Ati Capstone Responses

ATI CAPSTONE RESPONSES 1. A client is receiving home oxygen. What teaching points should the nurse provide the client and the caregiver regarding home oxygen safety? Instructed patient / caregiver about a few simple precautions that can be taken to create a safe home environment when using oxygen. Post signs in every room where oxygen is in use. Make sure that absolutely no smoking occurs in the home or in the car when oxygen is in use. Secure an oxygen cylinder to a solidly fixed object to avoid creating a missile out of the tank. This might happen if it was accidentally knocked over and gas was allowed to escape. Use caution with oxygen tubing so you do not trip over it or become entangled in furniture. Be familiar with the equipment and the safety checks established by the medical equipment provider. Keep their contact telephone numbers, and the numbers for other emergency services, posted near a phone. Do not try to repair broken equipment on your own. Request this service from the oxygen provider. Make sure smoke detectors in the home are working. Have fresh batteries installed. Perform monthly checks. Have a fire extinguisher available 2. A nurse is teaching a community course in home safety and providing first aid. What instructions should the nurse include for a client that is bleeding? Obtain consent: Tell the person your name, describes type and level of training, states what you think is wrong and what you plans to do, and asks permission to provide care. - Tell a bystander to get the AED and first aid kit: Point to a bystander and speak out loud. - Use appropriate PPE: Put on gloves, if available. 3. What are nursing interventions and appropriate communication techniques to utilize with a client who is anxious? Deep breathing. One of the easiest stress reducing exercises to learn is deep breathing; it's easy to use in any situation Listening to music. Music works as a relaxation method. ... Visualization and redirecting thoughts. ... Mindful movement Play out the scenarios. 4. What actions should be taken by the nurse when caring for a client that has refused prescribed medications? The main reason patients refuse treatment is that they have concerns about it. These concerns can range from not thinking the procedure is necessary, to being afraid that it will kill them. It is important to bring these concerns to light so that you can talk to the patient about them. 5. What are three (3) indications for folic acid therapy? For the treatment of folate deficiency megaloblastic anemia. For the treatment of folate deficiency megaloblastic anemia or macrocytic anemia secondary to folic acid deficiency, hepatic disease, alcoholism, intestinal obstruction, or excessive hemolysis 6. A critical care client has received propranolol to treat supraventricular tachycardia. What are three (3) complications the nurse should monitor for? The more common side effects of propranolol can include: slower heart rate. diarrhea. dry eyes. hair loss. nausea. weakness or tiredness. 7. A nurse is caring for a client with many different medications who is newly prescribed acetazolamide. What medications can interact with acetazolamide? Acetazolamide may interact with cisapride, methenamine, anticonvulsants, other diuretics, cyclosporine, digoxin, drugs for diabetes, drugs that cause loss of potassium, lithium, memantine, procainamide, quinidine, aspirin and other salicylates, sodium bicarbonate, stimulants, or tricyclic antidepressants. 8. A client has been prescribed misoprostol for the treatment of peptic ulcer disease. What is a true contraindication for this medication? Misoprostol is contraindicated during pregnancy for use to reduce the risk of stomach ulcers associated with NSAIDs (the FDA-approved indication). This agent causes reproductive risk, including uterine contractions, miscarriage, and other problems if administered during pregnancy. 9. A client has been prescribed oxybutynin for treatment of overactive bladder and has been experiencing anticholinergic side effects. List two (2) actions the client will take to prevent adverse effects of the medication therapy. Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them: More common Acid or sour stomach belching decreased sweating diarrhea difficulty having a bowel movement (stool) drowsiness dryness of the eyes, mouth, nose, or throat heartburn indigestion runny nose stomach discomfort, upset, or pain 10. A nurse is preparing to administer acetylcysteine. What are indications for therapy? When inhaled by mouth, acetylcysteine is used to help thin and loosen mucus in the airways due to certain lung diseases (such as emphysema, bronchitis, cystic fibrosis, pneumonia). This effect helps you to clear the mucus from your lungs so that you can breathe easier. 11. A nurse is caring for a client who has a new prescription for alosetron. What are the expected therapeutic effects of this medication? Alosetron blocks the action of a chemical called serotonin in the intestines. This slows the movement of stools (bowel movements) through the intestines. Alosetron is used to treat severe, chronic irritable bowel syndrome (IBS) in women who have had diarrhea as the main symptom for at least 6 months. 