NURSING ATI - Predictor 2K16/;GUIDE TO SCORE A

NURSING ATI - Predictor 2K16/;GUIDE TO SCORE A Xerostomia, what is it & how do you treat it Labs to check for pernicious anemia Contraindication for the use of combination oral contraceptives Sign of mild a ...

NURSING ATI - Predictor 2K16/;GUIDE TO SCORE A Xerostomia, what is it & how do you treat it Labs to check for pernicious anemia Contraindication for the use of combination oral contraceptives Sign of mild anxiety What is remote memory loss Heart failure dietary teaching Diverticulitis dietary teaching Diverticulosis dietary teaching IBS dietary teaching Urine Culture on baby = straight catheter Parents are nervous about how their 3-year-old will act when newborn arrives. What can they do Methylprednisolone sodium succinate lab to watch for? At 14 weeks' gestation, what should the patient report to the MD A patient is 14 weeks pregnant, where do you check to find the FHR Change of shift report should include Patient teaching for colostomy care Scoliosis manifestation Lab values that are elevated for Cushing's disease Cushing disease Sx: Administering medications through an NG tube = Tobramycin adverse reaction Anorexia expected finding Amniocentesis patient teaching Expected finding during cardiac catheterization Retinoblastoma = What action should you instruct the patient to do prior to postural drainage? IV phlebitis = IV is infiltrated = Discontinue IV & apply a cool compress Female is to undergo an NST = Doppler transducer placed around abdomen When a patient is receiving mannitol, what should the nurse monitor for = Hypovolemia Co-worker is impaired, what do you do = Report it to the charge nurse Fine hair is a result of this disease = HYPERthyroidism How do you draw blood out of a PICC line = Draw 10mL of blood and discard it, then draw another 10mL of blood for sample, and then flush with 10mL of 0.9% sodium chloride Crohn’s disease = LOW fiber diet latex allergy if they have a sensitivity to what food = Bananas Buddhist patient = vegetarians Food Label = greatest weight is listed first. Child with positional plagiocephaly = Child will wear a molded helmet for 23 hours a day Pregnant women should eat more of what to prevent neural defects = Folate/folic acid A caregiver states they are becoming tired when caring for their parent with Alzheimer's disease, what can the nurse suggest = Respite care (care to give caregivers a break) Clef t palate teaching for feeding = don’t use a spoon, Position infant upright while cradling head & burp them frequently A wound that would heal by primary intention = A surgical incision Sign of glaucoma is loss of = Peripheral vision loss Baby w/reflux = small frequent meals, thicken formula with rice cereal, HOB 30 Radiation implant precautions = * Private room with radiation sign * Wear dosimeter film badge * Limit visitors to 30 min and to remain 6ft away from the patient * Keep lead container in room and tongs * No pregnant ladies or anyone under the age of 16 should come into contact with the patient Discharge teaching for a patient who is going home with HIV/AIDS = * Good hygiene & frequent hand washing * Avoid crowds * Avoid cleaning litter boxes * Avoid raw foods such as veggies or meats Adolescent nutrition = 1300mg of calcium Priority nursing care for a patient who has been sexually assaulted = Assess their anxiety Identifying a need for hearing evaluation = * Absence of talking by 7 months * Uses gestures rather than talking by 15 months * Speaks in monotone * Speaks loudly for the situation Compartment syndrome = client with cast and has white extremity (6 P’s assessment) NG placement in the Jejunum = X-ray How should you confirm the placement of an NG tube = Aspirate gastric contents (pH less than 4) Methylphenidate patient teaching = It's Ritalin, so take once daily in the morning Simvastatin reaction that you report to the MD = Muscle aches/pain (rhabdomyolysis) Diabetic foot care patient teaching = Cut toe nails straight across, No lotion between toes, wear clean socks made of cotton or wool Where should you insert a peripheral catheter = Distal veins in the non-dominant hand Who receives Rhogam = an O- women following a spontaneous abortion Losartan adverse effect = Angioedema Patient teaching for dabigatran = Report bleeding (it's an anticoagulant) Pacemaker teaching = Take pulse at same time each day & report if HR