Ati Comprehensive Predictor

ATI COMPREHENSIVE PREDICTOR what to check with pregnancy - Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. Position of the baby by fetal heart sounds - Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. Ventilatory alarms - HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc ICP and Shock - ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp Cor pumonae - Right sided heart failure caused by left ventricular failure (edema, jugular vein distention) Heroin withdrawal neonate - irritable, poor sucking brachial pulse - pulse area on an infant lead poisoning - test at 12 months of age Before starting IV antibiotics - obtain cultures! pt with leukemia may have - epistaxis due to low platelets when a pt comes in and is in active labor - first action of nurse is to listen to fetal heart tones/rate for phobias - use systematic desensitization NCLEX answer tips - choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. ARDS and DIC - are always secondary to another disease or trauma In an emergency - patients with a greater chance to live are treated first Cardinal sign of ARDS - hypoxemia Edema is located - in the interstitial space, not the cardiovascular space (outside of the circulatory system) the best indicator of dehydration? - weight---and skin turgor heat/cold - hot for chronic pain; cold for accute pain (sprain etc) When pt is in distress....medication administration - is rarely a good choice pneumonia - fever and chills are usually present. For the elderly confusion is often present. before IV antibiotics? - check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. COPD and O2 - with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. Prednisone toxicity - Cushings (buffalo hump, moon face, high blood sugar, HTN) Neutropenic pts - no fresh fruits or flowers Chest tubes are placed - in the pleural space Preload/Afterload - Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart. CABG - Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart. Unstable Angina - not relieved by nitro RBC - females 4.2-5.4 million males 4.7-6.1 million decrease RBC - anemia WBC - 5,000-10,000 elevated WBC - infection decreased WBC - immunosuppression Iron - females 60-160 mcg males 80-180 elevated iron - hemochromatosis, iron excess liver disorder, magaloblastic anemia decreased iron - anemia or hemorrhage platelets - 150,000-4000,000 increased platelets - malignancy or polycythemia vera decreased platelets - autoimmune disease bone marrow suppression or enlarged spleen Hbg - females 12-16 males 14-18 decrease Hgb and Hct - anemia Hct - females 37%-47% males 42-52% anemia in children S & SX: - pallor, brittle spoon shaped nails irritability, muscle weakness systolic heart murmur, enlarged heart, HF iron supplements - give 1 hr before or 2 hr after antacid to prevent malabsorpt N/D and constipation common at start of therapy use straw for liquid iron to prevent staining of teeth aPTT - 1.5-2X control range of 30-40 seconds test clotting factors and monitor heparin therapy increased aPTT - hemophilia disseminated intravascular coagulation DIC liver disease PT - 11-12.5 seconds, 85-100% increased PT time - evidence of deficiency or clotting decreaed PT time - evidence of vit K excess= bleed out