12. A nurse is caring for a client with asthma who asks if montelukast sodium can be taken for acute asthma symptoms. When should montelukast sodium be taken? Montelukast is usually taken once a day with or without food. When montelukast is used to treat asthma, it should be taken in the evening. When montelukast is used to prevent breathing difficulties during exercise, it should be taken at least 2 hours before exercise 13. A nurse has provided education to a client who has a new prescription for exenatide. What statements by the client would indicate they understand the instructions? BYETTA (exenatide injection) should be initiated at 5 mcg administered twice daily at any time within the 60-minute period before the morning and evening meals (or before the two main meals of the day, approximately 6 hours or more apart). BYETTA (exenatide injection) should not be administered after a meal. 14. A client with hypertension is prescribed verapamil. What are the three (3) expected outcomes of this medication therapy? Decrease in frequency and severity of anginal attacks. Decrease in need for nitrate therapy. Increase in activity tolerance and sense of well-being. Suppression and prevention of atrial tachyarrhythmias. 15. A client has a new prescription for an albuterol inhaler and a beclomethasone inhaler. What instructions should the nurse include concerning use of these inhalers? A client has a new prescription for an albuterol inhaler and a beclomethasone inhaler. What instructions should the nurse include concerning use of these inhalers? Albuterol should be administered first. It promotes bronchodilatation and enhances absorption of the glucocorticoid 5. 16. A nurse is caring for a client who has a new prescription for raloxifene. What are contraindications for this medication that the nurse should discuss with the client? Contraindications: pregnancy, history of venous thromboembolism, stop 3 days before period. 17. A client receiving the chemotherapeutic agent, leuprolide for treatment of prostate cancer. What is one (1) important point to discuss with the client to prevent musculoskeletal complications. Important things to remember about the side effects of leuprolide: Most people do not experience all of the side effects listed. Side effects are often predictable in terms of their onset and duration. Side effects are almost always reversible and will go away after treatment is complete. There are many options to help minimize or prevent side effects. There is no relationship between the presence or severity of side effects and the effectiveness of the medication. The following side effects are common (occurring in greater than 30%) for patients taking leuprolide: Hot flashes (see sexuality) Loss of interest in sex (decreased libido) (see sexuality) Inability to obtain or sustain an erection (impotence) (see sexuality) 18. A nurse has an order to administer mannitol to a critical care client. What should the nurse expect following mannitol administration? A normal kidney function as well as a decrease in intracranial pressure and intraocular pressure. This happens due to this drug pooling the fluid out of the extravascular space and placing it back in to the bloodstream. 19. The nurse is caring for a client who has developed malignant hyperthermia. Identify three (3) priority actions the surgical team will need to implement. The surgical team will administer oxygen at 100%, Initiate cooling measures including administration of iced 0.9% sodium chloride, applying a cooling blanket, and placing ice bags in groin and other areas, and administer dantrolene to decrease metabolic activity of skeletal muscle. 20. A client is prescribed topical acyclovir. When teaching a client about application of the medication and management of the infection, what are three (3) points to discuss? Drink 6 to 8 glasses of water or fluids every day while you are taking this medicine. This will help prevent side effects. You can still pass chickenpox, shingles, or herpes to another person even while you are taking this medicine. Avoid contact with others as directed. 21. Drink 6 to 8 glasses of water or fluids every day while you are taking this medicine. This will help prevent side effects. You can still pass chickenpox, shingles, or herpes to another person even while you are taking this medicine. Avoid contact with others as directed. Instruct patient that ritonavir should not be shared with others. Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications. Inform patient that ritonavir does not cure AIDS or prevent associated or opportunistic infections. Ritonavir does not reduce the risk of transmission of HIV to others through sexual contact or blood contamination. Caution patient to use a condom during sexual contact and to avoid sharing needles or donating blood to prevent spreading the AIDS virus to others. Advise patient that the long-term effects of ritonavir are unknown at this time. Inform patient that ritonavir may cause hyperglycemia. Advise patient to notify health care professional if increased thirst or hunger; unexplained weight loss; increased urination; fatigue; or dry, itchy skin occurs. Instruct patient to notify health care professional immediately if rash appears 22. What is the priority assessment for a client receiving morphine sulfate? Assess each patient’s risk prior to prescribing morphine sulfate extended-release tablets, and monitor all patients regularly for the development of these behaviors or conditions 23. A nurse is providing discharge teaching to a client prescribed ketorolac, what adverse effects should the client report to the provider? Check for bruising Gastrointestinal discomfort Dyspepsia, Abdominal pain, heartburn, nausea Impaired Kidney function Decreased urine output, weight gain from fluid retention, Increased BUN, and creatinine levels Increased risk for bleeding hematomas, bleeding gums, blood in vomit or stool, decreased Hematocrit and Hemoglobin Ketorolac is contraindicated in clients who have advanced kidney disease. Use should be no longer than 5 days due to the risk of kidney injury. Ketorolac should not be used concurrently with other NSAIDS. 24. A 55-year-old client has experienced burns on 50% of his body. What immunization may be administered while hospitalized? Tetanus immunization should be updated if necessary for any burns deeper than superficial-thickness. 25. A nurse is caring for a client with a history of migraines with auras. What are the stages of this type of migraine? Prodromal stage: includes awareness of findings for hours to days before onset: irritability, depression, food cravings, diarrhea/constipation, and frequent urination. Aura stage: develops over minutes to an hour to include neurologic findings: numbness and tingling of mouth, lips, face, or hands; visual disturbances (light flashes, bright spots). Second stage: severe, incapacitating, throbbing headache that intensifies over several hours and is accompanied by nausea, vomiting, drowsiness, and vertigo. Third stage (4 to 72 hr): headache is dull. Older adults may continue with aura, and pain subsides (visual migraine). Recovery with pain and aura subsiding. Muscle aches and contraction of head and neck muscles are common. Physical activity worsens pain, and client may sleep. 26. A nurse is caring for a client with a tension pneumothorax. What is a tension pneumothorax and what manifestations should the nurse expect? Chest pain that usually has a sudden onset. The pain is sharp and may lead to feelings of tightness in the chest. Shortness of breath, rapid heart rate, rapid breathing, cough, and fatigue are other symptoms of pneumothorax. 27. A nurse is caring for a client with Rheumatoid Arthritis who is prescribed a non-steroidal anti-inflammatory drug (NSAID) for the treatment of joint pain. Provide three (3) points in client teaching the nurse should provide regarding this medication therapy. The most frequently reported side effects of NSAIDs are gastrointestinal (stomach and gut) symptoms, such as: Gas. Feeling bloated. Heartburn. Stomach pain. Nausea. Vomiting. Diarrhea and/or constipation. 28. What type of respiratory failure is caused by Guillain-Barre’ syndrome? Guillain-Barré Syndrome is the leading cause of nontraumatic acute paralysis in industrialized countries. Guillain-Barré Syndrome is thought to be a rare disorder and occurs when an individual's immune system begins to attack the nervous system. 29. he nurse is preparing to administer the Rho(D) immune globulin after an Rh-negative client gives birth. The client asks what the medication is for. What teaching should the nurse provide regarding this medication? RHo (D) immune globulin is a sterilized solution made from human blood. Rh is a substance that most people have in their blood (Rh positive) but some people don't (Rh negative). A person who is Rh negative can be exposed to Rh positive blood through a mismatched blood transfusion or during pregnancy when the baby has the opposite blood type. When this exposure happens, the Rh negative blood will respond by making antibodies that will try to destroy the Rh positive blood cells. This can cause medical problems such as anemia (low red blood cells), kidney failure, or shock. 30. The nurse is caring for a client in the transition stage of labor. What are common maternal characteristics the nurse might observe in this client? The transition will last about 30 min-2 hrs. Your cervix will dilate from 8cm to 10cm. Contractions during this phase will last about 60-90 seconds with a 30 second-2 minute rest in between. Contractions are long, strong, intense, and can overlap. The nurse might observe the client feeling tired, restless and irritable. Clients often feel out of control and feelings of being unable to continue. The client may experience nausea/vomiting. The client may feel the urge to push, an increase in rectal fullness or the need to have a bowel movement. 