ATI CAPSTONE COMBO ASSESSMENT A&B GRADED A
1. what is montelukast (singular) for?
a. a leukotriene modifier, and is taken on a regular basis, once a day, andnot prn,
and is not used for exercise induced asthma
2. what does advance directives contain?
a. written instructions regarding end of life care
3. what is the greatest risk to a pt receiving hemodialysis?
a. disequilibrium syndrome as a result of rapid loss of fluids and decreasebun
4. what is the clinical manifestation of disequilibrium?
a. restlessness and decreased level of consciousness
5. what are expected findings in hemodialysis?
a. elevated temp
weight loss
decreased bp
6. what should the nurse do when a pt feels lightheaded and begins to fall?
a. spread feet apart and extend one leg for the pt to slide down while
lowering the pt to the floor
7. what are the characteristics of a pt with dependent personality disorder?
a. they have problems making everyday decision without input from others
8. a pregnant pt who is bleeding is always?
a. priority
9. what should a pregnant pt with urgency and frequent urination do?
a. should perform kegel exercises
10. what should a pregnant pt with odorless vaginal mucus do?
a. practice good hygiene, use perineal pads
11. a pregnant pt with edema of the ankles do?
avoid prolonged standing, to wear support hose, and rest through out the daywith
legs/hip elevated
12. when should a colostomy bag be changed?
when is 1/3 -1/2 full
13. how large should the opening of the stoma pouch be?
no larger than 1/4 inch
14. what should the pt with a colostomy avoid?
the use of moisturizers, which will decrease the adherence of the pouch to theskin
15. what should the pt do with the pouch removing it?
they should empty the pouch to avoid spilling the effluent on to the skin
16. where should drops be instill into?
into the conjuctival sac
17. what is a positive way of dealing with a terminal illness?
"remembering things they used to do together"
18. what are normal findings after a colonoscopy?
, abd cramping
fatigue
passage of liquid stools
19. what are unexpected finding after a colonoscopy?
guarding- can indicate bowel perforation
20. what do you do if an order is questioned?
the nurse should record seeking clarification from the provider
21. what should pt with gastritis eat?
a well balanced diet, they should keep a record of foods that cause discomfort,pts can
modify their diet accordingly
22. what is the cause autonomic dysreflexia?
bladder distention
23. what are s/s of icp?
restlessness
change in LOC
24. what is late s/s of ICP?
widening pulse
decerebrate posturing
25. when can a child with varicella(chickenpox) return school?
the child can return to school when the blisters are dry and no longer drained
(scabbed over)
26. what is an appropriate behavior of a pt with hx of violence?
pt will avoid violence provoking situations
27. what is a skin cancer prevention?
pts should use sunscreen that protects against uva and uvb
28. what is the first thing you should do with excessive lochial discharge?
perform a fundal massage
29. what is the nurse responsibility of the nurse when witnessing the pts signature onan
informed consent?
that the pt is fully informed and understands the procedure befor signing the
consent form
30. who are at greater risk for std?
females because of increased vascularity to the vagina
31. does trichomonas vaginalis increased the risk for cervical cancer?
NO
32. Gonorrhea can lead to?
pelvic inflammatory disease and tubal scarring and can result in infertility
33. what should you do with postmortem care?
always check about religious practices prior to body preparation in order to honorfam
wishes
34. what can you not give to a pt with thickened liquids?
,35. no ice chips
no water
no icepops
36. what can a pt with thickened liquids have?
oatmeal
37. what should a pt do with incentive spirometer?
they should elevate the cylinder by inhaling deeply
assume semi fowlers or high fowlers position
38. in order to maintain sterile technique what should the nurse do?
should open all sterile packages prior to donning sterile gloves
39. what is psycho-motor learning?
have the pt demonstrate back the procedure
40. what places a newborn at risk for respiratory depression?
administration of an opioid analgesic
exa: fentanyl (sublimaze)
41. what is an effective method of bowel retraining?
anal stimulation with a gloved finger after the evening meal, it will help stimulatethe
gastrocolic reflex
42. when inserting an NG tube?
the nurse should insert the tube into the airway that is patent and has greaterairflow
43. what technique should be NG tube insertion?
clean technique
44. if NG tube meets resistance?
the nurse should rotate the tube without forcing it past the area of resistance
45. what kind of lubricant should be used during NG tube insertion?