is less than 5bpm below the pacemaker rate, Report dizzy, fatigue, hiccups or palpitations EKG that has no P wave, has a wavy baseline and increased HR = Atrial fibrillation Newborn genetic screening = Heel-stick test done 24 hours after birth and the infant must be fed within those 24 hours for accurate results Acupuncture contradiction: Herpes Zoster What medication is given for an ectopic pregnancy = Methotrexate Washing hands for a patient who is immunosuppressed = use chlorohexidine Betamethasone causes HYPERglycemia in the mom & HYPOglycemia in the neonate Betamethasone = used to promote fetal lung maturity NG Tube feeding = suction gas residuals every 4 hours. A client who has a history of domestic abuse = discuss an escape plan Cleansing a radiation area = Clean with mild soap or water, Avoid use of powders/lotions/creams Furosemide & gentamicin drug interaction causes = Kidney problems & dehydration What can you expect after ECT treatments = Temporary short term memory loss When a group strep B culture is obtained during the 35-36 week of gestation and is positive, what do you do = Administer penicillin every 4 hours during labor List some ways to prevent or treat supine hypotension syndrome = Left-lateral side lying, Semi-fowlers, Wedge under one hip while supine Long term use of Protein Pump Inhibitors causes = osteoporosis Magnesium Sulfate = Is an anticonvulsant, Reduces the seizure threshold, Secondary effect - lowers BP*** Administering Magnesium Sulfate = Restrict fluids to 100-125mL/hour, Maintain urine output of 30mL/hour S/S of Magnesium Sulfate Toxicity: C - Cardiac dysrhythmias O - Output less than 30mL/hour R - Respirations less than 12/min A - Absent deep tendon reflexes (HYPOREFLEXIA) L - LOC is decreased Prednisone adverse reaction = Infection, Fluid retention, Hyperglycemia SIDS Prevention = Place babies on their backs to sleep, Pacifier when sleeping, Breastfeeding Sumatriptan is used for = Migraines Pregnant adolescent with no financial help = refer to case manager Absence Seizure = Brief sudden lapse in attention, patient may appear to be day dreaming or staring into space Valporic Acid levels to watch for = This med can cause hepatic toxicity - monitor serum liver enzymes Kidney donor contraindication = Diabetes Situational Crisis example = Lost a grandparent in a MVC (unexpected event) Coarctation of the aorta symptoms = Diminished pulses in extremities (weak femoral pulses) Cocaine patient Signs/Sx = ↑ Temp Patient teaching for parents taking child home after circumcision = Petroleum jelly with diaper changes (change diaper every 4 hrs) Screening test done at 16 weeks' gestation = alpha-fetoprotein (AFP) 3-year-old child can do what? = ride a tricycle Stimulant withdrawal symptom = fatigue Patient teaching for patient with peripheral artery disease = apply lotion to feet to prevent dry, cracked skin. Patient experiencing mania = give a PB&J for a portable snack Patient has diarrhea with enteral feeding, what should you do = administer at slower rate (admin. at room temperature) When a patient is taking phenelzine what foods should be removed from their meal tray = Caffeinated beverages, Chocolate, Fava beans, Ginseng Lab test for pernicious anemia = Schilling test Sign of hypervolemia = Bounding pulses To ↓cardiac demand in an infant = feed infant when awake or crying Tidaling in water chamber of a chest tube is = Normal (bubbling is NOT) Narcissistic personality disorder expected behavior = infatuated with weight/appearance Clozapine lab contraindication = WBC 2900 (normal is 5,000-10,000) Anterior fontanelle closes = 12-18 months Confused patient = raise 1 side rail Posterior fontanelle closes = 2-3 months Acupuncture contraindication = Herpes zoster Chronic kidney disease hemodialysis patient teaching = 1g/kg of protein a day & ↑K Metoprolol report to MD = bradycardia Pregnant lady exercising teaching = drink lots of water Patient experiencing mania what should you encourage = encourage time in the day room Gentamicin adverse effect = creatinine 2.7 Sertraline adverse effect = dry cough Biofeedback is = a technique used to learn to control you body's functions Antisocial personality disorder can be characterized by = Lack of remorse Methadone withdrawal in newborn symptoms = hypertonicity Patient in ventricular tachycardia is found to be pulseless, what do you do = defibrillate Small pox