ATI Comprehensive Exam

ATI Comprehensive Exam Pt has a PE and is being given heparin continuously via IV at 1,200 units/hr and warfarin 5mg PO daily. The labs show aPTT of 98sec and INR of 1.8 [ANS] - Should withhold the heparin infusion because the aPTT is to high, the normal therapeutic range while receiving heparin is 60-80sec Pt in urgent care reports impaired vision in one eye. What would indicate a detached retina? [ANS] - A floating dark spot is one of the manifestations due to bulges, folds, or holes in the affected retina Infant with hydrocephalus and is 6hr post-op following a placement of ventriculoperitoneal shunt (VP). What finding should be reported to the HCP? [ANS] - Irritability when being held, this is a manifestation of increased ICP. This indicates that the VP shunt is malfunctioning and should be reported A pt is taking phenelzine, what food recommendation should be given? [ANS] - - Phenelzine is an MAOI, while taking the pt should avoid foods containing tyramine - Foods the pt can eat include broccoli, yogurt, cream cheese - Foods that do contain tyramine include processed like pepperoni and bologna A pt is 20wks of gestation and the nurse is discussing common prenatal discomforts. Which statement indicates understanding? [ANS] - - Wearing a supportive bra overnight, this will help with the breast changes - Increase intake of high-fiber foods, this will help with constipation - Development of face rash is normal, anti-inflammatory ointment doesn't help this - Sleep on side to help with back pain A nurse is providing discharge teaching to a pt receiving home oxygen therapy. What should the nurse include in the teaching? [ANS] - - Check the function of the equipment daily - Wear cotton clothing while oxygen is in use, this decreases static electricity from the clothing and risk of fire -Apply water-soluble lubricants to the nares vs. oil based - Store tanks in an upright position Pt receiving continuous bladder irrigation following a transuretheral resection of the prostate. The pt reports bladder spasms and there is decreased urinary output. What should be done? [ANS] - - Irrigate the catheter with 0.9% sodium chloride irrigation - This indicates internal obstruction of the catheter Child with sickle cell anemia who is having vaso-occlusive crisis. What intervention should be done first? [ANS] - - Infuse IV fluids, this promotes hydration and circulation, decreases the tissue and organ ischemia A nurse is teaching a pt about basal body temp. method of birth control. What information should the nurse include? [ANS] - - The body temp. might decrease slightly just prior to ovulation A nurse is assessing for hypocalcemia, where should the nurse tap on the face to elicit a positive Chvostek's sign? [ANS] - - The nurse should tap the pts facial nerve about an inch from the tragus of the ear. Facial twitching is positive finding for hypocalcemia A pt has acute glomerulonephritis, which of the following findings in the urine should be expected? [ANS] - - Protein is expected - Increased glomerular permeability allows protein to filter into the urine A nurse on an oncology unit is administering doxorubicin to a pt with breast cancer. Which action should be taken? [ANS] - - Inspect the pts mucosa for petechiae q8hr - This medication causes thrombocytopenia and increases the risk of bleeding - Should also assess for hematuria, guaiac, and bruising The nurse recognizes that a sedentary lifestyle is a risk factor for osteoporosis in older adult pts. What should this pt be taught? [ANS] - - The nurse should encourage the pt to engage in weight-bearing exercises to promote bone health, this will increase calcium and phosphorus levels Isolation precautions [ANS] - - A pt with measles should be placed on airborne precautions - A pt with airborne precautions should be placed in a negative-pressure airflow room - A pt with C-diff should be placed on contact plus precautions A child is taking valproic acid, what diagnostic test should be expected for the HCP to order? [ANS] - - Serum liver enzyme levels - Valproic acid can cause hepatic toxicity A pt with schizophrenia has started taking risperidone. What action should the nurse take? [ANS] - - Implement fall precautions for the pt - Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls A child in the ED who has a fever and fluid-filled vesicles on the trunk and extremities. What intervention is priority? [ANS] - - Initiate transmission-based precautions - This indicates that the child most likely has varicella, which is infectious A nurse is assessing a pt for compartment syndrome. What is an expected finding? [ANS] - - Edema - Compartment syndrome causes increased pain, pallor, and paresthesias from increased edema A nurse is assessing a pt after giving epinephrine for an anaphylactic reaction. What is an adverse effect of this medication? [ANS] - - Chest pain - Epinephrine increases cardiac workload and oxygen demand, which can result in angina A nurse is providing teaching to a pt who is 24wks gestation and is scheduled for a 3hr oral glucose tolerance test. Which of the following instructions should the nurse include? [ANS] - - You will need to fast the night before the test A nurse is assessing an older adult pt with pneumonia. Which finding should the nurse expect? [ANS] - - Acute confusion - Typical findings in an older adult is acute confusion, fatigue, lethargy, and anorexia A pt in the ED has been having nausea and vomiting for the past 2days. What finding should be expected? [ANS] - - Urine specific gravity of 1.052, this indicates dehydration - Normal urine specific gravity is 1.002-1.030 A nurse is caring for a post-op pt who received moderate (conscious) sedation. The pt suddenly becomes restless and reports feeling lightheaded. What actions is priority? [ANS] - - Check the O2 saturation - Restlessness and lightheadedness are indications of hypoxia A nurse is providing teaching to a pt newly diagnosed with type 1 diabetes. The nurse should instruct the pt to monitor for which finding as a sign of hypoglycemia? [ANS] - - Irritability A