Ati Comp Predictor Quiz A, B

ATI COMP PREDICTOR QUIZ A, B Fourth stage of labor and suspects bladder distention. Which following findings should the nurse anticipate with bladder distention? The bladder fluctuates with palpation – bladder distention, the bladder is suprapubic, round, bulging, is dull to percussion, and fluctuates, as a balloon filled with water would. The uterus is usually displaced to the right, is boggy, and is well above the umbilicus. Severe reactive airway disease about glucocorticoid therapy. Parent asks why inhale the medication instead of taking it orally? Oral glucocorticoids are more likely to slow linear growth in children – inhaled glucocorticoids deliver the anti-inflammatory agent directly to the local target area (the client’s airways) resulting in a decreased risk for adrenal suppression. Borderline Personality Disorder expressing concern about needing prolonged hospitalization. Which statement should nurse make? Help them express their feelings or a question in which helps expression their feelings - Borderline Personality Disorder pts have a hard time expressing their feelings Difference between angina pectoris and myocardial infarction (MI). SATA: Nausea, vomiting, and epigastric distress are common manifestations of MI New prescription for metoprolol. Which of the following instructions should the nurse include? SATA: Do not stop this medication abruptly Count your radial pulse daily Change positions slowly Clients who stop taking metoprolol abruptly increase their risk for angina, hypertension, and myocardial infarction. They should reduce the dosage gradually over 1 to 2 weeks. Assessing a pt with pancreatitis. Which is an expected elevation lab result? Amylase – the level remains elevated for 2-3 days Other expected labs for pancreatitis: Decrease in Mg Hypocalcemia Increase in WBC [indicating inflammation] Postanthesia care unit of a client wo has had a subtotal thyroidectomy. Which equipment should the nurse have available at bedside for this client? Tracheostomy tray – with laryngeal edema that is common with post thyroidectomy, respiratory distress could result in airway obstruction. Emergency intubation can be difficult due to laryngeal swelling, and endotracheal intubation can increase the risk for hemorrhage by increasing tension on the incision during insertion. Don’t need cardiac monitoring unless pt has had pre-existing cardiac dysrhythmia or is at risk for dysrhythmia. Defibrillator is available on every nursing unit, but unless pt has hx of cardiopulmonary arrest having it nearby is not essential. Thoracotomy tray; unless pt has hx of pneumothorax it is not essential. Nurse is admitting child with UTI and hx of myelomeningocele. Action take first? Attach a latex allergy alert identification band – myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk for latex allergy; therefore, the nurse should avoid the use of common medical products containing latex, such as latex gloves UTI is a common complication of myelomeingocele IUD information: Your risk for ectopic pregnancy increases with an IUD – provider inserts through cervix into the uterus to prevent pregnancy. Changes in weight does not affect IUD IUD is a reversible form of birth control, so having children is possible after it is removed Electroencephalogram (EEG): Shampoo your hair before the procedure, and don’t put any styling products in afterwards – hair must be clean for electrodes to adhere to the scalp. The client can eat normally, just NO CAFFEINE. Only monitors brain, does not stimulate it, so you do not feel anything. Electroconvulsive therapy: Short term memory loss is common after electroconvulsive therapy. Assessing an infant who has laryngotracheobronchitis. Which following findings should the nurse report as an indication of impending airway obstruction? Nasal Flaring – others include tachycardia, tachypnea, increasing restlessness, flaring nares, and intercostal retractions Pt has spinal cord injury and needs to perform intermittent urinary self-catherization at home after discharge. I will perform intermittent self-catheterization every 2 to 3 hours – with the frequency eventually increasing to every 4 to 6 hours. A longer interval can result in bladder distention and increase risk for uti – client at home uses clean not sterile technique. – drink at least 2 – 2.5L of fluid. – empty bladder fully. PKU screening test for newborn is done 24 hours