expected finding = rash in mouth Preventing uric acid stones = YOGURT! Client in need of PT = Nurse should include client in selection of provider for PT. Organizing workload (time management question) = goals for the day Sign/Symptom of preeclampsia = proteinuria Advanced directives = do not need a lawyer Sickle cell priority (during crisis) = HYDRATION/FLUIDS Pregnant woman has hepatitis C, can she breastfeed = yes, as long as she doesn't have cracked nipples Albumin is an indicator of = being well nourished Needles disposal at home = coffee container on top shelf Dehydration improving in baby sign = flat fontanelle Methotrexate adverse effect = high blood pressure NG tube nutrition = ↑ vitamin K 24-month old should be able to = walk up steps Pregnant woman should get what vaccine = flu shot To ↑ iron absorption, take with = vitamin C (orange juice) When scheduling when to take trough levels = take the level 30 minutes before the next dose is given Burn patient fluid/electrolyte imbalance = metabolic Acidosis EEG patient teaching = clean hair, no conditioner or gel/hairspray in it Parkinson Med - levodopa report = dark urine & monitor for HYPOtension Prostate cancer radiation therapy = wash irradiated area with mild soap & water Hepatitis A cleaning solution = 1:100 chloride solution Acarbuse is taken = with the first bite of each meal (diabetes med) Pregnant woman having late decelerations, what do you do = position the patient in left-lateral position STD that must reported to the CDC = chlamydia Side effect of ACE Inhibitors = Cough Justice = nurse treating a homeless person the same as anyone else Hypnosis intent = to alter the perception of pain African American = ↑ risk for heart disease Patient scheduled for an IV Pyelogram = administer a laxative High pressure alarm sounds on the vent, what do you assume is the cause = kinks, patient biting tubing Low pressure alarm sound on the vent, what do you assume is the cause = air leaks, displacement Patient arrives to ED after MVC, they are hypotensive & unresponsive. What solution will prescribed to increase intravascular volume & replace blood loss & increase BP?: = 5% dextrose in LR Patient's family asks you to pray with them, what is your response = refer them to spiritual services IUD puts women at risk for = having an ectopic pregnancy IV is infiltrated = discontinue and apply cold compress IV phlebitis has occurred = discontinue and apply warm/moist compress Patient asks the nurse to see his medical records = you have a right to see your records, let me initiate the process Adverse reaction of giving a patient a cooling blanket = SHIVERING Increase in PAWP means = left-sided heart failure Valproic acid adverse effects = LIVER failure, jaundice Frequent variable decelerations in FHR, what do you do = turn patient on left side Patient is in v. tach and pulseless, what do you do = defibrillate Threatening to insert an NG tube for a patient who refuses to eat is a sign of = assault Thrombocytopenia, you should avoid = blowing nose (wipe nose, not blow) Prior to liver biopsy, patient should have labs for = prothrombin time (PTT) Test for PKU = Guthrie test When should you take pancreatic enzymes = with each meal Contraindication of MMR = blood transfusion Gastric surgery, patient should eat = 3 meals/day What is true of lice = it can live for 48 hours on surfaces What do you hear when you palpate the abdomen = resonance Dying patient wants to be alone, what type of grieving = depression/dysfunctional Accessing a PICC line you need what type of needle = noncoring needle Care plan for a patient who has an indwelling urinary catheter = perineal care after defecation Hyperparathyroidism precaution = fall precaution (due to muscle weakness) Patient is experiencing diarrhea while receiving intermittent feeding, what nursing intervention should be done = administer at a slower rate PICC line understanding of teaching for a newly licensed nurse = informed consent is needed Epinephrine possible side effects = chest pain Amitriptyline adverse reaction to monitor for = urinary retention Group therapy for families adapting to loss of family members is do = determine roles First step to perform when a patient says they want to have a family home visit = clarify the source Referral that should be made for a patient who has a non-healing ulcer = dietitian referral Home safety for an older