NURS 1101 ATI Exit Practice Questions (Updated 2020) – Bowie State university | NURS1101 ATI Exit Practice Questions (Updated 2020) – A Grade

NURS 1101 ATI Exit Practice Questions (Updated 2020) – Bowie State university Carbohydrates: contain 4 calories per gram Proteins: contain 4 calories per gram Fats: contain 9 calories per gram Findings associated with Phlebitis • Erythema • Throbbing • Warmth at the insertion site • Streak formation Findings associated with infiltration: • Pallor • Local swelling • Decreased skin temperature. Telephone order (in addition to hand written notes): obtain the providers signature within 24 hours Preventing skin breakdown for a client with a spinal cord injury • Turn every 2 hours • Use pillows to keep the heels off the bed surface and prevent skin breakdown on the clients heels • Apply lotion and avoid applying powder to the skin, which would cause skin breakdown • Minimize skin exposure to moisture to prevent skin breakdown Multiple Myeloma: Increased Calcium• Decreased: Absolute Neutrophil Count (ANC), Platelets, and WBC count IV Cefoxitin (Mefoxin): a client with a suspected or documented history of allergy to penicillin’s may also have an allergy to cephalosporin’s that could result in anaphylaxis Fluoxetine (Prozac): the usual recommendation is to take fluoxetine as a single dose in the morning Dryness, Redness, and Scaling after radiation treatment: apply hydrating lotions that do not contain metal, alcohol, or perfume Early Signs of Lithium Toxicity: gastrointestinal distress, polyuria, muscle weakness, and slurred speech Late Signs of Lithium Toxicity: mental confusion, poor coordination, and coarse tremors Removal of PPE 1) Remove gloves 2) Removes protective eyewear 3) Remove gown 4) Remove mask 5) Perform hand hygiene Pneumonectomy: surgical removal of the lung, which is commonly performed to remove a tumor in a client who has lung cancer. • Positioning for a client with a right pneumonectomy: position on the right side (operative side), because it promotes ventilation of the only remaining lung.• After surgery: the operative side should be dependent so that the fluid in the pleural space remains below the level of the bronchial stump and the inoperative side can fully expand Contaminating a sterile field: opening a sterile package over the middle of the sterile field Estimating Age: 18 Months: anterior fontanels close 24 Months/ 2 years: child should speak in two-and-three word phrases 30 Months/ 2½ years: child completes primary dentition (24 deciduous teeth) Skeletal Traction Pin Care: Do not remove crust around pin site during cleaning because this provides a natural barrier from bacteria Urolithiasis (Uric Acid Stones): a diet high in foods containing purines is a risk factor for uric acid stones Iron sources in infants: iron sources deplete and needs to be supplemented in infants Chronic Bronchitis: resonance percussion sounds Pneumonia: dullness percussion sounds Pneumothorax: tympany percussion sounds Pleural Effusion: flatness percussion sounds “Dirty Bomb”: combines radiologic agents with an explosive device resulting in immediate effects of radiation exposureJaundice in an African American client: most reliable source to diagnose is the hard palate Risk for Addisonian Crisis: daily weights will alert the nurse that dehydration is occurring, which could indicate an impending crisis Thrombophlebitis: vein inflammation related to blood clots • Bed rest is usually prescribed for 5 to 7 days Gout: painful and disabling form of arthritis caused by an excess of uric acid in the body. • Should not take aspirin: can interfere with uric acid excretion and may precipitate an acute onset • Fluid intake of a minimum of 2,500 mL/day: recommended to minimize uric acid stones • NO Purine: avoid all foods high in purines • Alcohol: men who have gout are instructed to limit alcohol consumption to no more than two drinks a day, and women to only one drink a day Basal cell carcinoma: begins as a small, waxy nodule with rolled, translucent, pearly borders. Squamous cell carcinoma: appears as a rough, thickened, ulcerated tumor that may bleed; it may also be asymptomatic Right Cataract Extraction: avoid lifting anything heavier than 4.5 kg (10lb) for 1 week Sengstaken-Blakemore Tubes: provide oral and nares care every 2 hours• A client who has a Sengstaken-Blakemore tube in place will be unable to swallow. • If the client is alert, the nurse should provide tissues and encourage spitting of saliva into a tissue or basin. • If the client is not alert, gentle suctioning of the oral cavity may be needed to remove secretions. Sengstaken-Blakemore Tubes: maintain constant observation while balloons are inflated • A Sengstaken-Blakemore tube is used to stop or slow bleeding from the esophagus and stomach. • When balloons are inflated, they put pressure on the areas that are hemorrhaging to tamponade the bleeding. • While