ATI Comprehensive Exam Well Elaborated 2024

For cataract extraction surgery, what are the protocols? - ANSWERS-avoid taking aspirin -use cool compress on eye before calling MD if itchy -avoid bending at the waist b/c it can raise intraoccular pressure (BEND AT THE KNEES) -don't lift anything over 10 lbs If a patient 24 hours p/o refuses to ambulate, what should you do first? - ANSWERS-assess pain -THEN you can educate, turn patient, give PRN analgesic What happens during true labor? - ANSWERS-cervix transitions to anterior position -contractions felt in low ab and back -increases w/ ambulation -cervix thins What are common side effects of amitryptiline (antidepressant)? - ANSWERS-dry mouth and constipation (eat fiber and chew gum) and BLURRED VISION -take a night to minimize drowsiness -lack of ability to sweat-avoid overheating What should you do for diabetes insipidus? - ANSWERS-monitor increase urine output (polyuria-over 4 L/day) -monitor tachycardia -orthostatic hypotension -increased BUN -monitor for hyperthermia d/t dehydration What should you do to minimize risk of increased ICP? - ANSWERS-place client in quiet environment -spread out nursing activities throughout the day -keep head of bed no more than 25 degrees What should you do for a client who recently got a stoma and can't afford it d/t lack of insurance? - ANSWERS-arrange for social services -refer to american cancer society -refer to support groups -refer to enterostomal therapist -DO NOT delay discharge What should you teach for myasthenia gravis patients? - ANSWERS-cut food into small bites and eat slowly (SEMI-SOLID) -keep HOB elevated 30-60 mins after meal -weigh self daily -take anticholinesterase meds 45-60 mins before meals (NOT anticholinergics) -choose snacks high in calories -ANNUAL FLU VACCINE-avoid pulmonary disorders b/c compromised resp muscles What should you do for clients who have rheumatoid arthritis and are in pain? - ANSWERS-allow frequent rest periods throughout the day -recommend warm showers, not baths to prevent falls -apply ice to reduce inflammation -don't do morning ADLs until pain meds are given -don't take more than 4 g of acetaminophen/day -encourage high iron, protein and vitamins What should you give a toddler who has infectious gastroenteritis? - ANSWERS-initiate oral rehydration therapy -DONT give BRAT (bananas, rice, applesauce, toast) diet because it doesn't have electrolytes What should you do if the client vomits on a reusable BP cuff? - ANSWERS-send it off in a labeled bag for contamination -DONT throw it away -rinse in cold water immediately after -use chlorine bleach to clean blood spills What does petechiae over the chest after a lower leg injury mean? - ANSWERS-at risk for fat embolism syndrome -PRIORITY FINDING What is important about newborn safety? - ANSWERS-set hot water heater temp at 120 degree F or below -DONT sleep with blanket -make sure crib slats are no more than 2.5 in apart -place baby's car seat rear facing until 2 What is within the LVN scope? Assistive personnel? - ANSWERS-LVN: insert NG tube -AP scope: prepare bed, obtain stool sample What should you instruct the client of a newborn baby regarding motor vehicle safety? - ANSWERS-place baby at 45 degree angle -rear facing until 2 year old -place blanket over baby AFTER harness is set -secure retainer clip at level of baby's armpit What about a physicial assessment is wrong? - ANSWERS-SHOULDNT write detailed notes What are the steps of trach care for a child? - ANSWERS1. Take out inner cannula 2. Remove soiled dressing 3. Clean stoma 4. Replace collar What is important regarding NPH and regular insulin? - ANSWERS-air into NPH, air into regular -draw from regular, draw from NPH -roll NPH between palms -use same needle What is care like for patients with DVT? - ANSWERS-elevate leg to reduce edema and improve blood flow -encourage ambulation -drink 2-3 L of fluid to decrease platelet aggreggation and prevent dehydration -place warm compress on leg For clients with uric acid formation urinary calculi, what foods can they eat? - ANSWERS-oranges -AVOID meats, alcohol, chicken What is the first action a nurse should take when discharging a client who was abused? - ANSWERS-develop a safety/escape plan -THEN provide info about social services and support groups What is the priority for children with cystic fibrosis? - ANSWERS-hemoptysis over 250 ml/24 hours indicates risk for brain hemorrhage What are main manifestations of vaso occlusive crisis? - ANSWERS-hematuria (occlusion of kidneys) -swelling of hands and feet -visual disturbances (NOT hearing disturbances) What are manifestations of autonomic dysreflexia? - ANSWERS-facial flushing -nasal congestion -headache What is true about methadone? - ANSWERS-can keep taking when pregnant -can develop dependency -can cause sedation -don't take more than one dose EVER What are signs of oxygen toxicity? - ANSWERS-bradypnea d/t respiratory depression -substernal chest pain (for increased work of breathing) -crackles What are manifestations of digoxin toxicity? - ANSWERS-nausea -anorexia -stomach pain -bradycardia -visual disturbances -diarrhea -muscle weakness What are indications that a client is at risk for pressure ulcers? - ANSWERS-low albumin/Hgb -weight loss -diarrhea What is saw palmetto? - ANSWERS-herbal supplement that causes false-low prostate levels -can delay prostate cancer dx What is the rooting reflex for infants? Asymmetric Tonic neck reflex? Extrusion reflex? Glabellar reflex? - ANSWERS-stroke infants cheek -will cause infant to stick tongue out -glabellar: tap on infant's nose-close eyes -asymmetric tonic neck: turn head to one side-extend arms and legs on that side and flex on the other side -extrusion reflex: depress tongue-sick tongue out What are complications of obstructivee sleep apnea? - ANSWERS-hypertension d/t lack of oxygen and need for improved perfusion -heart failure -dysrhythmias -weight gain-hyperglycemia -enuresis What should you do when discharge planning for a client with stroke and right sided weakness? - ANSWERS-REFER TO OCCUPATIONAL THERAPY FIRST -referrals always first if care can be within the facility If feeling respiratory depression from lorazepam, what hsould you administer to reverse effects? - ANSWERS-flumazinil -naloxone is used for opioid overdose What are signs of lithium toxicity? - ANSWERS-confusion -blurred vision/diarrhea/vomiting -increased thirst -hand tremors -ECG changes -sedation If fetus is in the left occiput anterior position, where's the best place to listen for fetal heart tones? - ANSWERS-position of back -left lower quadrant if on the left side What is true about organ donations for children who are impending death? - ANSWERS-can have an open casket b/c it doesn't disfigure body -can receive antibiotics and still donate -doesn't need an autopsy What should you do for enteral feedings? - ANSWERS-keep HOB at 45 degree angle 1 hour after to decrease aspiration risk -give 20-30 ml of water to flush tube to prevent clogging -avoid adding dye to aspirate -inject 10-30 ml of air after checking for residual What are symptoms of ovarian cancer? - ANSWERS-abdominal bloating, constipation, urinary urgency -postcoital bleeding and back pain are indications of cervical cancer What is priority of a client 18 hr p/o c birth and breastfeeding? - ANSWERS-unilateral lower extremity tenderness (DVT) -low grade fever (99) is okay What are signs of delirium? - ANSWERS-rapid, incoherent speech What happens to children during the acute phase of Kawasaki's? Subacute phase? - ANSWERS-high fever unresponsive to antipyretics -tachycardia -subacute: peeling of soles and palms, pain of weight bearing joints What is important about hep A teaching? - ANSWERS-clean with chlorine bleach 1:100 solution or hydrogen peroxide -safe food handling and hand hygiene techniques What is important to do follow tonsillectomy? - ANSWERS-place head below level of chest to prevent aspiration -avoid coughing and using straws -give pain meds q 4 h What are common findings of cardiac tamponade? - ANSWERS-pulsus paradoxicus (SBP is over 10 mm Hg greater on expiration than inspiration) -JVD -bradycardia -hypotension If a patient if 4 hr postpartum with a boggy uterus and heavy lochia, what should you do? - ANSWERS-massage uterus to expel clots-will increase uterine firmness and decrease bleeding -do this before oxytocin! What teaching should the nurse give to a mother who has breast engorgement and is only bottle feeding their child? - ANSWERS-use ice packs on breast to reduce swelling -DONT express milk daily or allow temporary breastfeeding b/c it'll continue to produce milk -wear tight fitting bra to improve comfort What can clozapine cause? - ANSWERS-can cause agranulocytosis -do NOT give if WBC low (less than 3k) -hypotension What are manifestations for client's with Raynaud's phenomenon? - ANSWERS-blanching of fingers and toes-response to cold or emotional stress -pallor develops-then cyanosis-then redness as vessels reperfuse What is Naegele's rule? - ANSWERS-to find DOB, take last menstrual period and go back 3 months and add 7 days When assessing patients a nurse should see first, what matters most? - ANSWERS-assess client with no bowel sounds and ab distention postoperatively -could indicate paralytic ileus What is the best way to ensure cost effective care? - ANSWERS-assign non nursing tasks to ancillary staff -do NOT stock rooms with extra supplies -do NOT assign dedicated equipment to each room -IV tubing is to be changed every 96 hours What is true of clients with borderline PD? - ANSWERS-emotionally unstable -engage in harmful self mutilation -have trouble with relationships -feeling empty What is true of ginseng? St. John's wart? Valerian? Flaxseed? - ANSWERS-decreases effectiveness of timolol-antiglaucoma med -interacts with caffeine-irritability -can INCREASE effectiveness of warfarin (anticoagulants), stimulate mental activity and improve appetite -St. John's wart can increase effectiveness of fluoxetine -valerian: sedative, can lower BP -flaxseed: used for migraines, can cause GI symptoms When administering combined (2 meds) IM meds what should you do? - ANSWERS-use a 2 in needle -use large muscle mass (NOT deltoid) -inject air into both vials before