31. A 31-week client is experiencing contractions and bleeding. Placenta previa is suspected. What interventions are anticipated to address client-centered care? Assess baseline vital signs especially the blood pressure. Assess fetal heart sounds to monitor the wellbeing of the fetus. Monitor uterine contractions to establish the progress of labor of the mother. Weigh perineal pads used during bleeding to calculate the amount of blood lost. 32. What are two (2) contraindications for the administration of terbutaline during labor? Terbutaline sulfate is contraindicated in patients known to be hypersensitive to sympathomimetic amines or any component of this drug product. Immediate hypersensitivity reactions and exacerbations of acute bronchospasm have been reported after terbutaline administration. 33. A nurse is caring for a client with placenta previa. What interventions should be completed for this client? Treatment of placenta previa involves bed rest and limitation of activity. Tocolytic medications, intravenous fluids, and blood transfusions may be required depending upon the severity of the condition. A Cesarean delivery is required for complete placenta previa 34. A child was sent home from school with head lice. The child's mother has called the help line nurse for guidance. What are three (3) measures the nurse will inform the mother about to address the infestation of pediculosis capitis? The following are steps that can be taken to help prevent and control the spread of head lice: Avoid head-to-head (hair-to-hair) contact during play and other activities at home, school, and elsewhere (sports activities, playground, slumber parties, camp). Do not share clothing such as hats, scarves, coats, sports uniforms, hair ribbons, or barrettes. Do not share combs, brushes, or towels. Disinfest combs and brushes used by an infested person by soaking them in hot water (at least 130°F) for 5–10 minutes. Do not lie on beds, couches, pillows, carpets, or stuffed animals that have recently been in contact with an infested person. Machine wash and dry clothing, bed linens, and other items that an infested person wore or used during the 2 days before treatment using the hot water (130°F) laundry cycle and the high heat drying cycle. Clothing and items that are not washable can be dry-cleaned OR sealed in a plastic bag and stored for 2 weeks. Vacuum the floor and furniture 35. xplain how methylphenidate hydrochloride works in pediatric client who have Attention Deficit Hyperactivity Disorder (ADHD). 36. Methylphenidate is a stimulant medicine. Since children with ADHD are already over- stimulated, it is hard to understand how a stimulant drug will help to calm them down. Researchers think that the area of the brain that controls when to pay attention to certain activities and when to ignore other ones is immature and works poorly in people with ADHD. The medicine stimulates those areas of the brain so that the child can better pay attention and focus on his activities. The medicine works quickly so you'll know if it will help or not. The dosage may have to be adjusted by your healthcare provider. It is fairly inexpensive and has been used for many years. If your child is having problems with attention, focus, and being overactive in school, stimulant medicine may provide some relief. Benefits of this medicine often include: less trouble finishing class work and homework less fidgeting or squirming better control of emotions less impatience and impulsiveness. 37. Identify three (3) clinical manifestations of hydrocephalus in an infant client. 38. A full or bulging fontanel (soft spot located on the top of the head) Increasing head circumference (size) Seizures. Bulging eyes and an inability of the baby to look upward with the head facing forward. Clinical Manifestations: Irritability Lethargy, changes in level of consciousness Infant cries when picked up or rocked and quiets when allowed to lie still Vomiting Early infantile reflex acts may persist Lower extremity spasticity Normally expected responses fail to appear 39. 39. Which of the following clients would be the priority to assess first? A client diagnosed with schizophrenia that is exhibiting negative symptoms. A client with substance-induced psychotic disorder related to substance intoxication. A client who is suffering from delusions of grandeur. A client suffering from olfactory hallucinations. Schizophrenia that is exhibiting negative symptoms 40. Give an example of how a nurse exhibits fidelity in client care Fidelity is keeping one's promises. The nurse must be faithful and true to their professional promises and responsibilities by providing high quality, safe care in a competent manner. 