ATI PN Comprehensive Advanced Test 2017/2023

T/F the nurse should plug an NG tube and keep it above the level of the stomach when ambulating a client - Answers True. This prevents stomach contents from leaking into the pigtail T/F the nurse can NOT instil air into an NG pigtail but she can instil air IF there is leakage. - Answers True. If the nurse notes edema above the catheter insertion site, what is the best action of the nurse? - Answers This indicates infiltration. The nurse stop the IV infusion. THe presence of skin balancing indications infiltration as well. S/Sx of hypoglycemia: - Answers pale, sweaty skin, irritability, tachycardia, tremors and hungry S/Sx of hyperglycemia - Answers fruity breath, lethargy, weakness, thirst, polyuria, How can a pt decrease pain when replacing an ostomy pouch system - Answers Gently and gradually peeling the skin barrier away while *holding the skin taut* will minimize discomfort AND trauma to the peristomal skin If a pt does not meet goals or outcomes in the critical pathway due to an unexpected finding, or the nurse finds a need for additional interventions, what is the nurse's best action? - Answers document the findings as a variance as either a negative or positive variance. T/F Rifampin, for the tx of TB, can interact w/ and reduce the effectiveness of oral contraceptives, therefore the nurse should instruct the pt to use a secondary method to prevent pregnancy. - Answers True If a client taking Rifampin for the tx of TB complains of HA, fever, or muscle aches, what should the nurse's response be? - Answers Report the symptoms to HCP immediately as these indicate flu like symptoms and infection, which can lead to meningococcal meningitis A nurse in a providers office is reviewing pediculosis capitis management and prevention strategies w/ the parent of a school age child. What education should the nurse provide the parents with? - Answers Transmission of lice occurs via contact w/ personal items so store the childs clothing in a separate cubicle when at school. Do NOT use insecticides because they are a danger to young children and pets Boil brushes and combs in water for 10 minutes to kill lice and nits Dry bed linens and clothing in a HOT dryer for at least 20 minutes Contaminated non washable items should be sealed in a plastic bag for 14 days to kill the lice. Enoxaparin for the prevention of thrombosis should be administered how? - Answers SubQ Rotating injection sites A pt taking atorvastatin for hypercholesterolemia, experiences muscle pain, what does this indicate? - Answers This could be a manifestation of myopathy or muscle injury which is a potential serious adverse effect of statin drugs. Montelukast is a leukotriene modifier taken for asthma. Describe how it is appropriately used: - Answers Taken once daily for *maintenance* - it is NOT a rescue medication. How does the nurse appropriately obtain a blood draw? - Answers apply the tourniquet to find a vein *in the antecubital fossa*, then release the tourniquet cleanse the insertion site allow the site to dry reapply the tourniquet obtain blood draw Describe the first stool passed by a newborn: - Answers Meconium that develops in utero dark green to black and viscous contains components of amniotic fluid, cells, intestinal secretions and occult blood A nurse in contributing to a teaching plan for a group of male adolescents about the adverse effects of anabolic steroid use. What are the manifestations that the nurse should include: - Answers Reduced ht potential d/t premature epiphyseal closure reducing the full ht potential Liver disorders Hyperlipidemia Breast enlargement Acne Edema When a pt uses rationalization it is used as a means to what: - Answers justify unreasonable feelings, thoughts, or actions. ex. "I did not get a good grade because my teacher does not like me" When a pt uses denial, it is a means to what? - Answers Avoid unpleasant feelings, thoughts or needs by pretending they do not exist. ex. "I do not believe you because my mother cannot be gone" When a pt is compensating, the nurse would recognize this as what? - Answers The client is making up excuses for their negative behaviors. Ex. "When i've had a few drinks I feel much better about myself" What is suppression? - Answers The purposeful denial of an uncomfortable situation by putting it off until it is convenient for the client to address. ex. "I will call the doctor for my test results after I return from this vacation". A pt w/ a NG tube has continuous enteral feedings, what interventions should the nurse include: - Answers Aspirate gastric residual q 4 hrs Change enteral feeding bag and tubing q 24 hrs *W/hold feeding if more than 100ml to 250ml gastric residual volume is obtained* Measure the pH of gastric tube aspirate prior to administering nutrition, anything less than 5 indicates the tube resides in the stomach T/F sharing client information w/ the clients employer is a vilant of client confidentiality. The nurse should inform the employer he will need to speak directly with the client. - Answers True. A nurse is assisting w/ the care of a school age child immediately following surgery. The child weighs 21.8kg (48lbs) and has a chest tube applied to suction. What findings should the nurse report to the provider? - Answers Subcutaneous emphysema: this is an indication of an air leak under the clients skin. If there is more than 3mL/kg/hr of sanguineous drainage occurring for more than 2 to 3 consecutive hours following surgery this can indicate hemorrhaging and should be reported immediately. What are expected findings when a pt has a chest tube applied to suction: - Answers continuous bubbling in the suction control chamber - this is because it contains water and when suction is applied to the unit, continuous bubbling occurs. Fluctuation in the water seal chamber w/ inhalation returning to 2 cm - a higher level can impede the flow of air from the chest. T/F COPD causes respiratory stress that leads to hypermetabolism and wasting of the muscle mass. - Answers True. The client should drink high protein and high caloric nutritional supplements to maintain respiratory muscle fnx. Generalized petechiae over a newborn indicates what? - Answers Infection or a decreased platelet count and should be reported to the HCP immediately. Petechiae over the forehead, in a brow presentation of anywhere on the head of infants who had a nuchal cord, is an expected finding. A nurse is talking w/ a client who says the provider agreed to initiate a do not resuscitate prescription. After leaving the clients room what action should the nurse take? - Answers Check