ATI Comprehensive Exam Questions And Well Elaborated Answers New Update Version.

For cataract extraction surgery, what are the protocols? - correct answer -avoid taking aspirin -use cool compress on eye before calling MD if itchy -avoid bending at the waist b/c it can raise intraoccular pressure (BEND AT THE KNEES) -don't lift anything over 10 lbs If a patient 24 hours p/o refuses to ambulate, what should you do first? - correct answer -assess pain -THEN you can educate, turn patient, give PRN analgesic What happens during true labor? - correct answer -cervix transitions to anterior position -contractions felt in low ab and back -increases w/ ambulation -cervix thins What are common side effects of amitryptiline (antidepressant)? - correct answer -dry mouth and constipation (eat fiber and chew gum) and BLURRED VISION -take a night to minimize drowsiness -lack of ability to sweat-avoid overheating What should you do for diabetes insipidus? - correct answer -monitor increase urine output (polyuria-over 4 L/day) -monitor tachycardia -orthostatic hypotension -increased BUN -monitor for hyperthermia d/t dehydration What should you do to minimize risk of increased ICP? - correct answer -place client in quiet environment -spread out nursing activities throughout the day -keep head of bed no more than 25 degrees What should you do for a client who recently got a stoma and can't afford it d/t lack of insurance? - correct answer -arrange for social services -refer to american cancer society -refer to support groups -refer to enterostomal therapist -DO NOT delay discharge What should you teach for myasthenia gravis patients? - correct answer -cut food into small bites and eat slowly (SEMI-SOLID) -keep HOB elevated 30-60 mins after meal -weigh self daily -take anticholinesterase meds 45-60 mins before meals (NOT anticholinergics) -choose snacks high in calories -ANNUAL FLU VACCINE-avoid pulmonary disorders b/c compromised resp muscles What should you do for clients who have rheumatoid arthritis and are in pain? - correct answer -allow frequent rest periods throughout the day -recommend warm showers, not baths to prevent falls -apply ice to reduce inflammation -don't do morning ADLs until pain meds are given -don't take more than 4 g of acetaminophen/day -encourage high iron, protein and vitamins What should you give a toddler who has infectious gastroenteritis? - correct answer -initiate oral rehydration therapy -DONT give BRAT (bananas, rice, applesauce, toast) diet because it doesn't have electrolytes What should you do if the client vomits on a reusable BP cuff? - correct answer -send it off in a labeled bag for contamination -DONT throw it away -rinse in cold water immediately after -use chlorine bleach to clean blood spills What does petechiae over the chest after a lower leg injury mean? - correct answer -at risk for fat embolism syndrome -PRIORITY FINDING What is important about newborn safety? - correct answer -set hot water heater temp at 120 degree F or below -DONT sleep with blanket -make sure crib slats are no more than 2.5 in apart -place baby's car seat rear facing until 2 What is within the LVN scope? Assistive personnel? - correct answer -LVN: insert NG tube -AP scope: prepare bed, obtain stool sample What should you instruct the client of a newborn baby regarding motor vehicle safety? - correct answer -place baby at 45 degree angle -rear facing until 2 year old -place blanket over baby AFTER harness is set -secure retainer clip at level of baby's armpit What about a physicial assessment is wrong? - correct answer -SHOULDNT write detailed notes What are the steps of trach care for a child? - correct answer 1. Take out inner cannula 2. Remove soiled dressing 3. Clean stoma 4. Replace collar What is important regarding NPH and regular insulin? - correct answer -air into NPH, air into regular -draw from regular, draw from NPH -roll NPH between palms -use same needle What is care like for patients with DVT? - correct answer -elevate leg to reduce edema and improve blood flow -encourage ambulation -drink 2-3 L of fluid to decrease platelet aggreggation and prevent dehydration -place warm compress on leg For clients with uric acid formation urinary calculi, what foods can they eat? - correct answer -oranges -AVOID meats, alcohol, chicken What is the first action a nurse should take when discharging a client who was abused? - correct answer -develop a safety/escape plan -THEN provide info about social services and support groups What is the priority for children with cystic fibrosis? - correct answer -hemoptysis over 250 ml/24 hours indicates risk for brain hemorrhage What are main manifestations of vaso occlusive crisis? - correct answer -hematuria (occlusion of kidneys) -swelling of hands and feet -visual disturbances (NOT hearing disturbances) What are manifestations of autonomic dysreflexia? - correct answer -facial flushing -nasal congestion -headache What is true about methadone? - correct answer -can keep taking when pregnant -can develop dependency -can cause sedation -don't take more than one dose EVER What are signs of oxygen toxicity? - correct answer -bradypnea d/t respiratory depression -substernal chest pain (for increased work of breathing) -crackles What are manifestations of digoxin toxicity? - correct answer -nausea -anorexia -stomach pain -bradycardia -visual disturbances -diarrhea -muscle weakness What are indications that a client is at risk for pressure ulcers? - correct answer -low albumin/Hgb -weight loss -diarrhea What is saw palmetto? - correct answer -herbal supplement that causes false-low prostate levels -can delay prostate cancer dx What is the rooting reflex for infants? Asymmetric Tonic neck reflex? Extrusion reflex? Glabellar reflex? - correct answer -stroke infants cheek -will cause infant to stick tongue out -glabellar: tap on infant's nose-close eyes -asymmetric tonic neck: turn head to one side-extend arms and legs on that side and flex on the other side -extrusion reflex: depress tongue-sick tongue out What are complications of obstructivee sleep apnea? - correct answer -hypertension d/t lack of oxygen and need for improved perfusion -heart failure -dysrhythmias -weight gain-hyperglycemia -enuresis What should you do when dischar