water- based lubricant NOT petroleum jelly
46. what is pediculosis capitis management?
store child's clothing in a separate cubicle at schoolboil
brushes and combs in water for 10 mins
dry bed lines and clothing in a hot dryer for at least 20 mins
47. what can visual disturbances indicate?
preeclampsia
48. what is expected 24 hrs after surgery?
hypo active bowel sounds
pain
49. what is an abnormal finding 24 hrs after surgery?
low HGB
50. what must be done in bucks traction?
the pt must be in proper alignment
boots are secured by 3 straps, around pt leg
weights must hang freely
footplate is resting 15.24 cm (6inches) from the footboard
, 51. what does pts with delirium demonstrate?
a fluctuating LOC often at night or in am
52. pt with dementia demonstrate?
difficulty finding correct words to use
53. pt with anxiety disorders demonstrate?
obsessive behavior
54. how would the nurse determine progression of ascites?
abdominal girth should be measured daily
55. what is a food high in potassium?
cantaloupe
56. what is an indication of peripheral venous disease?
brown pigmentation around ankles
57. what is indication of peripheral arterial disease?
intermittent, leg muscle pain
58. what is some skin care for pts on radiation therapy?
59. pat area when dryinguse hand to wash
do not use sunscreen
60. what can hydromorpone cause?
urinary retention
61. what does bethanechol (urecholine) causes?
it stimulates urinary out put
62. how is nystatin best absorb?
if given 1 hour before or after a feeding
63. what is a sign that a newborn has finished eating?
a slowed suck/swallow pattern is a sign that the newborn isfinished eating
64. what not to do when breastfeeding?
is not necessary for the entire areola be in the moutheach feeding should start
at the opposite breast
do not push back of newborns head-toward the nipple
65. what should be included in a stool specimen?
visible blood, pus, or mucus
66. what is the first action in an infiltrated IV?
to d/c the saline lock
67. what is the first action when preparing to do a dressingchange?
to determine the pts level of pain
68. what should a with hemonymous hemionopsia with right visualfield, what will help pt
eat better?
the pt should turn head to the right to see all food on tray
69. what are some side effect for theophylline (theo-dur)?
1. what is montelukast (singular) for?
a. a leukotriene modifier, and is taken on a regular basis, once a day, andnot prn,
and is not used for exercise induced asthma
2. what does advance directives contain?
a. written instructions regarding end of life care
3. what is the greatest risk to a pt receiving hemodialysis?
a. disequilibrium syndrome as a result of rapid loss of fluids and decreasebun
4. what is the clinical manifestation of disequilibrium?
a. restlessness and decreased level of consciousness
5. what are expected findings in hemodialysis?
a. elevated temp
weight loss
decreased bp
6. what should the nurse do when a pt feels lightheaded and begins to fall?
a. spread feet apart and extend one leg for the pt to slide down while
lowering the pt to the floor
7. what are the characteristics of a pt with dependent personality disorder?
a. they have problems making everyday decision without input from others
8. a pregnant pt who is bleeding is always?
a. priority
9. what should a pregnant pt with urgency and frequent urination do?
a. should perform kegel exercises
10. what should a pregnant pt with odorless vaginal mucus do?
a. practice good hygiene, use perineal pads
11. a pregnant pt with edema of the ankles do?
avoid prolonged standing, to wear support hose, and rest through out the daywith
legs/hip elevated
12. when should a colostomy bag be changed?
when is 1/3 -1/2 full
13. how large should the opening of the stoma pouch be?
no larger than 1/4 inch
14. what should the pt with a colostomy avoid?
the use of moisturizers, which will decrease the adherence of the pouch to theskin
15. what should the pt do with the pouch removing it?
they should empty the pouch to avoid spilling the effluent on to the skin
16. where should drops be instill into?
into the conjuctival sac
17. what is a positive way of dealing with a terminal illness?
"remembering things they used to do together"
18. what are normal findings after a colonoscopy?
