NCLEX-RN ATI LIVE REVIEW
What are examples of clinical manifestations that would be present for a patient with
peripheral arterial insufficiency?
- Shiny/hairless lower extremities
- Absent/weak pedal pulses
- Altered skin color
What are general possible AE to infusion of blood products?
- SOB
- Stridor
- Nervousness
- Flank pain
- Swelling
- Fever
- Feelings of impending doom
- Hives
What are nursing interventions involved when caring for a patient with an infiltrated IV?
- DC IV
- Elevate affected extremity
- Apply cold compress to affected area
- Start IV infusion in another extremity –
What are areas of the nursing process that ONLY the RN can do?
"Don't delegate what you EAT":
- Initial patient education
- Initial patient assessment
- Initial patient teaching
What is the time frame for appropriate administration of TPA?
3-4.5 hours after initial symptoms of stroke
For a patient scheduled to undergo ECT (Electroconvulsive therapy), what medication class will
need to be held prior to the procedure? Why?
,Anticonvulsants - ECT's goal is to elicit a seizure, therefore anti-seizure medications should all
be held
Disorder of pediatrics characterized by mixing of oxygenated and deoxygenated blood, allowing
for ineffective tissue perfusion
Tetralogy of Fallot
For patients receiving TPN, how often should the BG be checked?
q4-6hr
What is the nurses initial action when a bag of TPN is about to run out and another bag of TPN
is not yet available?
Hang an IV bag of 5% dextrose
What does an incident report typically include?
- Description of incident (Subjective from patient or objective from RN)
- Actions taken
Where should documentation of an incident report NEVER be included?
THE PATIENT'S CHART!
What are the 5 rights of delegation?
- Right person
- Right task
- Right circumstance
- Right direction
- Right supervision
What are appropriate tasks for the RN to delegate to the LPN (PN)?
- Care of stable clients
- Data collection
- Reinforcement of teaching done by RN
- Maintenance of IV piggybacks & infusions initially started by RN
Related to L&D nursing, what medication are LPN's (PN's) prohibited to administer? Why?
RhoGAM - blood product that is outside the LPN's scope of practice
, For pediatric patients diagnosed with glomerulonephritis, what are they at highest risk for?
HTN - Due to angiotensin being the most vasoconstrictive chemical metabolized by the renal
system
Who is legally able to give informed consent?
- Emancipated minor
- Individuals 18 years or older
- Married minor
- Patient/DPOA
- Pregnant minor
What is the RN's role in informed consent?
WITNESSING informed consent & ensuring that the patient is making an informed/non-
coerced decision
If the RN administers an amount of prescribed excessive medication dosage, who is liable if the
patient is harmed?
- The pharmacist who filled the prescription
- The physician who ordered the prescription
- The RN who administered the medication
- What is an example of negligence in nursing practice? When is it not considered negligence?
- If the RN fails to notify the physician that their patient has a 210/100 BP and the patient has
a stroke and ends up with left sided paralysis, THIS IS NEGLIGENCE because the patient was
harmed in the process of the RN's negligent behavior;
- Negligence is not present if the patient was not harmed in some way
What are examples of primary prevention in community health nursing?
- Education
- Prevention
- Vaccinations
- Immunizations
- Implementation of car seats for children
- Education of importance of helmets for children (Cars, bikes, etc)
What are examples of secondary prevention in community health nursing?
What are examples of clinical manifestations that would be present for a patient with
peripheral arterial insufficiency?
- Shiny/hairless lower extremities
- Absent/weak pedal pulses
- Altered skin color
What are general possible AE to infusion of blood products?
- SOB
- Stridor
- Nervousness
- Flank pain
- Swelling
- Fever
- Feelings of impending doom
- Hives
What are nursing interventions involved when caring for a patient with an infiltrated IV?
- DC IV
- Elevate affected extremity
- Apply cold compress to affected area
- Start IV infusion in another extremity –
What are areas of the nursing process that ONLY the RN can do?
"Don't delegate what you EAT":
- Initial patient education
- Initial patient assessment
- Initial patient teaching
What is the time frame for appropriate administration of TPA?
3-4.5 hours after initial symptoms of stroke
For a patient scheduled to undergo ECT (Electroconvulsive therapy), what medication class will
need to be held prior to the procedure? Why?
,Anticonvulsants - ECT's goal is to elicit a seizure, therefore anti-seizure medications should all
be held
Disorder of pediatrics characterized by mixing of oxygenated and deoxygenated blood, allowing
for ineffective tissue perfusion
Tetralogy of Fallot
For patients receiving TPN, how often should the BG be checked?
q4-6hr
What is the nurses initial action when a bag of TPN is about to run out and another bag of TPN
is not yet available?
Hang an IV bag of 5% dextrose
What does an incident report typically include?
- Description of incident (Subjective from patient or objective from RN)
- Actions taken
Where should documentation of an incident report NEVER be included?
THE PATIENT'S CHART!
What are the 5 rights of delegation?
- Right person
- Right task
- Right circumstance
- Right direction
- Right supervision
What are appropriate tasks for the RN to delegate to the LPN (PN)?
- Care of stable clients
- Data collection
- Reinforcement of teaching done by RN
- Maintenance of IV piggybacks & infusions initially started by RN
Related to L&D nursing, what medication are LPN's (PN's) prohibited to administer? Why?
RhoGAM - blood product that is outside the LPN's scope of practice
, For pediatric patients diagnosed with glomerulonephritis, what are they at highest risk for?
HTN - Due to angiotensin being the most vasoconstrictive chemical metabolized by the renal
system
Who is legally able to give informed consent?
- Emancipated minor
- Individuals 18 years or older
- Married minor
- Patient/DPOA
- Pregnant minor
What is the RN's role in informed consent?
WITNESSING informed consent & ensuring that the patient is making an informed/non-
coerced decision
If the RN administers an amount of prescribed excessive medication dosage, who is liable if the
patient is harmed?
- The pharmacist who filled the prescription
- The physician who ordered the prescription
- The RN who administered the medication
- What is an example of negligence in nursing practice? When is it not considered negligence?
- If the RN fails to notify the physician that their patient has a 210/100 BP and the patient has
a stroke and ends up with left sided paralysis, THIS IS NEGLIGENCE because the patient was
harmed in the process of the RN's negligent behavior;
- Negligence is not present if the patient was not harmed in some way
What are examples of primary prevention in community health nursing?
- Education
- Prevention
- Vaccinations
- Immunizations
- Implementation of car seats for children
- Education of importance of helmets for children (Cars, bikes, etc)
What are examples of secondary prevention in community health nursing?