adult = install grab bars in the tub Patient has a potassium level of 5.2, what med should be held = spironolactone (because it is potassium-sparing) Patient states they wish they were dead, nurse should respond by saying = "you seem to be feeling hopeless" Acute MI w/alteplase contraindication = acute cardiac failure 6 months ago To promote sleep = eat a small bedtime snack Safety measures for a patient with Parkinson’s disease = clear the area (risk for falls) Home tracheostomy care, correct statement by family is = have suction set to 60 mm HG Complication of immobility = swollen area in calf Phenelzine = smoked fish Cefazolin = can be used to treat sore throat Home teaching for a client on Oxygen = keep tanks away from drapes/curtains (windows – to avoid static electricity) Stomatitis = patient to use a soft bristle tooth brush. LPN delegation = post op NG tube, dressing change When using an interpreter = nurse speaks directly to client (always get interpreter, not family or staff) Mitral Valve = antibiotics Patient to assess 1st = patient with cast and pallor toes Client at risk for development of strep = child with impetigo Client most at risk for aspiration = client w/GERD Patient understands teaching of sertraline when they state = it takes a few weeks for take effect Symptom to report = urine output of 20mL/hr (LOW) CPT (chest physiotherapy) on a child = done by using hands – percussion & vibration. Client who is schizophrenic and hearing voices = nurse response, “I know you are hearing voices, but I’m not hearing them” 70% NPH & 30% Regular(Humalog) Insulin = a mixed insulin of intermediate and short acting. List the presumptive signs of pregnancy? Missed menstrual period, Breast change: nipples tingle, fuller, darker, More frequent urination, Morning sickness, Skin change: chloasma, linea nigra, striae. What are the appropriate episode findings for a client with bipolar experiencing mania? Inappropriate affect, Inappropriate dress, Inability to sleep or eat, Becomes angry quickly, Pressured speech, Persecutory delusion What are the appropriate episode findings for a client with bipolar experiencing depression? Inability to make decisions, Lack of energy, Lack of self-confidence Describe displacement in mental health. = A client who is angry with a physician, but yells at the RN. Describe regression in mental health. = A 3-year old hospitalized for leukemia only wants to be fed with a bottle while being held by his mother. Describe intellectualization in mental health = A wife who talks about the love of her family, but doesn't demonstrate love towards them. Describe suppression in mental health. = An adolescent who was involved in a drunk driving accident in which his best friend died, says he doesn't remember drinking and driving, even though he gave a report of the incident to the police. Gestalt therapy = Emphasis is on "here and now". Aversion therapy = Negative reinforcement is used. Cognitive therapy = Active, directive, time limited, structured approach. Supportive therapy = Reinforcement of client's existing coping mechanisms. Reconstructive = Emotional/cognitive restructuring takes place. Desensitization therapy = Repeated exposure to stimulus which gradually reduces intense reaction. Behavior therapy = Belief is that most behaviors are learned. Transactional analysis = Goal is that individuals in group will communicate from proper ego states/responses of others. What is the key finding for Pertussis? = Paroxysmal coughing episodes. What is the function of the pituitary gland? = It's the master gland. What is the function of the Adrenal gland? = Sodium/electrolyte balance/SNS response. What is the function of the thyroid gland = Basal metabolic rate/growth rate. What is the function of the parathyroid gland? = Calcium/phosphorus metabolism. What is the function of the pancreas? = Carbohydrate/fat/protein metabolism. What is the function of the ovaries? = Progesterone/estrogen production. What is the function of the testes? = Development secondary sex characteristics. What types of airborne diseases require a negative pressure room and N-95 fitted masks? = Rubella, Varicella and Tuberculosis What types of diseases require droplet precautions? = Streptococcal pharyngitis or pneumonia, haemophilus influenza type B, scarlet fever, pertussis, mumps, meningococcal meningitis. Where do you place droplet precautions