ATI Review Questions and Answers

ATI Review Questions and Answers Deligation to LPN CAN: Monitor findings (as input to RN's ongoing assessment) Reinforce teaching Trach care Suctioning Checking NG patency (Inserting NG tube according to ATI practice test) Administering enteral feedings Inserting urinary catheter Administer meds (excluding IV meds in some states) CAN'T: Administer blood products TPN Use infusion pump to deliver at controlled rate. Taper rate before discontinuing to prevent hypoglycemia. If unable to continue infusion by pump, administer dextrose 10% in water via manual tubing. NG Tube HOB elevated to 45˚ for 1 hr after feedings to decrease risk of aspiration. Never use dye Flush NG tube with 20 mL tap water before and after each feeding. Inject 10-30 mL air into NG tube before checking residual to clear tube of any feeding. Chlorpromazine Anti-psychotic Use: Schizophrenia Common adverse effects: HA, vomiting, constipation, orthostatic hypertension Serious Adverse: tardive dyskinesia (involuntary movements) - Antidote for this is Amantadine Life-threatening adverse effect: Neuroleptic Malignant Syndrome (s/s: high fever, dysrhythmia, decreased LOC, labile blood pressure) Ear drops 3 years old: pull pinna upward and back 3 years old: pull pinna downward and back Allow otic medication stored in refrigerator to warm to room temp before administering to prevent dizziness and pain. Gently massage tragus on anterior of ear to allow medication to reach entire canal. Lye on unaffected side for a few minutes to allow med to remain in ear canal. Autonomic Dysreflexia Neurologic emergency in clients who have sustained spinal cord injury above the level of T6. Most often associated with a full bladder and distended rectum Expected findings include: Facial flushing of head and neck, severe HA, blurred vision, nasal congestion, extreme HTN, bradycardia Thrombocytopenia Decreased platelet count Risk for bleeding Expected reference range for axillary temperature of a newborn? 36.5˚ C - 37.5˚ C (97.7˚ F - 100˚ F) Stage II pressure ulcer Partial thickness skin loss or blister formation. Moist bright red wound bed indicates healing is taking place. Stage III pressure ulcer Visible subcutaneous tissue Use hydrocolloid dressing to keep wound bed moist. Stage IV pressure ulcer Tendon exposure Muscle damage Clang Association Alteration in speech in which the client chooses words based on their sound (ex: Big bat boat) Echolalia Alteration in speech in which the client repeats back what the other person is saying Neologisms Made up words that have no meaning to others but have meaning to the client Word Salad Alteration in speech in which the client jumbles words because of an extreme level of disorganization. Blood spills Chlorine bleach solution Vomit on reusable hospital equipment Rinse with cold water, place in labeled bag after removing from clients room, send to proper facility location for decontamination. Hep A Contracted through consumption of contaminated food or water. Use 1:100 chlorine bleach solution to clean kitchen surfaces to kill virus and prevent transmission. Encourage safe food handling and hand hygiene techniques. Pediculosis Capitis Seal non washable items in plastic bag for two weeks Trach care Remove soiled dressing, remove inner cannula, clean stoma with 0.9% NACL irrigation, change trach collar Warfarin Risk for bleeding (report changes in stool color, no tylenol b/c it can increase risk). Adequate intake of Vitamin K. Daily blood draws for first 5 days to establish appropriate dosage. Fluoxetine (Prozac) SSRI used to treat depression, OCD, bulimia, panic disorder. Risk for serotonin syndrome 2-72 hrs after starting (s/s: tremors, agitation, confusion, anxiety, hallucinations). Adverse effects: weight gain, GI bleeding, rash. St. John's Wort can increase the effectiveness. Cardiac Tamponade Pulsus paradoxus, jugular vein distention, bradycardia, hypotension, muffled heart sounds, fatigue, dyspnea, Artherosclerosis Carotid bruit Physiological changes associated with Aging Increased BP Decreased CO Decreased oral temperature Decreased lung expansion (b/c less mobility of ribs) Fat embolism syndrome Life threatening complication of fractures s/s: chest petechiae Myasthenia gravis patient education Keep HOB elevated during meals and 30-60 min after meals to prevent aspiration. Cut food into small bites and eat slowly. Take anticholinesterase medication 45-60 min before meals to prevent aspiration. Daily weight to monitor nutritional status. Eat high calorie snacks. Botulism toxin Foodborne illness s/s: dysphagia, drooping eyelids, vision changes, and develop neurologic s/s after 