41. List three (3) seizure precautions to implement for a client who is at risk due to substance use. These are general steps to help someone who is having any type seizure: Stay with the person until the seizure ends and he or she is fully awake. After it ends, help the person sit in a safe place. Once they are alert and able to communicate, tell them what happened in very simple terms. Comfort the person and speak calmly. Check to see if the person is wearing a medical bracelet or other emergency information. Keep yourself and other people calm. Offer to call a taxi or another person to make sure the person gets home safely 42. The nurse is caring for a client with anxiety disorder. Identify three (3) expected findings related to this disorder. Physical signs and symptoms may include: Fatigue Trouble sleeping Muscle tension or muscle aches Trembling, feeling twitchy Nervousness or being easily startled Sweating Nausea, diarrhea or irritable bowel syndrome Irritability 43. A nurse is caring for a client with panic disorder. Discuss nursing care of this client During the panic attack, the patient will require reassurance and advice to control their breathing and avoid hyperventilation. - Should hyperventilation occur, the patient can address this by breathing into cupped hands or a paper bag. 44. The nurse is planning discharge for a client that is recovering from a stroke. Describe how the nurse uses collaboration to aid in discharge planning. Close follow-up is important to stroke rehabilitation and recovery. Some medicines require blood tests to check for progress or problems. Keep follow-up appointments for any blood tests ordered by your providers. 45. While giving change-of-shift report using I-SBAR, a nurse suggests that a client be ambulated at least four times during the next shift in order to decrease the client’s peripheral edema. Which portion of I-SBAR does a nurse make suggestions regarding actions and interventions? SBAR is an easy to use, structured form of communication that enables information to be transferred accurately between individuals It allows staff to communicate assertively and effectively, reducing the need for repetition and the likelihood for errors 46. A nurse is caring for a 48-year-old client with terminal cancer that is concerned about maintaining confidentiality about his diagnosis. What is the role of the nurse to advocate for this client? A nurse advocate is a nurse who works on behalf of patients to maintain quality of care and protect patients' rights. They intervene when there is a care concern, and following the proper channels, work to resolve any patient care issues. Realistically, every nurse is an advocate. 47. The nurse is assessing a client upon admission. What factors should the nurse look for that would increase a client’s risk for injury? Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health. Instead of being viewed as a major public health problem, injuries have been recognized as inevitable accidents that happen in our daily life. However, a considerable epidemiological and medical study has shown that injuries, unlike accidents do not occur by chance. Like any disease, the risk of injury follows a predictable pattern, thus making them preventable. Implementation of favorable injury prevention program is an important part of nursing care in any healthcare setting and needs a multifaceted approach. Nurses also have a significant role in educating patients, families, and caregivers about the prevention of falls beyond the care continuum. 48. The nurse is caring for a client prescribed ceftriaxone. What are two (2) factors that would be considered contraindications to administration of the medication? diarrhea from an infection with Clostridium difficile bacteria. a type of blood disorder where the red blood cells burst called hemolytic anemia. liver problems. disease of the gallbladder. severe renal impairment. yellowing of the skin in a newborn child. 49. A committee of nurses have been tasked with reviewing an increase in central line infections on their unit. Explain the process that they should follow. Use appropriate hand hygiene. Use chlorhexidine for skin preparation. Use full-barrier precautions during central venous catheter insertion. Avoid using the femoral vein for catheters in adult patients. Remove unnecessary catheters. 50. The nurse takes a telephone order for morphine 50 mg IVP every 3 hours. After hanging up the phone, the nurse feels this order is not safe. List three (3) strategies to prevent errors of miscommunication when receiving telephone orders. Ensure that the order is complete before ending the conversation with the provider, spell out unfamiliar drug names, read back the order in its entirely, write the order directly onto the provider's order sheet, indicate 51. An ethical dilemma regarding sustaining life is being examined. What would be some appropriate resources for the nurse to use to help review and address ethical dilemmas? Informed consent. Concerns that patients and their families have not been fully informed about their treatments or clinical prognosis is a common ethical concern of nurses, Ulrich reported. ... Disclosing medical conditions Incompetence among peers. ... Broader ethical issues. 