after birth and after at least 2 days Child who has strabismus. Which of the following instructions should the nurse include to prevent development of amblyopia? Patch the unaffected eye – amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another problem such as strabismus. Strabismus is a muscle weakness allows one eye to wander. Mydiatric eye drops – during ophthalmic examinations Low-pressure alarm on the ventilator sounds indicates what? A leak within the ventilator’s circuitry – means ventilator tubing has come apart or tubing detached from client. High-pressure alarms indicate an increase in resistance each time the ventilator administers a breath to the client. Excessive airway secretions could generate a high-pressure alarm. Decreased lung compliance can also trigger high-pressure alarm. Coughing or attempting to talk can also trigger high-pressure alarm. Positive end expiratory pressure (PEEP) via mechanical ventilation, monitor client for what a/e? Tension pneumothorax – monitor client’s lung sounds hourly for indications like tracheal deviation, absent breath sounds, distended neck veins, hypotension PEEP is used to tx hypoxemia and improve oxygenation, used to prevent atelectasis [partial or complete lung collapse] Performing client triage while participating in disaster drill. The nurse should recommend that which of the following clients receive treatment first? Hemothorax – is life threatening, but chest-tube insertion and stabilization the client is likely to survive Open humerus fracture – pt can wait for tx as it is not life threatening Superficial partial-thickness burns on both legs – minor burns is not threat to life can wait for tx Lactose intolerant and needs calcium source: Collard Green Folic acid – broccoli Abdominal aortic aneurysm (AAA) – which indicates AAA is expanding? Report of sudden, severe back pain – sudden and increasing lower abdominal and back pain indicates that aneurysm is extending downward. Can have decreased BP and increase pulse rate Presbyopia – difficulty reading the paper [difficult to change shape to focus on objects close up] Myopia [nearsightedness] – seeing numbers on highway signs Astigmatism – Driving at night Medication is at risk for delayed wound healing? Prednisone – clients who have arthritis often require high doses of prednisone to help resolve exacerbations. Nifedipine – can cause dermatitis and urticaria Chlorpromazine – can cause dermatitis and eczema Prescription for sildenafil citrate. Which of the following data in the client’s record should the nurse identify as a contraindication for the use of this medication? Concurrent use of isoborbid to tx heart failure- taking any nitrates, such as isosorbide and nitroglycerin is a contraindication of sildenafil, a medication for erectile dysfunction. Taking it with nitrates can cause life-threatening hypotension. Sildenafil citrate – erectile dysfunction medication Pt at 38 weeks of gestation and in the active phase of the first stage of labor. The nurse notes two late decelerations of the fetal heart rate during the last five contractions. Which action to take? Assist the client in a lateral position – side lying position improves blood flow Antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client’s behavior? Speak to the pt with clear, calm, caring statements – to remain in control should use clear, calm statements that are nonthreatening to the pt. The nurse should set limits for pts who exhibit potentially violent behavior Intellectualization as a way of coping with anxiety of admission? I have read that problems with substances can have a variety of predisposing factors – the nurse should identify this response as a use of intellectualization. Intellectualization is an attempt to use intellectual processes to avoid expressing the emotions that stem from stressful situations. Denial: I was just using the medication to help me out during a rough time in my life. I can stop whenever I want. Rationalization: This all happened because my spouse is unemployed. That puts an enormous amount of stress on me. [excuses] Suppression: I just don’t want to talk about it. There is nothing you can do about it anyway. [avoiding discussion of substance abuse] Epistaxis (bloody nose): apply continuous pressure to lower part of his nose. [child sitting up and breathing through his mouth for 10 mins.] Diaphragm usage – use spermicidal jelly whenever using diaphragm as it is