suction on standby -maintain distraction free environment what is heat therapy used for increase blood flow increase tissue metabolism relax muscles eases joint stiffness and pain what is cold therapy used for decreases inflammation prevents swelling reduces bleeding reduces fever diminishes muscle spasms decreases pain by decreasing velocity of nerve conduction contraindications for heat therapy avoid metal devices such as pacemakers, prosthetic joints do not apply to abdomen of pregnant woman because it will harm the fetus do not place on clients who are immobile because it can increase the risk of burns do not use during the first 24 hrs after traumatic injury, active bleeding, noninflammatory edema, and some skin disorders incident reports should be completed by the person who identifies the event has occurred should be completed asap within 24 hrs of the incident considered confidential. not placed or mentioned in the clients health record should be objective and forwarded to the risk management department or officer nationally notifiable diseases anthrax, botulism gonorrhea, hep ABC HIV, Lyme, malaria meningococcal, mumps pertussis, polio, rabies salmonellosis, SARS shingles, smallpox syphilis, tetanus TB, typhoid developmental task for 24 month old walks up and down stairs by placing both feet on each step builds a tower of 6 or 7 blocks turns pages of a books one at a time 300 word vocabulary. able to make 2 to 3 word sentences dietary recommendations for a client with osetoporosis calcium- milk products, green veggeis, fortified orange juice and cereals, red and white beans and figs vitamin D- fish, egg yolks, fortified milk and cereal limit carbonated, caffeine, and alcoholic beverages get 5-30 mins of sunlight twice a week other minerals include protein, magnesium, vitamin k engage in weight-bearing exercises calcium normal lab levels 9.0-10.5 hypocalcemia lab level less than 9.0 mg/dL suspected hypocalcemia tetany (muscle spasms) parethesia of fingers and lips seizure painful muscle spasms hyperactive DTRs positive chvostek sign positive trosseaus signs prolonged QT intervals result of prolonged ST segment sibling bonding -take the sibling on a tour of the ob unit -encourage parents to let the sibling be the first to see the infant -provide gift from infant to sibling -one parent spend time with infant, the other with the sibling -allow older siblings to help provide care for the infant -provide school-aged siblings with a doll to care for priority response for a client experiencing hallucinations -ask about the hallucinations directly do not argue or agree with the clients view of the situation, but offer a comment such as "i don't hear anything, but you seem to be feeling frightened" -focus on the clients feelings -assess for risk of violence -attempt to focus conversations on reality-based subjects -identify trigger symptoms -be genuine and empathetic communication with client who has bipolar disorder calm matter of fact concise explanations consistency and limit-setting avoid power struggles listen to and act on legit client issues reinforce non-manipulative behaviors therapeutic techniques promoting urination after childbirth encourage client to void every 2-3 hours increase fluid intake catherization if unable to void expected findings for client with anorexia nervosa body weight less than 85% of normal weight fine, downy hair (lanugo) on face and back. yellowed skin, mottled, cool extremities, poor skin turgor low blood pressure with possible orthostatic hypotension decreased body temp dysrhythmias muscle weakness, decreased energy, loss of bone denisty amenorrhea medication for bipolar disorder lithium or anti-epileptic medications such as valproic acid and carbamazepine what lab values do you monitor when taking bipolar medications BUN and creatinine T3, T4, and TSH levels lithium (0.5-1.2) what is Haloperidol used for? antipsychotics adverse effects of haloperidol EPSs (extrapyramidal side effects) Parkinsonism CONTINUED.. 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