52. A client newly admitted with abdominal pain asks the nurse to explain how their blood test indicating that they are positive for Helicobacter pylori has to do with their abdominal pain. How should the nurse respond? The bacteria are believed to cause stomach problems when they penetrate the stomach's mucous lining and generate substances that neutralize stomach acids. This makes the stomach cells more vulnerable to the harsh acids. 53. A community health nurse is assigned to a rural health clinic, servicing migrant workers. Identify one (1) challenge this population encounters and name one (1) primary prevention strategy the nurse can teaching and integrate into servicing this population. Population health management (PHM) strives to achieve IHI's Triple Aim, including better outcomes for individuals across communities. Health systems working to improve healthcare outcomes can meet their goals by aligning improvement and PHM strategies 54. An occupational health nurse is working with their employer to identify and address physical agents present in the current work environment. What are two (2) examples of physical agents the nurse needs to be aware of? Physical agents (temperature extremes, vibrations, noise, radiation, lighting). Agent factors ... Occupational health nurse's responsibilities (primary prevention) ... contributes to the base of knowledge for school health and educational needs. 55. A 2-year-old client presents to the provider's office for their well child visit. The nurse notes several bruises on the child’s back and bilateral arms at different stages of healing. What should the nurse’s next action be? Question the parents on how the injuries occurred 56. A client is being transferred from the acute care setting to hospice care. Identify three (3) teaching points the nurse should discuss with the client and family about hospice care. Hospice Care. Hospice, which now exists in every state, provides home care and support for terminally ill patients. Considered to be a model for quality compassionate care at the end of life, hospice involves a team approach to care that helps patients remain comfortable and independent for as long as possible. 57. A nurse is teaching a family member precaution tips when visiting a client with active tuberculosis. What type of precautions are being used for the client? Airborne precautions help keep staff, visitors, and other people from breathing in these germs and getting sick. Germs that warrant airborne precautions include chickenpox, measles, and tuberculosis (TB) bacteria infecting the lungs or larynx (voicebox). 58. A mass casualty event has occurred nearby and the nurse needs to prepare to accommodate clients scheduled to arrive soon. Name one (1) criteria to be used to determine which clients to discharge or relocate during a mass casualty event. Staff should review patients in clinical assignment for any potential discharges/ transfers to make room for potential MCI admissions, a process known as “surge discharge” 59. A nurse is caring for a client newly diagnosed with pertussis. What is one (1) intervention the nurse will incorporate into the plan of care? Educate about coughing and breathing. Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession 60. During botulism management of a client, what treatment measures will the nurse implement? The respiratory failure and paralysis that occur with severe botulism may require a patient to be on a breathing machine (mechanical ventilator) for weeks and may require intensive medical and nursing care (nasogastric suction, IV augmented nutrition, and Foley catheter, for example) 61. A nurse is working on a maternal newborn unit. What security measures should the nurse ensure are in place to prevent abduction? Implement an infant security tag or abduction alarm system, such as a bar-coding system or umbilical clamp, which triggers an alarm, locks doors, and freezes elevators if the infant comes within 4 feet of an exit or elevator. 62. The home health nurse is conducting a home safety assessment for an older adult client following a hospital admission for frequent falls. List three (3) assessment findings that require intervention. The nurse will assess every shift the patient Morse Fall Score. -The patient will wear a yellow fall risk bracelet and yellow non-skid socks so other nursing staff will know the patient is a fall risk. The nurse will keep the patient’s bed in the lowest position at all times. -The nurse will use the bed and chair alarm as needed. -The nurse will assess the patient need to use the bathroom every two hours. -The nurse will move the patient close to the nurses station for closer observation. 63. The community health nurse is speaking to a men's civic group about health promotion for men. The question is posed regarding how and when to properly perform testicular self-examination (TSE). What information should the nurse provide to the group? look & feel for any lumps or changes in size, shape, or consistency of the testes by gently rolling them between fingers & thumb ----Start at puberty perform monthly after shower in front of mirror