for documentation that the provider spoke with the client about the DNR Why should the nurse maintain a drainage flow rate, keeping the urine diluted to a reddish pink color on a pt w/ continuous bladder irrigation following a transurethral resection of teh prostate? - Answers This keeps the tubing free of clots and bleeding To maintain patency of a feeding tube and to ensure that a pt receives all their medication, what action is essential that the nurse perform? - Answers Flush the feeding tube w/ water before and after administration of medication. How often should the nurse check the neurovascular status of an affected extremity, postoperatively. - Answers Hourly for 24 hours Then q 2 to 4 hours How is the FLACC score determined? - Answers Five categories of behavior Facial expression Leg movement Activity Cry Consolability Why would a pregnancy place a vulnerable partner at risk for intimate partner violence? - Answers The perpetrator may selfishly view the pregnancy as a threat to the relationship and will likely envy the attention the child receives An orthodox judaism, following the death of a family member, likely would request what practice? - Answers That a family member can remain with the body of the loved one until burial. These individuals discourage or oppose autopsies, as well as cremation. Individuals who practice catholicism, following the death of a family member, likely would request what practice? - Answers That he/she will receive the last rites immediately after the death. Why should the nurse keep a pt in a side lying position after experiencing a clonic tonic seizure - Answers To facilitate the drainage of any secretions and prevent aspiration Adverse affects of betaxolol to treat glaucoma: - Answers HOTN Bradycardia (systemic effects) T/F a pt use home oxygen therapy should used petroleum jelly to protect his nares to prevent irritation from the nasal cannula. - Answers FALSE. Petroleum and oil based products are combustible, and should not be used with oxygen therapy. The pt SHOULD use a WATER BASED LUBRICANT. Why would the nurse identify a need for a referral to an occupational therapist - Answers They aid in finding pts special equipment to help them develop, recover and improve the skills needed for daily living and working T/F Ibuprofen or any other NSAID's can reduce the AntiHTN effects of medications meant to lower BP - Answers True Airborne PPE removal - Answers Gloves Gown Goggles Respirator AFTER leaving the pts room and closing the door. T/F a pt taking phenytoin is at risk for gingival hyperplasia, massaging the gums can help minimize this effect - Answers True Why should a pt who is undergoing a thoracentesis for a pleural effusion be positioned upright with their arms resting on the overbed table? - Answers This position widens the intercostal spaces and improves access the pleural fluid A pt is receiving radiation therapy for cancer of the larynx and is instructed to wear soft, loose clothing and wants to know why. What is the nurses best response? - Answers The affected area needs protect from sun exposure, wearing a something such as a soft scarf around your neck while outside will protect your skin. s/sx of dehydration: - Answers fever tachycardia decreased BP tachypnea weak and thready pulse low serum potassium levels T/F before a pt begins disulfiram (antabuse) therapy, the nurse should educate the pt that the pt will need to sign an informed consent, as well as undergoing a comprehensive medical examination. - Answers True a nurse is caring for a client who is scheduled for peritoneal dialysis. Which of the following actions should the nurse take first - Answers Ensure that the dialysate solution is at room temp OR the clients body temperature. A nurse observes a client in labor. Which of the following interventions should the nurse recommend for this client? - Answers Squatting using a birthing ball Counterpressure to the sacral area Leaning forward while kneeling When a nurse demonstrates the ethical principle of fidelity by fulfilling commitments and promises made to a client, this is considered what? - Answers Fidelity An expected PR interval is: - Answers 0.12 to 0.20 seconds An expected QRS duration is: - Answers 0.04 - 0.12 An expected ventricular rate is: - Answers 60 to 100/min T/F a nurse should realize that going back to sleep quickly is an indication of a child who is experiencing nightmares, and a child that does not fall back asleep quickly is experiencing sleep terrors, and are unable to fall asleep quickly d/t continued fear. - Answers FALSE. The nurse should realize that going back to sleep quickly is an indication of sleep terrors, NOT nightmares. *A child who is experiencing nightmares has difficulty in returning to sleep because of continued fear.* A nurse in collecting data from a client who has chronic pancreatitis and is receiving *pancrelipase*. What therapeutic response would indicate that the medication is working? - Answers Pt reports a decrease in the number of stools. A nurse is assisting with the plan of care for a client who has a continent urinary diversion. What intervention should the nurse plan to implement to facilitate urinary elimination? - Answers The use of intermittent urinary catheterization for client at regular intervals Females who have chlamydia are at an increased risk for: - Answers infertility Females who have gonorrhea are at an increased risk for: - Answers PID leading to infertility vitamin K is the antidote for: - Answers warfarin overdose Epoetin alfa is used for: - Answers the stimulation of RBC production Protamine sulfate is the antidote for: - Answers heparin Calcium gluconate is the antidote for: - Answers magnesium sulfate overdose Excessive mechanical ventilation can cause: - Answers respiratory alkalosis, increasing the pH of the pt A nurse is reinforcing teaching with an older adult client who has osteoarthritis. What instructions should the nurse include? - Answers Apply capsaicin cream 4 times daily to provide warmth and relieve joint pain. It should not be applied more than 4 times a day to avoid skin irritation Why is CAD a contraindication to the use of oral contraceptives - Answers It increases the pts risk for MI other contraindications are: gallbladder disease, breast cancer and HTN T/F clients who have diabetes insipidus usually have colorless urine w/ a specific gravity of 1.005 or less. - Answers True A nurse is reinforcing teaching w/ a client who has a new prescription for metronidazole (flagyl). The nurse should instruct the client to expect which of the following adverse effects while taking the medication?