12-36 hrs (systemic flaccid paralysis, cranial nerve dysfunction). Must report to the CDC. Erythema infectiosum Caused by the parvovirus. Characterized by a red facial rash that spreads all over the body. Alprazolam Use: anxiety Side effects: orthostatic hypotension, dizziness, drowsiness, fainting upon standing, diarrhea or constipation. Hemolytic transfusion reaction Low back pain, tachycardia, hypotension, apprehension, Kawaski Disease Acute phase: high fever unresponsive to antibiotics or antipyretics, tachycardia Subacute phase: pain in child's joints, peeling of palms of hands and soles of feet. Immobile client and body allignment No pillow under knees b/c it can impede venous return and contribute to thrombus formation. Use trochanter rolls to prevent external rotation and abduction of the hips. 2 to 3 Liters of fluid per day No massaging lower extremities. Oxygen toxicity in COPD patient Bradypnea (due to depression of respiratory drive) Crackles and substernal chest pain Deligation to AP CAN Vital signs before and after medication administration Weigh client Provide gastrostomy feedings through established tube CAN'T Request dietary referral Teach Review MAR Monitor post-op vitals (although the book says can if patient is stable) Tube feeds or feed patient with swallow precautions FVE HTN SOB/ Dyspnea Visual disturbances such as blurred vision Tachycardia Bounding pulse FVD Orthostatic hypotension Increased BUN Oliguria Poor skin turgor Vaso-occlusive sickle-cell crisis Manifestations: Hematuria (from ischemia of the kidneys) Painful swelling of hands and feet Visual disturbances Priority action: Administer IV fluids to promote hydration and circulation and reduce tissue and organ ischemia caused by clumping of RBC's Suctioning tracheostomy Use surgical asepsis when suctioning Apply suction for only 5-10 seconds Once resistance is met, withdraw catheter 1-2 cm to prevent damaging bronchial tissue. Coughing OK Preoxygenate with 100% O2 for 30 sec to 3 min to prevent hypoxemia. Suction pressure between 80-120 mm HG May suction up to 3 times max Saw palmetto Can result in false low prostate specific antigen level which can delay diagnosis of prostate cancer. Valerian root Used as a tranquilizer or sedative. Can cause low BP Flaxseed Used as a migraine prophylaxis. Can cause GI symptoms (bloating, abdominal pain, gas) Ginseng Used to stimulate mental activity and increase appetite. Can interact with caffeine and cause irritability. Can increase the effectiveness of Warfarin (anticoagulant) Can decrease the effectiveness of Timolol (Ophthalmic antiglaucoma medication) True labor Cervix transitions to anterior position Lose mucus plug Cervix progressively shortens and thins Contractions intensify with ambulation Contractions felt in lower abdomen and back clozapine (Clozaril) Antipsychotic Use: Schizophrenia Adverse: Orthostatic hypotension, GI upset (anticholinergic effects), hyperglycemia, weight gain Potential serious adverse effect: Agranulocytosis (↓WBC) Delirium Rapid, inappropriate, incoherent, rambling speech. Digoxin Toxicity Nausea, diarrhea, muscle weakness Misoprostol Reduces gastric acid secretion so ulcers caused by NSAIDS can heal and prevents development of new ulcers. Can induce contractions Can cause diarrhea (must avoid magnesium containing antacids) Tunneled central line patient education Flush daily with heparin when not in use. Clamp catheter when not in use. Restrict physical activities until tissue adheres to cuff. No water activities. Change dressing every 5 to 7 days. Troponin T Myocardial muscle protein that is released into circulation after cardiac injury. Level increases within 2-3 hours of MI Increase in Amylase Acute pancreatitis, cholecystitis, or renal failure. Abruptio placentae Persistent uterine contractions, board-like abdomen, dark red vaginal bleeding Placenta Previa Relaxed uterus and painless vaginal bleeding. Fundal height greater than expected gestational age Lithium Toxicity Course hand TREMORS, confusion, ECG changes, sedation, INCREASED THIRST, VOMITING, DIARRHEA, BLURRED VISION Discontinue medication and notify provider Lithium Adverse effects: HA, polyuria, hyperglycemia Take with meals (irritating to stomach lining) Fiberglass cast patient education Do not keep in dependent position more than 30 min. Cover cast with plastic when bathing. Do not apply heat for the first 24 hours after injury b/c it can increase bleeding and swelling. Report loss of sensation, numbness, tingling, paralysis. Obstructive sleep apnea complications HTN, HF, cardiac dysrhythmias, enuresis, weight gain, hyperglycemia Uric acid calculi formation Avoid organ meats, chicken, alcohol. Can eat citrus fruits such as oranges Glaucoma Increased interocular pressure s/s: HA, foggy vision, halos around light Acute angle closure: severe eye pain and blurred vision Retinal detachment Floating dark-spots due to bulges, folds, or holes in affected retina, flashes of light across the eye. Develops suddenly and usually painless. Macular Degeneration Decreased Central Vision Cataracts Cloudy or opaque area in the lens of the eye that inhibits light penetration. s/s double-Vision, cloudy vision. Estradiol Serious adverse effects: HTN, HA (can cause thromboembolism which can lead to stroke), genitourinary candidasis, swelling and tenderness in calf. Amitriptyline Tricyclic Antidepressant Adverse effects: anticholinergic effects (dry mouth, constipation, blurred vision, urinary retention), Cardiovascular effects (obtain ECG on older adults prior to start of therapy to establish baseline) Avoid overheating b/c of lack of ability to sweat. Take at night to promote sleep and minimize daytime drowsiness MAOI food drug interaction Avoid foods that contain Tyramine (smoked meat, chesses [cream cheese ok], ripe avocados, cheeseburger) to avoid adverse effects such as HTN Newborn car seat 45˚ angle Secure retainer clip at baby's axillae Rear-facing for 2 years Back seat Antidote for benzodiazepine overdose Flumazenil Cholinesterase inhibitor overdose (ie Neostigimine) Atropine Mechanical restraints Staff member must remain continuously with client or watch client via camera. Assess client for physical needs, safety, and comfort every 15-30 min and document findings. Provider must renew a prescription every 4 hours for patient over 18 years old, every 2 hours for children 9-17 years old, and every hour for children younger that 9 years old. FFP Administration Administer each unit over 30-60 min Guaifenesin Mucolytic medication used to thin secretions to promote airway clearance s/s hypoglycemia Cool, clammy skin, irritability s/s hyperglycemia Kussmaul respirations Abdominal cramping Increased UOP Voniting Coronary Artery Bypass Graft Post-operative Nursing Interventions Monitor for drop in temperature (client cooled during procedure to reduce metabolic needs) Monitor for reduced magnesium levels (due to hemodilution or diuretic therapy) Sildenafil (Viagra) Used to treat erectile dysfunction Contraindications: isosorbide mononitrate (nitrates) b/c it can cause severe hypotension Lead poisioning Referral to social services for blood level 5 mcg/dL Contact poison control for blood level 20 mcg/dL Chelation therapy for blood level 45 mcg/dL Parent education: Provide an increase in calcium and iron for prevention of lead poisoning. Milk is a good source of calcium. Herbal supplement milk thistle can decrease effectiveness of ethinyl estradiol drospirenone (birth control) Timolol Ophthalmic antiglaucoma medication Ginseng can decrease effectiveness of medication PEEP Used to improve oxygenation, prevent hypoxemia and atelectasis Adverse effect: Tension pneumothorax Tension pneumothorax Trachial deviation to unaffected side, absent breath sounds, distended neck veins Doxorubicin Chemotherapy Serious adverse effect: Thrombocytopenia (risk for bleeding, assess mucosa for petechiae q 8 hrs, hematuria, guaiac, bruising) Administer antiemetic 30-60 min prior Inject over 3-5 min b/c medication extremely irritating to extravascular tissue. Administer 50% of dose if client's bilirubin level between 1.2 and 3 mg/dL Romberg test Used to assess balance and motor function. Stand with feet together. Place arms at side in resting position. Nurse stands close to client to prevent fall. Performed once with eyes open and once with eyes closed. IM Injection on obese client Use ventrogluteal site b/c it has a thick area of muscle and contains no large nerves or blood vessels . Insert at a 90 degree angle Use z-track method Albuterol metered dose inhaler patient education Clean mouthpiece with soap and warm water daily, dry before placing back on inhaler. Wait at least 1 min between inhalations. Long, slow inhalation while activating dispenser. 5-20 min prior to exercise to promote bronchodilation. Medication effects begin immediately, peak 30-60 min, last up to 5 hours. Granulocyte Colony Stimulating Factor Promotes production of granulocytes in bone marrow to help fight infection in patient with low neutrophil count Valproic Acid Seizure control Adverse effects: Hepatic toxicity (LFT's, monitor for jaundice), thrombocytopenia and prolonged bleeding (monitor platelet count), weight gain Propranolol Adverse effect: Coughing at night Signs of hypoxia Restlessness and lightheadedness (check O2 saturation)