ATI Comprehensive Exam Study Guide

Do not delegate - What you can EAT E-evaluate A-assess T-teach Addison's & Cushings - Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia Better peripheral perfusion? - EleVate Veins, DAngle Arteries APGAR - Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) Airborne precautions - My chicken hez tb (measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip - private room, neg pressure with 6-12 air exchanges/hr mask N95 for TB Droplet precautions - spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room or cohort mask!) Contact precaution - MRS WEE Multidrug resistant organism Rresiratory infection Skin infection Wound infection Enteric infection (C diff) Eye infection (conjunctivitis) Skin infection - VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism - S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) Woman in labor (un-reassuring FHR) - late decels, decreased variability, fetal bradycardia, etc Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC - Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) After lumbar puncture and oil based myelogram - pt is flat SUPINE (prevent headache and leaking of CSF) Pt with heat stroke - flat with legs elevated during Continuous Bladder Irrigation (CBI) - catheter is taped to the thigh. leg must be kept straight. After Myringotomy - position on the side of AFFECTED ear, allows drainage. After Cataract surgery - pt sleep on UNAFFECTED side with a night shield for 1-4 weeks after Thyroidectomy - low or semi-fowler's position, support head, neck and shoulders. Infant with Spina Bifida - Prone so that sac does not rupture Buck's Traction (skin) - elevate foot of bed for counter traction After total hip replacement - don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Prolapsed cord - Knee to chest or Trendelenburg Cleft Lip - position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. To prevent dumping syndrome - (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. AKA (above knee amputation) - elevate for first 24 hours on pillow. position prone daily to maintain hip extension. BKA (below knee amputation) - foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina - area of detachment should be in the dependent position administration of enema - pt should be left side lying (Sim's) with knee flexed. After supratentorial surgery - (incision behind hairline on forhead) elevate HOB 30-40 degrees After infratentorial surgery - (incision at the nape of neck) position pt flat and lateral on either side. During internal radiation - on bed rest while implant in place Autonomic Dysreflexia/Hyperreflexia - S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! Shock - bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) Head Injury - elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis (when outflow is inadequate) - turn pt from side to side BEFORE checking for kinks in tubing Lumbar Puncture - After the procedure, the pt should be supine for 4-12 hours as prescribed. Myesthenia Gravis - worsens with exercise and improves with rest Myesthenia Gravis - a positive reaction to Tensilon---will improve symptoms Cholinergic Crisis - Caused by excessive medication ---stop giving Tensilon...will make it worse. Liver biopsy (prior) - must have lab results for prothrombin time Myxedema/ hypothyroidism - slowed physical and mental function, sensitivity to cold, dry skin and hair. Grave's Disease/ hyperthyroidism - accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. Thyroid storm - increased temp, pulse and HTN Post-Thyroidectomy - semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypo-parathyroid - CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hyper-parathyroid - fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypovolemia - increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030 Hypervolemia - bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's Diabetes insipidus (decreased ADH) - excessive urine output and thirst, dehydration, weakness, administer Pitressin SIADH (increased ADH) - change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics hypokalemia - muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia - MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes Hyponatremia - nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids Hypernatremia - increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. Hypocalcemia - CATS Convulsions, Arrythmias, Tetany, spasms and stridor Hypercalcemia - muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! Hypo Mg - Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) Hyper Mg - depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY Addison's - Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Cushings - Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump Addesonian crisis - N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Pheochromocytoma - hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) Tetrology of Fallot - DROP -Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis Autonomic Dysreflexia - (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) FHR patterns for OB - Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill 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.