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LECTSTEPHEN
ATI CAPSTONE COMBO ASSESSMENT A:B
what is montelukast (singular) for?
• a leukotriene modifier, and is taken on a regular basis, once a day, and not
prn, and is not used for exercise induced asthma
• what does advance directives contain?
• written instructions regarding end of life care
• what is the greatest risk to a pt receiving hemodialysis?
• disequilibrium syndrome as a result of rapid loss of fluids and decrease
bun
• what is the clinical manifestation of disequilibrium?
• restlessness and decreased level of consciousness
• what are expected findings in hemodialysis?
• elevated temp
weight loss
decreased bp
• what should the nurse do when a pt feels lightheaded and begins to fall?
• spread feet apart and extend one leg for the pt to slide down while
lowering the pt to the floor
• what are the characteristics of a pt with dependent personality disorder?
• they have problems making everyday decision without input from others
• a pregnant pt who is bleeding is always?
• priority
• what should a pregnant pt with urgency and frequent urination do?
• should perform kegel exercises
• what should a pregnant pt with odorless vaginal mucus do?
• practice good hygiene, use perineal pads
• a pregnant pt with edema of the ankles do?
• avoid prolonged standing, to wear support hose, and rest through out the day
with legs/hip elevated
• when should a colostomy bag be changed?
• when is 1/3 -1/2 full
• how large should the opening of the stoma pouch be?
• no larger than 1/4 inch
• what should the pt with a colostomy avoid?
• the use of moisturizers, which will decrease the adherence of the pouch to the
skin
• what should the pt do with the pouch removing it?
• they should empty the pouch to avoid spilling the effluent on to the skin
• where should drops be instill into?
• into the conjuctival sac
• what is a positive way of dealing with a terminal illness?
• "remembering things they used to do together"
• what are normal findings after a colonoscopy?
• abd cramping
fatigue
passage of liquid stools
• what are unexpected finding after a colonoscopy?
• guarding- can indicate bowel perforation
• what do you do if an order is questioned?
• the nurse should record seeking clarification from the provider
• what should pt with gastritis eat?
• a well balanced diet, they should keep a record of foods that cause discomfort,
pts can modify their diet accordingly
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• what is the cause autonomic dysreflexia?
• bladder distention
• what are s/s of icp?
• restlessness
change in LOC
• what is late s/s of ICP?
• widening pulse
decerebrate posturing
• when can a child with varicella(chickenpox) return school?
• the child can return to school when the blisters are dry and no longer drained
(scabbed over)
• what is an appropriate behavior of a pt with hx of violence?
• pt will avoid violence provoking situations
• what is a skin cancer prevention?
• pts should use sunscreen that protects against uva and uvb
• what is the first thing you should do with excessive lochial discharge?
• perform a fundal massage
• what is the nurse responsibility of the nurse when witnessing the pts signature on
an informed consent?
• that the pt is fully informed and understands the procedure befor signing the
consent form
• who are at greater risk for std?
• females because of increased vascularity to the vagina
• does trichomonas vaginalis increased the risk for cervical cancer?
• NO
• Gonorrhea can lead to?
• pelvic inflammatory disease and tubal scarring and can result in infertility
• what should you do with postmortem care?
• always check about religious practices prior to body preparation in order to honor
fam wishes
• what can you not give to a pt with thickened liquids?
• no ice chips
no water
no icepops
• what can a pt with thickened liquids have?
• oatmeal
• what should a pt do with incentive spirometer?
• they should elevate the cylinder by inhaling deeply
assume semi fowlers or high fowlers position
• in order to maintain sterile technique what should the nurse do?
• should open all sterile packages prior to donning sterile gloves
• what is psycho-motor learning?
• have the pt demonstrate back the procedure
• what places a newborn at risk for respiratory depression?
• administration of an opioid analgesic
exa: fentanyl (sublimaze)
• what is an effective method of bowel retraining?
• anal stimulation with a gloved finger after the evening meal, it will help stimulate
the gastrocolic reflex
• when inserting an NG tube?