not 100% effective alone. Women should insert diaphragm up to 6 hours before vaginal intercourse. Wait at least 6 hours after vaginal intercourse before removing diaphragm COPD ; use nasal cannula Child abuse signs: Spiral fracture – indicates twisting of extremity Lacerations or abrasions to backs of legs Pain with urination or recurrent UTI ABD pain and swelling In order to prevent the manifestations of tachycardia, dyspnea, a cough, and distended neck veins in the pt who is receiving a transfusion of packed red blood cells what to do? Use a transfusion pump to regulate and maintain the transfusion at a slower rate Meperidine is not recommended for chronic pain because using it long-term can cause accumulation of toxic metabolite. More effective for residual limb pain. Amitriptyline, gabapentin, and propranolol can help manage phantom limb pain. Toddler who is undergoing insertion of tympanostomy tubes. The tubes should stay in place until they fall out on their own - tympanostomy tubes allow for drainage from and ventilation to the middle ear. They usually fall out on their own 6 to 12 months after insertion. Should wear earplugs whenever it is possibility getting wet. Hyperthyroidism managing the disorder Increase her caloric intake with meals – increased protein, lipid, and carbohydrate. Have cooling blanket and environment ready Common to have inability to sleep Often restless have an increased systolic BP, tachycardia, and other dysrhythmias. Syndrome of inappropriate antidiuretic hormone – which med expect will prescribe? Tolvapatan – SIADHA is a disorder of water intoxication due to the inappropriate, continuous secretion of antidiuretic hormones causing hypervolemia and hyponatremia. Tx of SIADHA include fluid restriction, sodium replacement with small amounts of 0.9% NaCl . Tolvapatan promotes excretion of water. Clozapine to tx schizophrenia: parameters as an early indication of an adverse effect of this medication? Temperature – this medication is the depletion of WBCS. This increase the pts risk for infection. Fever is an early indication that pt should have WBC checked Lupus expected increase lab – ESR Autonomic dysreflexia: Facial flushing, nasal congestion, headache, blurred vision Hepatitis A: Use a 1:100 chlorine bleach solution to clean kitchen surfaces, encourage safe food handling and appropriate hand hygiene techniques Pediculosis capitis should seal nonwashable items in a plastic bag for 2 weeks Anencephaly – a fetus with an underdeveloped brain Obstructive sleep apnea – complications to monitor: hypertension, heart failure, and dysrhythmias Root reflex of infant – stroke infant’s cheek; will cause infant to turn towards that side and suck Extrusion reflex – depress the infant’s tongue; makes them stick their tongue out Glabellar reflex – a tap on bridge of nose; cause them to close eyes tightly Retinal detachment – floating dark spots Glacoma – increased intraocular pressure Macular degeneration – decreased ventral vision Cataracts – double vision Methadone teaching – sedation is a common a/e, can take this when pregnant, can develop physical dependency, can cause respiratory depression Therapeutic touch for – pain, depression, healing of body tissues, physiological needs such as reducing blood pressure, fever, and nausea Acupuncture – alter and improve immune, neurologic, cardiac, and endocrine function. It can help relieve pain and assist with substance withdrawal Spinal manipulation – help with back pain, asthma, and allergies Guided imagery – good for PTSD patients, it is useful therapy for anxiety and pain, pt can learn how to relive own symptoms Tonsillectomy postop – Position pt so head is lower than chest NO STRAWS, NO COUGHING/CLEARING THROAT, administer analgesic q4 for first 24-48 hours Risks for developing pressure ulcer: Diarrhea Recent wt loss of 5% body weight Diabetes insipidus monitor: 3P’S Poluria Polydipsia Tachycardia hyperthermia Identify true labor signs: The cervix transitions to an anterior position Contractions felt in lower abdomen and back Cervix progressively shortens and thins Sterile technique catheter for males: Open flap away from body Use dominant hand to clean penis Dong sterile gloves before touching any items in sterile field Set cath tray on overbed table at waist height Program of All-Inclusive Care for the Elderly (PACE) Provides adult day care services along with in-home assessments and supportive services Type 