ATI Exit Exam Form C refresher

A nurse is reinforcing teaching with a client about diabetes mellitus and insulin lispro and insulin glargine? - Put them in separate syringes When mixing insulin, what should the nurse do after injecting air into the regular insulin vial? - Put 15 units of air into the regular The procedure steps for an amniocentesis: - -Obtain and document baseline vital signs and FHR prior to the procedure. -Assist client into a supine position, and place a wedge under their right hip to displace the uterus off the vena cava, and place a drape over the client exposing only the abdomen. -Prepare the client for an ultrasound to locate the placenta. -Cleanse the client's abdomen with an antiseptic solution prior to the administration of a local anesthetic by the provider. -CLIENT EDUCATION: There will be a feeling of slight pressure as the needle is inserted. Continue breathing, because holding breath will lower the diaphragm against the uterus and shift the intrauterine contents. The patient is at 37 weeks gestation and has HELLP syndrome, which of the following lab values should the nurse report to the provider? - Platelet 77,000 Polycystic - Patient should have a BMI of 25+ Cystic Fibrosis: Reinforcing teaching with guardians - -Encourage regular physical activity and frequent position changes. Encourage rest upon frequent periods. -Answer: "Let them play a sport" Propranolol adverse effects - Bradycardia Why do we give vitamin K to a newborn? - For bleeding (decrease risk of hemorrhage) If a patient has a seizure while in their bed, what action should the nurse take? - The nurse should time it The patient starts to have a seizure while on the floor. What action should the nurse take? - Place a pillow under their head Isolation precautions - MRSA (A) Varicella (A) >>>Answer: Use negative air pressure room C. Diff. (C) TB (A) Proper PPE apparel - Gloves over gown Teaching a diabetic patient about exercising and dieting - Eat a fruit BEFORE exercising A patient is receiving a blood transfusion...urticaria...what kind of reaction... - Anaphylactic (allergic) Choose an example of Autonomy - Letting the patient make a decision for themselves Wrist Restraints - The nurse should check every 2 hrs Transdermal patch (Nitroglycerin) SATA - Apply to a hairless area Dispose of patch in a child proof container Wear gloves when applying the patch Nursing prioritization/time management SATA - >Create a time limit for activities >Finish tasks with one patient before moving onto the next >Delegate vital signs to AP (if the patients are stable) >Make a priority list for the patients that need to be seen on the floor, from highest priority to least priority Montelukast - Use once daily in the evening (bedtime!) Instilling eye ointment medication for a child - Massage the medication into the eye >Take out the excess medication from the eye Heparin Therapy - aPtt should be 1.5-2 times the baseline (30-40 seconds) Warfarin Therapy - INR should be 1.5-2 times the baseline (11-12.5 seconds) What should the nurse instruct a patient who is now post op after eye surgery? - Take a stool softener Diseases the nurse should report to the State department - Chlamydia Gonorrhea Aids TB When to apply embolic stockings? - In the morning before the patient gets out of bed What's an example of a ball-socket joint? - The shoulder Identify sodium imbalance manifestations - VITAL SIGNS (WITH HYPOVOLEMIA): Hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension, diminished peripheral pulses NEUROMUSCULOSKELETAL: Headache, confusion, lethargy, muscle weakness to the point of possible respiratory compromise, fatigue, decreased deep-tendon reflexes (DTRs), seizures, lightheadedness, dizziness GASTROINTESTINAL: Increased motility, hyperactive bowel sounds, abdominal cramping, nausea, vomiting CPAP machine - The mask for this machine should fit 1 finger-breadth between the mask and face. Hand hygiene: How to dry your hands? - Drying from fingers to wrist How should the nurse position their hands when they are washing them? - Hands should be washed in a position where they are slightly above elbows What should the nurse remember to do when having jewelry on while washing their hands? - Interlace your fingers instead of take off your jewelry Food that can be recommended for a low sodium diet? - Frozen fruit Normal or expected finding for a patient of 10 weeks gestation? - Leukorrhea What to report (MAR; COPD patient) - Thick, green mucus What is the nurse's priority action when caring for a patient who has just come into the clinic and has been diagnosed with TB? - Place a mask on the patient Torticollis - Stiff neck in infants What do you monitor in a patient who has Steven Johnson syndrome? - Skin and temperature Define utilitarianism - Decision-making based on what provides the greatest good for the greatest amount of people Delegating an appropriate task to an AP - Providing postmortem care What should the nurse's priority action be for a patient who has just passed away? - Close the patient's eyes A postpartum patient is complaining that the baby is still crying after being changed and fed. The client states "they no longer know what to do!". What should be the nurse's response? - The nurse should say, "Let's swaddle your baby, first I will show you and then you will try." My newborn is being "fussy", what should I do? - The nurse should instruct the mother to swaddle the newborn to promote comfort. Parent teaching for a newborn's crib - Make sure the mattress is firm The nurse is teaching parents about feeding a newborn: - the newborn should be fed every two to three hours What type of care is given at the end of a person's life to provide comfort? - Palliative care