NURS 203:ATI Comprehensive exam 2020.STUDY GUIDE - 52 PAGES.

1. ABCs (Airway, Breathing, Circulation) 2. When in distress DO NOT ASSESS! Unless 2nd hand information is received. 3. Scenario  Expected outcome with Disease Process: Continue to monitor & Document finding  Unexp ...

1. ABCs (Airway, Breathing, Circulation) 2. When in distress DO NOT ASSESS! Unless 2nd hand information is received. 3. Scenario  Expected outcome with Disease Process: Continue to monitor & Document finding  Unexpected finding with Disease Process: Nursing intervention that must make a difference & Call HCP 4. Mini Maslow’s 1) ABCs (& Pain unrelieved by meds) 2) Safety 3) Comfort (Pain) 4) Psychological 5) Social 6) Spiritual 5. STAT words → Pick the answer that failing to do so will kill or cause great harm ● Highest Priority ● Most Important ● Immediate Action 6. *Least Invasive First* 7. Secondhand Info → Any time you have 2nd hand info, the right answer is ASSESS ∙ UAP ∙ Family ∙ Labs ∙ EMR ∙ EKG ∙ BP machine 8. Never ever take away the coping mechanism a patient uses during a crisis, except if the mechanism puts the patient or others @ risk 9. Eliminate answer choices & DNR 10. Never withhold Tx! If you are left with two answer choices and the options are to Tx, or watch the patient, Pick Tx! 11. Anytime there is a reversal from the norm, you must worry! Ex: rebound tenderness (pain after you relieve pressure) 12. Assign Stable Patients to: ∙ UAP ∙ LPN ∙ New nurse ∙ Graduate Nurse ∙ Float Nurse ∙ Travel nurse 13. Anytime you see excessive findings, that is not normal! 14. Always empower your patient 15. If a question has “”, pick an answer that has what they’re feeling & not what they’re saying 16. 3 R’s of Psych 1) Reality – Functional psych pt. 2) Reassure – pt. with Delirium 3) Redirect – pt. with Dementia Default Answers 2 Give meds either 1 hour before meal or 2 hours after meal 3 Give antacids 1 hour before med or 4 hours after med 4 When in doubt pick K (potassium) 5 2– 3 L of fluids 6 When in doubt pick answer that has you stay with patient 7 Anytime you see restless & ↓ level of consciousness = early sign - PICK 8 Head of Bead → 30-45 degrees for any neuro patient 9 Elderly with acute onset confusion → UTI 10 Secretions will turn Orange/Red for meds 11 Anytime you have GI problem/exacerbation = NPO 11. All surgeries RISK: 1 st 24 hrs. – bleeding 48 hrs. – infection 12 Check daily weights if it is a fluid problem 13 Lateral position for maternity 14 Remove answer choices that are ‘absolutes’ Rules for Delegation RN ASSIGNMENT = Do not delegate what you can E.A.T : Evaluate Assess Teach ● Cannot delegate assessment, teaching, or nursing judgement LPN/LVN ASSIGNMENT ● Assign stable with expected outcomes UAP ASSIGNMENT ● Delegate standard, unchanging procedures Five Rights of Delegation RIGHT TASK – scope of practice, stable client RIGHT CIRCUMSTANCES – workload RIGHT PERSON – scope of practice RIGHT COMMUNICATION – specific task to be performed, expected results, follow-up communication RIGHT SUPERVISION – clear directions, intervene if necessary Therapeutic Communication Tips DO: DO NOT: Do respond to feeling tone Do provide information Do focus on the client Do use silence Do use presence ● Do not ask “why” questions - NEVER pick WHY ● Do not ask ‘yes/no’ questions, except in the case of possible self-harm ● Do not focus on the nurse ● Do not explore ● Do not say, “Don’t worry!” Who Do You See First? Consider: ∙ Unstable vs. Stable ∙ Acute vs. Chronic ∙ Unexpected vs. Expected ∙ Actual vs. Potential ∙ ABCs Common Traps ∙ Do not ask “Why?” ∙ Do not ‘do nothing.’ ∙ Do not leave the client. ∙ Do not read into the question ∙ Do not persuade the client. ∙ Do not pass the buck. ∙ Do not say, “Don’t worry!” Strategies ● Only use textbook nursing – textbook knowledge ● Pain is psychosocial, unless, it is severe, acute, & unrelenting ● If it is a position question, is it going to prevent or promote something – position, prevent, promote ● Teaching/learning – use T/F on each answer – same strategy for SATA questions ● Risk Questions – use Risk Factors ● If the answers have an absolute in them, do not pick them ● Question that have the phrase ‘And Then’ – did they miss something Important Lab Values WBC 4K – 11K RBC 4 – 6 Hgb 12 – 16, 0r 12-18 Hct 36 – 48, or 37-52 Plt 150K – 400K BUN 8 – 20, or 7-22 Cr/Lithiu m 0.6 – 1.2 Urine Clearanc e 85 – 135, (GFR)=maintain above 60 Uric Acid 250 – 750 mg Na 135 – 145 Cl 98 – 106 Ca 8.5 – 10.5 K 3.5 – 5.0 PO 2.5 – 4.5g Mag 1.5 – 2.5, 4-7 if