ATI Comprehensive Final Quiz, RN Comprehensive Predictor 2019 A, RN Comprehensive Predictor 2019 Form B and C

What is a nurses priority action when a patient is experiencing anaphylactic shock while receiving IV medications? ANSWER Priority action: stop the medication infusion The nurse can also: Administer epinephrine; infuse .9% sodium chloride, and elevate the lower extremities to help maintain adequate blood pressure A nurse is caring for a group of clients in a long-term facility. One of the clients is walking in the hallway and bumping into walls and does not respond to his name. which of the following actions should the nurse take first? ANSWER Accompany the client back to his room. What medication is contra indicated while taking St. John's wort? And why? ANSWER Sertraline Taking concurrently puts the patient at risk for serotonin syndrome Both of these are used for Tx of depression Persistent otitis media ANSWER An infection of the middle ear Passive smoking promote adherence of respiratory pathogen's to the lining of the middle ear space which prolongs inflammation and impedes drainage from the ear Exposure to cold weather does not cause otitis media Acarbose (Precose) adverse effects ANSWER Sleepiness, headaches, anemia; the most common adverse effects are gastrointestinal - diarrhea, abdominal distention, cramping, flatulence presbyopia ANSWER impaired vision as a result of aging Can affect one's ability to read the newspaper, the lens is unable to change shape to focus on close up objects Myelomeningocele ANSWER Most severe form of spina bifida in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac and protrude through the spine Neural tube defect pts are at Rx for latex allergy Most common complication of this disorder is UTI Prevention of the development of amblyopia ANSWER A disorder of the eye and which unilateral central blindness occurs as a result of another problem, such as strabismus Parents should patch the unaffected I Strabismus ANSWER Cross eyed Without treatment by 6 years of age this can lead to central blindness (amblyopia) Ethambutol (Myambutol) ANSWER Med for TB, report vision changes immediately Adverse effects: loss of red/green color discrimination due to optic neuritis; d/c if this occurs Isoniazid (INH) ANSWER Antitubercular Adverse effects: hepatotoxicity, peripheral neuropathy, yellowing of the sclera is an indication of jaundice that accompanies liver failure Rifampin (Rifadin) ANSWER Anti TB and Antibiotic Adverse effects: changes in color of bodily secretions to red-orange What is a patient at risk for when they're platelet count is below the reference range? ANSWER Indicates thrombocytopenia, which puts the patient at increased risk for bleeding What should a nurse anticipate with bladder distention in the fourth stage of labor? ANSWER Bladder will fluctuate with palpation Bladder is dull to percussion Uterus will be displaced to the right, is boggy, well above the umbilicus cystitis ANSWER inflammation of the bladder lining, Commonly occurs with UTI Prevention methods: Stay well hydrated, urinate before and after sex, wipe front to back, avoid tub baths Intrauterine device (IUD) ANSWER Small, T-shaped device inserted by a physician inside the uterus to prevent pregnancy Increased risk for a topic pregnancy Does not protect from STI's or HIV Manifestations of retinal detachment ANSWER sudden onset of decreased peripheral or central vision, dark floaters, flashes of light. curtain vision over part of visual field Manifestations of cataract ANSWER Decreased color perception, blurry vision,clouding of the lens of the eye Without treatment leads to blindness Manifestations of Angle-closure glaucoma ANSWER Rapid onset of e severe pain around the eyes and face, reduced vision, colored halos, headaches, sudden onset of elevated IOP Manifestations of macular degeneration ANSWER Gradual, mild to moderate reduction of central vision Nursing actions for a patient in Balanced skeletal traction ANSWER Patient who is in mobile is at risk for constipation, nurse should encourage a high fiber diet and increased fluid intake Active range of motion of the affected limb is not feasible due to limited mobility with the traction apparatus The nurse should not remove the weights after they're in place Nurse should inspect the pin site at least every 8 to 12 hours due to risk of infection Priority assessment for infant experiencing dehydration ANSWER Measure the patient's weight daily; critical for infants and children because fluid accounts for a greater portion of their body weight What is included in an infant Hydration assessment what does it determine? ANSWER Checking for absence of tears, palpating the fontanelles excess skin turgor Assessing these factors determines degree or severity of an infants dehydration Priority action for a patient who had a seizure and is unconscious ANSWER Priority action: CHECK AIRWAY PATENCY (airway always first) A nurse can then assess the patient for injuries perform a neurological exam and measure the patient's vital signs once an airway is established Vaginal yeast infections during pregnancy ANSWER Hormonal changes of pregnancy change the acidity of the vagina, making used infections more common Clozapine (Clozaril) ANSWER Atypical Antipsychotic Tx of schizophrenia Adverse effects: urinary retention, orthostatic hypotension, agranulocytosis Fever is an early indication of possible depletion of WBCs or agranulocytosis; WBC count should be checked tympanostomy tube placement ANSWER placement of a tube in the tympanic membrane to relieve symptoms caused by fluid buildup Most children do not need tubes from more than one year; usually fall out on their own between 6 to 12 months after insertion Should wear air plugs to prevent contaminated or soapy water from entering the ears Hearing impairment common with otitis media and can continue after tubes are in place Thrombocytopenia precautions ANSWER Thrombocytopenia is a low platelet count, common after bone marrow transplant's Patients are at increased risk for bleeding Prevention: avoid hard foods No fresh flowers because patient is in protective isolation Use of an electric shaver Do not blow nose or insert objects into nares Lactose free calcium sources ANSWER One cup of collard greens provides about the same amount of calcium equivalent to 8 ounces of milk