• the nurse should insert the tube into the airway that is patent and has greater
airflow
• what technique should be NG tube insertion?
• clean technique
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• if NG tube meets resistance?
• the nurse should rotate the tube without forcing it past the area of resistance
• what kind of lubricant should be used during NG tube insertion?
• water- based lubricant NOT petroleum jelly
• what is pediculosis capitis management?
• store child's clothing in a separate cubicle at school
boil brushes and combs in water for 10 mins
dry bed lines and clothing in a hot dryer for at least 20 mins
• what can visual disturbances indicate?
• preeclampsia
• what is expected 24 hrs after surgery?
• hypo active bowel sounds
pain
• what is an abnormal finding 24 hrs after surgery?
• low HGB
• what must be done in bucks traction?
• the pt must be in proper alignment
boots are secured by 3 straps, around pt leg
weights must hang freely
footplate is resting 15.24 cm (6inches) from the footboard
• what does pts with delirium demonstrate?
• a fluctuating LOC often at night or in am
• pt with dementia demonstrate?
• difficulty finding correct words to use
• pt with anxiety disorders demonstrate?
• obsessive behavior
• how would the nurse determine progression of ascites?
• abdominal girth should be measured daily
• what is a food high in potassium?
• cantaloupe
• what is an indication of peripheral venous disease?
• brown pigmentation around ankles
• what is indication of peripheral arterial disease?
• intermittent, leg muscle pain
• what is some skin care for pts on radiation therapy?
• pat area when drying
use hand to wash
do not use sunscreen
• what can hydromorpone cause?
• urinary retention
• what does bethanechol (urecholine) causes?
• it stimulates urinary out put
• how is nystatin best absorb?
• if given 1 hour before or after a feeding
• what is a sign that a newborn has finished eating?
• a slowed suck/swallow pattern is a sign that the newborn is finished eating
• what not to do when breastfeeding?
• is not necessary for the entire areola be in the mouth
each feeding should start at the opposite breast
do not push back of newborns head-toward the nipple
• what should be included in a stool specimen?
• visible blood, pus, or mucus
• what is the first action in an infiltrated IV?
• to d/c the saline lock
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• what is the first action when preparing to do a dressing change?
• to determine the pts level of pain
• what should a with hemonymous hemionopsia with right visual field, what will
help pt eat better?
• the pt should turn head to the right to see all food on tray
• what are some side effect for theophylline (theo-dur)?
• is used to prevent wheezing,sob, chest tightness in asthma
irregular pulse and dysrhythmias
seizures
anxiety
urinary frequency
anorexia
n/v
diarrhea
• what should you do when given enoxaparin (lovenox)?
• it should be injected SUBQ
do not aspirate
do not massage
do not inject in same area
• what is the babinski reflex?
• stroke sole of the foot upward, toward the great toe
• what is the moro reflex?
• startle the infant by clapping hands`
• what is the stepping reflex?
• hold infant upright and allow one foot to touch tables surface
• what is the palmer grasp reflex?
• place an object in the palm of infant hand
• what should you do when catheterizing a male pt?
• pt should be place in supine position
penis should be at 90 degree angle
retract the foreskin and clean the glans prior to catherization
• what color is the meconium?
• it is the first stool passed and it is dark green and viscous
• what is an inportant thing to ask when pt having cardiac catherization?
• if pt allergic to iodine
• what should be done with nitroglycerin (nitrostat)?
• if pt continues to have pain after taking 1 tab, they should call 911 and take a
second tab
• what is normal after taking a nitroglycerin (nitrostat) tab?
• h/a
change positions slowly
it should be kept in original, dark colored bottle to avoid light exposure
• what to do for restrains use?
• observe skin condition before applying restrains
use a quick release knot to secure the restraints
belt restrains should be placed over pts waist
able to insert two fingers under restraints
do not use all four side of rails to restrain pt
• what would indicate an active peristalsis?
• the presence of vowel sounds
• what does pt with COPD have?
• increased metabolism due to work of labored breathing
they have dry mouth/thick mucus
constipation
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LECTSTEPHEN
ATI CAPSTONE COMBO ASSESSMENT A:B
what is montelukast (singular) for?