1 Diabetes Mellitus: NO COLD THERAPY as they already have impaired circulation Client has appendicitis. Which area is McBurney’s point? Right lower quadrant between umbilicus and anterior iliac crest Anti social personality disorder manifestations : lack of remorse Narcissistic personality disorder: sensitivity to rejection Bipolar disorder: extreme mood swings Borderline personality disorder: self-mutilating behavior Assess a client that is taking methylenedioxymethamphetamine (MDMA) what to expect? Diaphoresis – and lowered inhibition ,chills, muscle cramping, teeth clenching, and mild hallucinogenic effects LPN: can insert an NG tube AP: preparation of client’s postoperative bed, collection of stool specimen Cystic fibrosis finding is a priority? Hemoptysis 275mL/24 – is is greater than 250mL/24hr indicates that client is at greatest risk for hemorrhage. Pt got lorazepam for panic attacks, RR 6/min, BP 90/44 what med to give? Flumazenil – reverse sedative effects of lorazepam. Naloxone reversal agent for morphine. Acetycysteine is reversal agent for acetaminophen. Atropine is reversal agent for neostigmine. Mechanical restraints – Make sure staff member to stay in with pt continuously Assess q15-30mins Check new prescription q2hr Ginseng can stimulate mental activity and increase appetite, can interact with caffeine + cause irritability Infectious gastroenteritis – initiate oral rehydration therapy for the toddler – diarrhea causes dehydration, which results in fluid volume deficit. Oral rehydration solution that contains sodium, potassium, chloride, citrate, bicarbonate, and glucose Pt receiving heparin to tx DVT what interventions to do? Elevate the affected leg – to reduce edema and decrease chronic venous insufficiency Encourage pt to ambulate Drink 2 – 3L of fluid Warm compresses on affected area Assessing pt taking lithium carbonate for past month to tx bipolar disorder. Which assessment is priority? Confusion – others including hand tremors, confusion, ECG changes, and sedation. Polyuria, headache, and hyperglycemia are expected findings of a/e Breast engorgement – bottle feeding baby: Wear tight fitting bra or breast binder Ice packs on breast to reduce swelling and relieve pain Indication of fluid volume deficit: Increased BUN levels Orthostatic hypotension Indication of fluid volume overload: Visual disturbances SOB Root cause analysis: Look at overall systems or processes that affect a situation to identify the fundamental cause of the problem. NG Tube: Inject 10-30 mL of air into NG tube before checking residual to clear tube of any feeding. Flush NV tube of 20 mL water before and after each feeding Elevate HOB 45 degrees for 1 hr after feeding Blood transfusion: Collect 1 unit of blood at a time Initiate the blood transfusion within 30 mins of removing it from blood bank Report to CDC: Foodborne botulism Total hip arthroplasty: Install a raised toilet seat at home Maintain the hip at angle less than 90 degrees Use walker to minimize falls/injury NO PILLOW under knees when lying down. Pt had stroke 6 hrs ago. Intervention to lower the risk of increased intracranial pressure? Place the pt in a quiet environment Elevate HOB no more than 25 degrees Spread out nursing activities throughout the day Myasthenia gravis – instructions to include: Cut foods into small bites and eat slowly – prevent aspiration Choose snacks that are high in calories – maintain adequate nutrition Keep HOB elevated during meals and for 30 to 60 mins following meals – prevent aspiration Weigh pt daily – nutritional status Administer 2 units of fresh frozen plasma to an older adult pt. Which action should the nurse plan to take? Enter plasma product number into pt’s medical record Administer each unit of plasma over 30 to 60 mins. Transfuse plasma immediately after obtaining it from blood bank. Tracheostomy care: Remove inner cannula, remove soiled dressing, clean stoma with sterile saline, change tracheostomy collar Manifestations of ovarian cancer: Increase in abdominal girth Abdominal bloating Pelvic or abdominal pain Early satiety Urinary frequency/urgency Digoxin Toxicity: Nausea Diarrhea Muscle weakness Rheumatoid Arthritis: Allow for frequent rest periods throughout the day Warm shower NOT bath Only take 4g of acetaminophen each day Priority finding in postoperative c-section: Unilateral tenderness of the lower left extremity – can indicate the pt is developing DVT Tunneled central