, abd cramping
fatigue
passage of liquid stools
19. what are unexpected finding after a colonoscopy?
guarding- can indicate bowel perforation
20. what do you do if an order is questioned?
the nurse should record seeking clarification from the provider
21. what should pt with gastritis eat?
a well balanced diet, they should keep a record of foods that cause discomfort,pts can
modify their diet accordingly
22. what is the cause autonomic dysreflexia?
bladder distention
23. what are s/s of icp?
restlessness
change in LOC
24. what is late s/s of ICP?
widening pulse
decerebrate posturing
25. when can a child with varicella(chickenpox) return school?
the child can return to school when the blisters are dry and no longer drained
(scabbed over)
26. what is an appropriate behavior of a pt with hx of violence?
pt will avoid violence provoking situations
27. what is a skin cancer prevention?
pts should use sunscreen that protects against uva and uvb
28. what is the first thing you should do with excessive lochial discharge?
perform a fundal massage
29. what is the nurse responsibility of the nurse when witnessing the pts signature onan
informed consent?
that the pt is fully informed and understands the procedure befor signing the
consent form
30. who are at greater risk for std?
females because of increased vascularity to the vagina
31. does trichomonas vaginalis increased the risk for cervical cancer?
NO
32. Gonorrhea can lead to?
pelvic inflammatory disease and tubal scarring and can result in infertility
33. what should you do with postmortem care?
always check about religious practices prior to body preparation in order to honorfam
wishes
34. what can you not give to a pt with thickened liquids?
,35. no ice chips
no water
no icepops
36. what can a pt with thickened liquids have?
oatmeal
37. what should a pt do with incentive spirometer?
they should elevate the cylinder by inhaling deeply
assume semi fowlers or high fowlers position
38. in order to maintain sterile technique what should the nurse do?
should open all sterile packages prior to donning sterile gloves
39. what is psycho-motor learning?
have the pt demonstrate back the procedure
40. what places a newborn at risk for respiratory depression?
administration of an opioid analgesic
exa: fentanyl (sublimaze)
41. what is an effective method of bowel retraining?
anal stimulation with a gloved finger after the evening meal, it will help stimulatethe
gastrocolic reflex
42. when inserting an NG tube?
the nurse should insert the tube into the airway that is patent and has greaterairflow
43. what technique should be NG tube insertion?
clean technique
44. if NG tube meets resistance?
the nurse should rotate the tube without forcing it past the area of resistance
45. what kind of lubricant should be used during NG tube insertion?
water- based lubricant NOT petroleum jelly
46. what is pediculosis capitis management?
store child's clothing in a separate cubicle at schoolboil
brushes and combs in water for 10 mins
dry bed lines and clothing in a hot dryer for at least 20 mins
47. what can visual disturbances indicate?
preeclampsia
48. what is expected 24 hrs after surgery?
hypo active bowel sounds
pain
49. what is an abnormal finding 24 hrs after surgery?
low HGB
50. what must be done in bucks traction?
the pt must be in proper alignment
boots are secured by 3 straps, around pt leg
weights must hang freely
footplate is resting 15.24 cm (6inches) from the footboard
, 51. what does pts with delirium demonstrate?
a fluctuating LOC often at night or in am
52. pt with dementia demonstrate?
difficulty finding correct words to use
53. pt with anxiety disorders demonstrate?
obsessive behavior
54. how would the nurse determine progression of ascites?
abdominal girth should be measured daily
55. what is a food high in potassium?
cantaloupe
56. what is an indication of peripheral venous disease?
brown pigmentation around ankles
57. what is indication of peripheral arterial disease?
intermittent, leg muscle pain
58. what is some skin care for pts on radiation therapy?
59. pat area when dryinguse hand to wash
do not use sunscreen
60. what can hydromorpone cause?
urinary retention
61. what does bethanechol (urecholine) causes?
it stimulates urinary out put
62. how is nystatin best absorb?
if given 1 hour before or after a feeding
63. what is a sign that a newborn has finished eating?
a slowed suck/swallow pattern is a sign that the newborn isfinished eating
64. what not to do when breastfeeding?
is not necessary for the entire areola be in the moutheach feeding should start
at the opposite breast
do not push back of newborns head-toward the nipple
65. what should be included in a stool specimen?
visible blood, pus, or mucus
66. what is the first action in an infiltrated IV?
to d/c the saline lock
67. what is the first action when preparing to do a dressingchange?
to determine the pts level of pain
68. what should a with hemonymous hemionopsia with right visualfield, what will help pt
eat better?
the pt should turn head to the right to see all food on tray
69. what are some side effect for theophylline (theo-dur)?