clients? = Best is in a private room or can be placed in a room with others that have the same condition. What types of diseases are placed in contact precautions? Enteric diseases caused by microorganisms, wound infection, herpes simplex, scabies, multidrug resistant organisms. Pregnant women with herpes = ask if she has any active lesions Cardioversion should be initially set to? = 50-100 joules What is cardiac output? = heart rate x stroke volume A presumptive sign of pregnancy = More frequent urination Therapeutic effects of mannitol = Increased Diuresis CVA 10 days ago appropriate action by nurse = Swallow study Pneumonectomy weaned from mechanical ventilation and transferred from ICU to MedSurg what should be in transfer report = The clients last dose of pain medication Closed head injury placed on Seizure precautions what should be in room = Set up suctioning equipment at the bedside Post vaginal delivery have you Lucia and boggy fundus administer what = Oxytocin Which client should nurse assessed first after receiving report = Post-operative with abdominal distention and no bowel sounds Client with PCA postoperative pain control requires blood pressure check in 10 minutes which staff should charge nurse assigned to collect information = AP assisting a client to return to bed, Correct placement of clients in G feeding tube before feeding, Aspirate contents from the tube and verify the pH Charge nurse observes staff nurse document dressing change that wasn't performed what should the nurse do = Gather more information about nurses actions Counseling a client who is experiencing an emotional crisis = Assist the client in identifying the cause of the issue Client wants to review the information and her chart = There's a protocol for reviewing your chart and I can initiate the process Teaching about self-administration of insulin what is correct = Pinches skin prior to injecting insulin Assessing a newborn, findings indicating a need for immediate intervention = Grunting, tachypnea, nasal flaring Crutches while climbing stairs = Standing tripod, place bodyweight on crutches, place unaffected on stair, move affected leg ABG results of client who has COPD = Uncompensated respiratory acidosis Mother who has objected routine administration of erythromycin ointment to the newborn eyes = Have Mother sign the facilities refusal form and document completion of the form Home teaching to a client who has mild preeclampsia = Swelling of hands and face, rest in sideline position, notify provider of decreased urinary output, fetal kick counts Client who has active tuberculosis what precautions should be taken = Client wear a mask outside the room Antisocial personality disorder = Lack of remorse Removal of NG Tube = have client take a deep breath and hold it Assessing a client receiving blood transfusion, signs of hemolytic transfusion reaction = Low back pain Sterile field aseptic technique = Maintain sterile objects within the line of vision Sterile gloves required for = tracheostomy care Estradiol side effect = Headaches Plan for dealing with mass casualty incident, tasks assigned to nursing staff = Triage Incoming victims Assessment on 12-year-old child with bacterial meningitis sign of increased ICP = Memory loss Child who has autism = Lack of responsiveness Thoracentesis for a client who has pleurisy = Instruct the client to avoid deep breathing Client who is receiving continuous passive motion = Turn off the CPM machine during meal time Clients urine output is 15 mils per hour additional assessment data indicative of fluid volume deficit = Orthostatic hypotension New nurse reports concerns about ability to complete assignments, time management strategies = Group activities together, ensure that all equipment has been gathered, delegates selected tasks, develop schedule Codeine to preschool child who weighs 33 pounds = 2.5 mls Postpartum client who has decided to bottle-feed her new baby = Please ice packs on breasts for 15 minutes 3 to 4 times per day Mental health facility, client becoming increasingly loud and belligerent = Use calm and clear statements to set limits Hand roll in each hand = Maintains a functional position School-age child with Scald Burns to both hands and wrists = Contacting the designated state agency about her suspicion Evaluating a client who is taking chlorpromazine = Decreased hallucinations