venous catheter teachings Flush catheter daily with heparin when not using regularly Catheter clamped to prevent blood backflow – as tunneled catheter does not have a two-way valve Restrict physical activities until tissue adheres to the cuff Change dressing every 5-7 days Fluoxetine report what? Tremors - this drug can cause serotonin syndrome within 2-72 hr after starting tx. Can experience tremors, agitation, confusion, anxiety, and hallucinations Stage II pressure ulcer – partial thickness skin loss [blister formation] Stage IV pressure ulcer: muscle damage, tendon exposure Stage III pressure ulcer – visible subcutaneous tissue Deficit with Cranial nerve II – what is nurse plan? Clear objects in client’s walking area [visual impairment lead to falls] CN IX: impair swallowing CVIII: hearing loss, restate directions K level 3 mEq/L.Clinical manifestation should the nurse monitor? Decreased deep tendon reflexes – muscle weakness, hypoactive bowel sounds Dry sticky mucous membranes – hypernatremia Numbness and tingling of extremities – hypocalcemia Placenta previa – painless vaginal bleeding Abruptio placentae – persistent uterine contractions – dark red vaginal bleeding Preeclampsia – hyperactive deep tendon reflexes Vasooclusive crisis indication – hematuria , painful swelling of hands & feet, visual disturbances Acute Kawasaki disease – fever unresponsive to antipyretics , tachycardia Subacute phase of Kawasaki disease – pain in wt bearing joints, peeling of soles of feet Car seat: 45 degree angle Back rear facing car seat until 2 yo Secure retainer clip at level of baby’s armpit Furosemide – high potassium diet [b/c they’re lose k+] Phenytoin – can have milkshake/dairy Vermapil + TPN is okay Clonidine – a/e reactions: [BP med, cancer pain med] Dry mouth Constipation Alter taste Rashes, pruiritus, edema Abdominal assessment: INSPECT - AUSCULTATE - PERCUSSION - PALPATE Hyperthyroidism: TACHYcardia, diaphoresis, wt loss, insomnia, exophthalmia (bulging of eye), tremors Acute glomerulonephritis expect in urine: Protein Urolithiasis expect in urine: Uric acid crystals Asthma: NO carpet Record highest three readings of peak expiratmatory flow meter No aspirin Yearly flu shot helps Postpartum with baby: Feedings with newborn’s cues – at least 8-12 times in 24/hr Cover baby’s body when washing hair so that there is no heat loss Use bulb syringe in mouth first then nose No bathing baby daily No baby sleeping on stomach Paracentesis: Instruct client to void – empty bladder Fowler’s position Nagele’s rule: minus 3 months, add 7 days Dissociation as defense mechanism: describe own child abuse as if it was someone else Compensation: shorter than average more assertive to co-workers Repression: forget to buy gift for bf because of disagreement Lithium: Notify provide if you feel extreme thirst Stop med if blurred vision Take med with meal Amitriptyline a/e: Constipation Urinary retention Dry mouth Blurred vision Fluid overload: Dyspnea Tachycardia Basal body temperature method of birth control: Body temperature will decrease slightly prior to ovulation (0.5F) Measure each morning before getting out of bed Body temp rises about 0.5-1F within 1-2 days after ovulation Lab test prior to adjusting heparin: aPTT should be 60 to 80 seconds WARFARIN lab test: INR Digital evacuating stool: Lube gloved finger along rectal wall Pulmonary edema = pink frothy sputum, crackles in lungs, clammy skin, tachycardia Resuscitation phase of burn injury labs: HYPERkalemia, HYPOnatremia, Increased HCT, decreased albumin Hypoglycemia: Irritability Hyperglycemia: Increased urination, vomiting Chlorpromazine effective indication [antipsychotic medication] - Decreased hallucinations a/e: orthostatic hypotension Continuous passive motion (CPM) following total knee arthroplasty Turn off during meal times to promote comfort and dietary intake Gastric Lavage: Client lie on left side Instill 200-300mL of water or 0.9% NaCl Snellen Chart: Stand 10 ft away Keep glasses on, then off Keep both eyes open Compartment syndrome: edema Pain Pallor Paresthesia Peripheral artery disease: Applies lubricating lotion to feet to prevent cracked skin Trim toenails straight across No heat directly DO NOT elevate feet above heart Blood lead level for child should be less than 5 IM injection for obese pt: 90 degree angle Use ventrogluteal site Z track method Risperidone: Impelemnt fall precautions Hypoxia: Lightheadedness, restlessness