Exam (elaborations) NURS 4723 RN Comp Online Practice ATI

Exam (elaborations) NURS 4723 RN Comp Online Practice ATI . A nurse is providing teaching about improving nutrition for a client who has MS. Which of the following instructions should to nurse include? "A speech pathologist will be performing a swallowing study for you." is correct. The nurse should instruct the client that a swallowing study will be performed to determine the client's risk for aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. "You should rest before eating a meal." is correct. The nurse should encourage the client to rest before each meal. Clients who have multiple sclerosis often report weakness and are easily fatigued. "You should restrict foods that are high in vitamin D." is incorrect. The nurse should instruct the client to maintain adequate vitamin D levels, because vitamin D deficiency is a risk factor for multiple sclerosis. "Reduce your intake of dietary fiber." is incorrect. The nurse should instruct the client to increase dietary fiber and fluids to decrease the risk of constipation, which is a manifestation of multiple sclerosis. "Thicken your beverages before drinking." is correct. The nurse should instruct the client that liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. 2. An RN is planning care for a group of clients and is working with a LPN and an AP. Which of the following tasks should the RN delegate to the LPN? Collection of a stool specimen 3. MY ANSWER The nurse should delegate collection of a stool specimen to an AP because this task is within the AP's range of function. Preparation of a client's postoperative bed The nurse should delegate preparation of a client's postoperative bed to an AP because this task is within the AP's range of function. Preparation of a teaching plan about pneumonia The RN should prepare the teaching plan because creating a teaching plan is not within the scope of practice for an LPN or the range of function for an AP. Insertion of a nasogastric tube The nurse should delegate the insertion of a nasogastric tube to the LPN because this task is within the LPN's scope of practice. 4. A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the clients airway? Withdraw the catheter if the client begins coughing. Suctioning can initiate the cough reflex as it opens the airway further and allows for more effective removal of mucus. Apply suction for 10 seconds. 5. MY ANSWER NURS 4723 RN Comp Online Practice ATI The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss. Advance the catheter 2 cm (0.8 in) after resistance is met. Once resistance is met, the nurse should withdraw the catheter 1 to 2 cm (0.4 in to 0.8 in) to prevent damaging bronchial tissues. Use medical asepsis when performing the procedure. The nurse should use surgical asepsis when suctioning a newly created tracheostomy to reduce the risk for infection. 6. Anytime a patient is receiving TPN they will also receive blood glucose readings A nurse is caring for a client with a closed head injury. When pressure is applied to the client's nail beds, the client's eyes open and adduction of the arms with flexion of the elbows and wrists is noted. The client also moans with stimulation. What is this client's Glasgow Coma Score? Eye opening (E) - The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice. 2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur. Verbal (V) - The best verbal response, with responses ranging from 5 to 1 5 = Conversation is coherent and oriented. 4 = Conversation is incoherent and disoriented. 3 = Words are spoken, but inappropriately. 2 = Sounds are made, but no words. 1 = Vocalization does not occur. Motor (M) - The best motor response, with responses ranging from 6 to 1 6 = Commands are followed. 5 = Local reaction to pain occurs. 4 = There is a general withdrawal to pain. 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present. 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present. 1 = Motor response does not occur. Laboratory Values While lab values vary slightly according to the source, knowing an average range for the following common lab tests will be very helpful on to you when answering questions. Sodium 136-145 mEq/L Potassium 3.5-5.0 mEq/L Total Calcium 9.0-10.5 mg/dL Magnesium 1.3-2.1 mg/dL Phosphorus 3.0 –4.5 mg/dL BUN 10-20 mg/dL Creatinine 0.6 – 1.2mg/dL males, 0.5 – 1.1 mg/dL females Glucose 70 -105 mg/dL HgbA1c <6.5% WBC5,000-10,000/mm3 RBC Men 4.7-6.1 million/mm3 , Women 4.2-5.4 million/mm3 Hemoglobin Men 14-18g/100 mL, Women 12-16 g/100 mL Hematocrit Men 42-52%,Women 37-47% Platelet150,000-400,000/mm3 pH 7.35-7.45 pC02 35 to45 mm Hg p02 80-100 mmHg HCO3 21-26mmol/L Normal PT = 