Chlorpromazine = causes dry mouth – sip water throughout the day. Nurse is assessing at an older client who has delirium what is expected = Fluctuating level of consciousness Client who has impaired vision is discharged home, safety measures to prevent injury = Mark step edges with colored tape Home one care to the family of a child who has a large wound = Provide a diet high in protein School-aged child who is taking valproic acid = Serum liver enzyme levels Child with fever and fluid filled vesicles on the trunk and extremities = Implement transmission based precautions Caring for a client following an EGD = Cool, clammy skin Digoxin about manifestations of toxicity = Nausea Digoxin adverse effects: bleeding gums, bloody urine/stools, arrhythmias, petichiae Digoxin teaching = limit potassium in diet Client who is receiving oxytocin for labor induction and notes frequent variable decelerations = Turn the client to her left side Planning care for a toddler who has failure to thrive = Develop a structured routine Radiation therapy, large area of dry shiny red skin over the clients neck and clavicular area = Wash the area with mild soap and water Toddler following tonsillectomy = Administer pain medication on a regular schedule for the first postoperative day Client who is taking valproic acid for seizure control, side effects = Jaundice Discharge instructions to a client who has a new prescription for warfarin = I should report a change in the color of my stools Client who has undergone an open procedure for a ruptured appendix 48 hours ago, assessment findings should be immediately reported to provide = Temperature absent bowel sounds rigid board like abdomen and white blood cell count First trimester of pregnancy, using an adjustable band with a Bead that applies pressure to the P6 Meridian on her wrists = I have not vomited for the past two weeks During the first trimester of pregnancy, the FHR can be heard = above the pubis symphysis Diet for iron deficiency anemia and elevated cholesterol = Black beans Client who has a hip fracture and isn't bucks traction, AP should not = Adjust the clients hanging weights Nurse should assess the infants pulse at which of the following sites = Brachial Administering a blood transfusion to a client, ensure proper client identification = Verify the client and blood product information with another licensed nurse Discharge instructions to a client who has a new prescription for amitriptyline to treat depression = I should Watch for common reactions like dry mouth and constipation 18 hours postoperative following a C-section and is breast-feeding = Unilateral tenderness of the lower extremity Delegated movement of client up in bed, when RN should intervene = The AP in the LPN grass the client under the arms to lift him up in bed Discharge teaching to a postpartum client, promote circulation to the perineal area = Warm sitz bath Infection control nurse determining whether infection rates have decreased following a policy revision = Outcome Therapeutic effects of mannitol = Increased Diuresis CVA 10 days ago appropriate action by nurse = we check the client’s blood glucose immediately prior to administration of glyburide Severe hypo tonic dehydration laboratory results indicating response to treatment = Sodium 136 Patent ductus arteriosus (PDA) is = an opening between two blood vessels leading from the heart. Magnesium toxicity = results in both respiratory depression and a loss of deep tendon reflexes (hyporeflexia). Calcium gluconate is the antidote for magnesium sulfate toxicity. Preeclampsia Sx: persistent H/A Paracentesis (end stage of liver disease Tx), how to evaluate effectiveness = monitor weight, ultrasound, labs, measurement of abdominal girth. Acute glomerulonephritis symptoms = HEMATURIA - blood or excess protein in your urine, which may be microscopic and show up in urine tests, high blood pressure, swelling in ankles and face (edema), frequent nighttime urination, bubbly or foamy urine (from excess protein), abdominal pain, frequent nosebleeds. Dash diet = ↑ fruits, veges, low fat dairy, k, mg, ca Delegate to an AP = chest compressions Difficult voiding = warm water Early decelerations = head compressions Tertiary Prevention for Clients Who Have HIV- Maximization of recovery after an injury or illness (rehabilitation); Nutrition counseling, exercise rehabilitation, and support groups.