ATI Comprehensive Exam
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? - Answers -1. 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
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? - Answers -1. 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