drawing it up What is true of hospice care? - ANSWERS-includes bereavement services post death -will teach family how to provide pain meds, but is also on call 24 hours -includes respite services For an occlusive crisis in sickle cell, what should you do first? - ANSWERS-GIVE IV FLUIDS to promote blood flow through ischemic areas -then can give pain meds, warm packs, collect blood To prevent heat loss by CONDUCTION directly after birth, what should the nurses do? - ANSWERS-use protective cover when weighing the baby -drying baby after birth-evaporation -maintaining ambient room temp-convection -placing baby bassinett away from outside windows-radiation What are adverse effects of electroconvulsive therapy? - ANSWERS-short term memory loss -NOT post treatment seizures What is the first thing you should do following a laryngectomy where the client is unable to speak? - ANSWERS-determine client's reading skills When administering chemo meds, what are things to check? - ANSWERS-if bilirubin levels between 1.2-3, give 50% of med -inject solution 3-5 mins -give antiemetics 30-60 mins before -check mucosa for petechiae every 8 hours bc med can cause thrombocytopenia and risk for bleeding What is valproic acid? - ANSWERS-helps treat seizure disorders -used for peds patients -can cause hepatic toxicity and jaundice as adverse effects What is true of infection control precautions? - ANSWERS-for measles (rubeola) and varicella, initiate airborne -airborne precautions=negative pressure room (TB!)-6-12 exchanges/hour with HEPA mask -C. Diff/Herpes simplex/MRSA=contact -pneumonia, flu, pertussis, rubella, pharyngitis=droplet -immunocompromised=protective env in room with 12 exchanges/hour and positive air flow What are expected/unexpected findings of newborns? - ANSWERS-expected: tongue not protruding -unexpected: nasal flaring, retractions, grunting What are mental health group tasks assigned to group members? - ANSWERS-orienter: noting progress of group towards assigned goals -evaluator: measures group's work against assigned goals -information giver: sharing experiences as an authority figure -initiator-contributor: offering new and fresh ideas of an issue What is the range for albumin? - ANSWERS-less than 3.5 indicates need for additional nutritional supplements What is an adverse effect of ibuprofen? - ANSWERS-stomach pain -bloody stools -both from GI bleeds -decreased urine output For visual acuity testing using the Snellen chart, what should you do? - ANSWERS-keep both eyes open during test -assess with glasses first, then without glasses -stand 10 ft away -in order to pass a line, must get 4-6 symbols correct What should you do if receiving heprain infusion and warfarin and INR is 1.8 and aPTT is 98? - ANSWERS-withhold heparin infusion -give protamine sulfate For a 26 week gestation client about to have oral glucose test, what should you do? - ANSWERS-reduce carbs 3 days prior -fast overnight -blood will be collected every hour during test -avoid caffeine -maintain normal activity level What should you do if the client got a terminal cancer dx and wants to go home to spend time with loved ones? - ANSWERS-refer to social services What is the purpose of Agency for Healthcare Research and Quality? National Institute of Health? Dep of Agriculture? WHO? - ANSWERS-AHRQ: improves healthcare services for migrant farmworkers, low income and minorities -NIH: focuses on research to prevent and treat diseases -Agr: focuses on availability of food/nutrition services -WHO: develops research programs for entire nation using stats and conducting studies For a client with GI bleed and NG tube in place, what action should the nurse take when performing a gastric lavage? - ANSWERS-200-300 mL room temperature solution (tap water, sterile water, NaCl) should be instilled -lie on left side What clients can be discharged home? - ANSWERS-cellulitis with oral antibiotics every 8 hours What foods can you eat when taking phenelzine (MAOI)? - ANSWERS-food with no tyramine-food with tyramine with MAOIs can cause HTN -broccoli, yogurt, cream cheese -pepperoni pizza and bologna both have meat, meat=tyramine What is true of instructions for amoxacillin suspension at home? - ANSWERS-give med every 8-12 hours -shake bottle well before giving -store in refrigerator -report diarrhea to provider immediately -discard unused medication after 14 days For hypocalcemia, where do you tap to ellicit positive Chvostik sign? - ANSWERS-cheek about an inch in front of tragus -ellicits facial nerve What is an adverse affect of clonidine? - ANSWERS-used to treat BP -dry mouth -rashes, pruritis -edema -taste alterations For a child with asthma, what should you do? - ANSWERS-get flu vaccine once/year -take the highest reading out of 3 PEF meter readings (not average) -remove carpet from bedroom What is true of ostomy care? - ANSWERS-cleanse skin at stoma site with washcloth and warm water -dry skin around stoma before applying barrier -place skin barrier adhesive over stoma and hold it there for 30 seconds -wear clean gloves (not sterile) -cut the skin barrier no more than .3 (.13 in) cm larger than the stoma