11-12.5 sec, Normal INR = 0.7-1.8 (Therapeutic INR 2-3) Normal PTT = 30-40 sec (Therapeutic PTT 1.5 – 2 x normal or control values) Digoxin 0.5 to 2.0ng/mL Lithium 0.8 to 1.4 mEq/L Dilantin 10-20 mcg/mL Theophylline 10 to 20mcg/mL Latex Allergies: Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well. Order of assessment: I-inspection P-palpation P-percussion A-auscultation Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate. Cane walking: C-cane O-opposite A-affected L-leg Crutch walking: Remember the phase “step up” when picturing a person going up stairs with crutches. The good leg goes up first followed by the crutches and the bad leg. The opposite happens going down the stairs….OR “up to heaven…down to hell” Delegation: RNs DO NOT delegate what they can EAT--evaluate, assess, teach Helpful tool to remember Isolation Precautions: AIRBORNE: "My Chicken Hez TB" -Measles -Chicken pox -Herpes zoster -TB Management: neg. pressure room, private room, mask, n-95 for TB. DROPLET: "SPIDERMAn" -Sepsis -Scarlet Fever -Strep -Pertussis -Pneumonia -Parvovirus -Influenza -Diphtheria -Epiglottitis -Rubella -Mumps -Adenovirus -Meningitis Management: Private room/mask CONTACT: "MRS WEE" -MRSA -VRSA -RSV -Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, and staphylococcus) -Wound infections -Enteric infections (Clostridium difficile) -Eye infections (conjunctivitis) Management: gown, gloves, goggles, private room Antiemetics An antiemetic is a medication used in the treatment and/or prevention of nausea and vomiting. Remember generic names are our friend because meds in the same classification often have similar generic names but brand names can come and go. Here are some common classes of antiemetics and their generic names – notice the similarities in the generic names: 5-HT3 receptor antagonists (serotonin antagonists) Dolasetron (Anzemet) Granisetron (Kytril , Sancuso) Ondansetron (Zofran) Tropisetron (Navoban) It’s ‘Tron’ to the rescue! Dopamine antagonists Prometha zine (Phenergan) Prochlorperazine (Compazine) Metoclopramide (Reglan): Now this one is different in generic name because it can have some different side effects – watch for extra-pyramidal side effects with metoclopramide. Sometimes the generic names are not as helpful and you have to remember what meds fall under certain classes. Antihistamines and cannabinoids are used as antiemetics as well: Antihistamines (H1 histamine receptor antagonists) Diphenhydramine (Benadryl) Dimenhydrinate (Gravol, Dramamine) Meclozine (Bonine, Antivert) Cannabinoids Cannabis - Medical marijuana, in the U.S., it is a Schedule I drug. Dronabinol (Marinol) - a Schedule III drug in the U.S. *Remember most antiemetics can cause sedation so watch out for additive effect if given with narcotic analgesics and protect your client from injury. Proton Pump Inhibitors (PPIs) PPIs decrease stomach acid by inhibiting those gastric proton pumps that make the acid – they stop the acid at the pump! Remember generic names are our friends because meds in the same class often have similar generic names but brand names come and go: Here are some common PPIsOmeprazole (brand names: Prilosec, Zegerid, Omepral, Omez) Lansoprazole (brand names: Prevacid, Zoton, Inhibitol) Dexlansoprazole (brand name: Kapidex, Dexilant) Esomeprazole (brand names: Nexium, Esotrex) Pantoprazole (brand names: Protonix, Somac, Pantozol, Zentro) Think of a pump in your stomach just churning out the acid – ‘Zole’ is the nice guy who shuts off the pump. ‘Zole’ is very friendly (well-tolerated by most clients) but can cause vitamin B-12 deficiency if he stays around too long (with long-term use). Erectile Dysfunction Agents Erectile dysfunction (ED) meds act by increasing nitric oxide which opens and relaxes the blood vessels of the penis causing increased blood flow (helping lead to getting and keeping an erection). Here is where the generic name is our friend again – meds in the same class often have similar generic names but brand names will come and go: Here are some common ED medsSildenafil (Viagra) Vardenafil (Levitra) Tadalafil (Cialis) Notice these end in ‘fil’. ‘Fil’ helps the nitric oxide to ‘fil’ the penis. While ‘Fil’ is a great guy (well-tolerated by most clients) he does have a few side effects – headache, flushing, back pain and muscle aches (with Levitra), temporary vision changes, including "blue vision" (with Viagra) and not all men can spend time with ‘Fil’. Men who have heart problems, uncontrolled blood pressure problems, history of stroke, or a health problem at can cause priapism can’t hang out with ‘Fil.’ Antianemics There are many causes of anemia and the antianemic prescribed will be based upon the cause. With iron deficiency anemia, iron supplements are commonly prescribed. Beware though - Iron is ‘heavy’ stuff and shouldn’t be taken ‘lightly’! · Iron can cause teeth staining (liquid form). Teach clients to dilute liquid iron with water or juice, drink with a straw, and rinse mouth after swallowing. · Iron can cause staining of skin and other tissues with IM injections. If IM route must be used, give IM doses deep IM using Z track technique. · Iron also has several drug administration interactions- of antacids or tetracycline’s reduces absorption of iron. Separate use by at least 2 hr. · Vitamin C increases absorption, but also increases incidence of GI complications. Avoid vitamin C intake when taking medication. · Instruct clients to take iron on an empty stomach such as 1 hr before meals to maximize absorption. Stomach acid increases absorption. However, iron can cause GI distress(nausea, constipation, heartburn) If intolerable, iron can be administered with food to increase compliance with therapy but this does reduce absorption. · Instruct clients to space doses at approximately equal intervals throughout day to most efficiently increase red blood cell production. · Inform clients to anticipate a harmless dark green or black color of stool. · Instruct clients to increase water and fiber intake (unless contraindicated), and to maintain an exercise program to counter the constipation effects. · Encourage concurrent intake of appropriate quantities of foods high in iron (liver, egg yolks, muscle meats, yeast). Statins HMG CoA Reductase Inhibitors also known as ‘statins’ are some of the most prescribed medications in this country. Statins are used to treat primary hypercholesterolemia, for prevention of coronary events (primary and secondary), for protection against MI and stroke for clients with diabetes, and to help increase HDL levels in clients with primary hypercholesterolemia. Remember LDL is the ‘bad’ cholesterol and HDL is the ‘good’ cholesterol (HDL helps keep the ’bad’ cholesterol from building up in artery walls). You want your LOW (LDL)LOW and your HIGH (HDL) HIGH. Statins are another example that generic names are our friends – check out these common ‘statins’- Atorva statin (Lipitor) Simva statin (Zocor) Lova statin (Mevacor) Prava statin (Pravachol) Rosuva statin (Crestor) Fluva statin (Lescol) While statins are a wonderful addition to our pharmaceutical arsenal, they are not without risk. When you think ‘statins’ think that we need to protect the liver and muscles stat: There is a risk of hepatotoxicity. It is important to obtain a baseline liver function and to monitor liver function tests after12 weeks and then every 6 months and to avoid alcohol. There is also a risk of myopathy and peripheral neuropathy. Clients should be told to report muscle weakness and/or aches, pain, tingling and tenderness. CK levels will be monitored periodically during treatment as well. Anticoagulants Anticoagulants prevent the formation of blood clots by interfering with the clotting cascade, thereby preventing coagulation. The use of this class of medications is contraindicated with active bleeding, such as with bleeding disorders, ulcers, or hemorrhagic brain injuries. HEPARIN and COUMADIN are the two main anticoagulant medications. See the acrostics below for helpful hints and important facts about these drugs. HEPARIN H eparin sodium prevents thrombin from converting fibrinogen to fibrin. It is administered IV or SQ. E noxaparin (Lovenox) is a low-molecular weight heparin. It has the same action as heparin, but has a longer half-life. It is administered via subcutaneous injection. P rotamine sulfate is the antidote for heparin. A dminister heparin when there is the likelihood of clot formation, such as with myocardial infarction or deep-vein thrombosis. R isk for bleeding is the major side effect that clients should be educated about. Clients should be educated to monitor for bleeding, including bleeding gums, bruises, hematuria, and petechiae. I nstruct clients to avoid corticosteroid use, salicylates, NSAIDs, green leafy vegetables, and foods high in Vitamin K. N ormal activated partial thromboplastin time (aPTT) is 20 to 36 seconds, but to maintain a therapeutic level of anticoagulation while on heparin, the aPTT should be 1.5 to 2 times the normal value (60 to 80 seconds). COUMADIN C oumadin (generic name Warfarin sodium) interferes with coagulation factors by antagonizing vitamin K. O ral administration is typically used. Clients may need continued heparin infusion via IV until therapeutic effect of Coumadin is experienced (may take3-5 days). U se is contraindicated in clients with low platelet counts or uncontrolled bleeding