• a leukotriene modifier, and is taken on a regular basis, once a day, and not
prn, and is not used for exercise induced asthma
• what does advance directives contain?
• written instructions regarding end of life care
• what is the greatest risk to a pt receiving hemodialysis?
• disequilibrium syndrome as a result of rapid loss of fluids and decrease
bun
• what is the clinical manifestation of disequilibrium?
• restlessness and decreased level of consciousness
• what are expected findings in hemodialysis?
• elevated temp
weight loss
decreased bp
• what should the nurse do when a pt feels lightheaded and begins to fall?
• spread feet apart and extend one leg for the pt to slide down while
lowering the pt to the floor
• what are the characteristics of a pt with dependent personality disorder?
• they have problems making everyday decision without input from others
• a pregnant pt who is bleeding is always?
• priority
• what should a pregnant pt with urgency and frequent urination do?
• should perform kegel exercises
• what should a pregnant pt with odorless vaginal mucus do?
• practice good hygiene, use perineal pads
• a pregnant pt with edema of the ankles do?
• avoid prolonged standing, to wear support hose, and rest through out the day
with legs/hip elevated
• when should a colostomy bag be changed?
• when is 1/3 -1/2 full
• how large should the opening of the stoma pouch be?
• no larger than 1/4 inch
• what should the pt with a colostomy avoid?
• the use of moisturizers, which will decrease the adherence of the pouch to the
skin
• what should the pt do with the pouch removing it?
• they should empty the pouch to avoid spilling the effluent on to the skin
• where should drops be instill into?
• into the conjuctival sac
• what is a positive way of dealing with a terminal illness?
• "remembering things they used to do together"
• what are normal findings after a colonoscopy?
• abd cramping
fatigue
passage of liquid stools
• what are unexpected finding after a colonoscopy?
• guarding- can indicate bowel perforation
• what do you do if an order is questioned?
• the nurse should record seeking clarification from the provider
• what should pt with gastritis eat?
• a well balanced diet, they should keep a record of foods that cause discomfort,
pts can modify their diet accordingly
Downloaded by: Lectmarcus |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
• what is the cause autonomic dysreflexia?
• bladder distention
• what are s/s of icp?
• restlessness
change in LOC
• what is late s/s of ICP?
• widening pulse
decerebrate posturing
• when can a child with varicella(chickenpox) return school?
• the child can return to school when the blisters are dry and no longer drained
(scabbed over)
• what is an appropriate behavior of a pt with hx of violence?
• pt will avoid violence provoking situations
• what is a skin cancer prevention?
• pts should use sunscreen that protects against uva and uvb
• what is the first thing you should do with excessive lochial discharge?
• perform a fundal massage
• what is the nurse responsibility of the nurse when witnessing the pts signature on
an informed consent?
• that the pt is fully informed and understands the procedure befor signing the
consent form
• who are at greater risk for std?
• females because of increased vascularity to the vagina
• does trichomonas vaginalis increased the risk for cervical cancer?
• NO
• Gonorrhea can lead to?
• pelvic inflammatory disease and tubal scarring and can result in infertility
• what should you do with postmortem care?
• always check about religious practices prior to body preparation in order to honor
fam wishes
• what can you not give to a pt with thickened liquids?
• no ice chips
no water
no icepops
• what can a pt with thickened liquids have?
• oatmeal
• what should a pt do with incentive spirometer?
• they should elevate the cylinder by inhaling deeply
assume semi fowlers or high fowlers position
• in order to maintain sterile technique what should the nurse do?
• should open all sterile packages prior to donning sterile gloves
• what is psycho-motor learning?
• have the pt demonstrate back the procedure
• what places a newborn at risk for respiratory depression?
• administration of an opioid analgesic
exa: fentanyl (sublimaze)
• what is an effective method of bowel retraining?
• anal stimulation with a gloved finger after the evening meal, it will help stimulate
the gastrocolic reflex
• when inserting an NG tube?
• the nurse should insert the tube into the airway that is patent and has greater
airflow
• what technique should be NG tube insertion?
• clean technique
Downloaded by: Lectmarcus |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
• if NG tube meets resistance?
• the nurse should rotate the tube without forcing it past the area of resistance
• what kind of lubricant should be used during NG tube insertion?
• water- based lubricant NOT petroleum jelly
• what is pediculosis capitis management?
• store child's clothing in a separate cubicle at school
boil brushes and combs in water for 10 mins
dry bed lines and clothing in a hot dryer for at least 20 mins
• what can visual disturbances indicate?
• preeclampsia
• what is expected 24 hrs after surgery?
• hypo active bowel sounds
pain
• what is an abnormal finding 24 hrs after surgery?
• low HGB
• what must be done in bucks traction?
• the pt must be in proper alignment
boots are secured by 3 straps, around pt leg
weights must hang freely
footplate is resting 15.24 cm (6inches) from the footboard
• what does pts with delirium demonstrate?
• a fluctuating LOC often at night or in am
• pt with dementia demonstrate?
• difficulty finding correct words to use
• pt with anxiety disorders demonstrate?
• obsessive behavior
• how would the nurse determine progression of ascites?
• abdominal girth should be measured daily
• what is a food high in potassium?
• cantaloupe
• what is an indication of peripheral venous disease?
• brown pigmentation around ankles
• what is indication of peripheral arterial disease?
• intermittent, leg muscle pain
• what is some skin care for pts on radiation therapy?
• pat area when drying
use hand to wash
do not use sunscreen
• what can hydromorpone cause?
• urinary retention
• what does bethanechol (urecholine) causes?
• it stimulates urinary out put
• how is nystatin best absorb?
• if given 1 hour before or after a feeding
• what is a sign that a newborn has finished eating?
• a slowed suck/swallow pattern is a sign that the newborn is finished eating
• what not to do when breastfeeding?
• is not necessary for the entire areola be in the mouth
each feeding should start at the opposite breast
do not push back of newborns head-toward the nipple
• what should be included in a stool specimen?
• visible blood, pus, or mucus
• what is the first action in an infiltrated IV?
• to d/c the saline lock
Downloaded by: Lectmarcus |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
• what is the first action when preparing to do a dressing change?
• to determine the pts level of pain
• what should a with hemonymous hemionopsia with right visual field, what will
help pt eat better?
• the pt should turn head to the right to see all food on tray
• what are some side effect for theophylline (theo-dur)?
• is used to prevent wheezing,sob, chest tightness in asthma
irregular pulse and dysrhythmias
seizures
anxiety
urinary frequency
anorexia
n/v
diarrhea
• what should you do when given enoxaparin (lovenox)?
• it should be injected SUBQ
do not aspirate
do not massage
do not inject in same area
• what is the babinski reflex?
• stroke sole of the foot upward, toward the great toe
• what is the moro reflex?
• startle the infant by clapping hands`
• what is the stepping reflex?
• hold infant upright and allow one foot to touch tables surface
• what is the palmer grasp reflex?
• place an object in the palm of infant hand
• what should you do when catheterizing a male pt?
• pt should be place in supine position
penis should be at 90 degree angle
retract the foreskin and clean the glans prior to catherization
• what color is the meconium?
• it is the first stool passed and it is dark green and viscous
• what is an inportant thing to ask when pt having cardiac catherization?
• if pt allergic to iodine
• what should be done with nitroglycerin (nitrostat)?
• if pt continues to have pain after taking 1 tab, they should call 911 and take a
second tab
• what is normal after taking a nitroglycerin (nitrostat) tab?
• h/a
change positions slowly
it should be kept in original, dark colored bottle to avoid light exposure
• what to do for restrains use?
• observe skin condition before applying restrains
use a quick release knot to secure the restraints
belt restrains should be placed over pts waist
able to insert two fingers under restraints
do not use all four side of rails to restrain pt
• what would indicate an active peristalsis?
• the presence of vowel sounds
• what does pt with COPD have?
• increased metabolism due to work of labored breathing
they have dry mouth/thick mucus
constipation
Downloaded by: Lectmarcus |
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