the balloons are inflated, the client must be observed constantly because displacement can cause airway obstruction. Cardiac Enzyme Studies and Acute MI • Cardiac enzyme studies are obtained because their degree of elevation reflects the degree of damage to the myocardium. • CPK and Troponin: enzymes have a characteristic rise and fall pattern after an MI Knee Arthroplasty: clients are allowed to walk, as tolerated, following the procedure but should not overuse or strain the joint. • Crutches or a knee brace are prescribed when weight-bearing limitations are indicated. Systemic Lupus Erythematosus (SLE): exacerbating factors • Sunlight • Pregnancy • Infection• Exercise is NOT an exacerbating factor Left Sided CVA program goals: establish the ability to communicate effectively • Left hemisphere: dominant for language • Right hemisphere: learn how to control impulsive behavior Skeletal traction: hang freely at all time and are never to be removed without a specific provider prescription unless there is a life-threatening situation Transsphenoidal hypohysecotomy & clear drainage seeping from the nasal packing • Check the drainage for glucose: indicates that the drainage is CSF Gastric drainage: pH of 4.0 Hypothyroidism: elevated thyroid stimulating hormone (TSH) Cranial Nerve III (Oculomotor), IV (Trochlear), and VI (abducens): eye movement and pupillary response to light Cranial Nerve II (Optic): visual acuity Cranial Nerve VII (Facial): motor nerve that controls facial asymmetry Cranial Nerves IX (Glossopharyngeal) and X (Vagus): controls gag reflex Aspirin and Rheumatoid Arthritis • Erythrocyte sedimentation rate (ESR) is useful in detecting and monitoring tissue inflammation in clients with RH Decreasing Serum Ammonia Levels in End-Stage Cirrhosis of the Liver: start the client on a low-protein, high-calorie dietEndometrial Cancer: hx. of postmenopausal bleeding • The most common manifestation of endometrial cancer is abnormal uterine bleeding, including postmenopausal bleeding and bleeding between normal periods in premenopausal women. Cataracts symptoms: seeing halos and rainbows when looking at lights • Symptoms of cataracts include difficulty seeing at night, seeing halos around lights, having glare sensitivity, and experiencing decreased visual acuity, even in daylight Radiation therapy & maintaining skin integrity: use of ice packs is contraindicated • Avoiding ice packs helps avoid tissue damage. For clients undergoing radiation therapy, the most common issue is skin irritation in the area being irradiated. • Radiated skin also becomes thinner and may lack tissue receptors that would normally alert the client to a potential burn injury, so the use of ice packs is contraindicated Autonomic dysreflexia trigger: bladder distention • Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury • Catheter changes, a distended bladder or bowel, enemas, and sudden position Autonomic dysreflexia: clinical manifestations • Elevated blood pressure • Severe headache • Flushed faceMost reliable screening tool for pulmonary TB: sputum culture for acid-fast bacillus • Noted in the sputum, secretions, or tissues of the client is the only method to actually confirm the diagnosis Most reliable screening tool for TB: Mantoux skin test • Most and valuable screening tool available for TB. A positive result means only that the client has been exposed to TB; it does not mean that the client has active TB disease. Systemic Scleroderma skin changes: finger contractures • Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. • Symptoms include skin changes, Raynaud’s phenomenon, arthritis, muscle weakness, and dryness of the mucous membranes • Contractures will occur with advanced systemic scleroderma unless the client follows a regimen of range-of-motion and musclestrengthening exercises, pain management, and joint protection Aluminum hydroxide (Amphojel): aluminum-based formulas are also phosphate binder, helping to lower serum phosphorus levels in clients who have chronic renal failure. Complications for Hypothermia Blanket: Shivering • The hypothermia (cooling) blanket, if used improperly (at inappropriately low temperature, or without protection), can cause the client to cool too fast, leading to shivering. • To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ALL INDICATE RESPIRATORY DISTRESS IN A NEWBORN aPTT expected results in hemophilia A client: 45 seconds • This value is above the expected range (30 - 40 secs), indicating a risk for spontaneous bleeding, which is a manifestation of hemophilia AAntisocial Personality Disorder Finding: Lack of Remorse • Clients who have antisocial personality disorder show a lack of remorse Important Finding in Depressed Client to Report: The client’s appetite has diminished over the last week • When using Maslow’s hierarchy of needs, the nurse determines the priority finding to report to an interdisciplinary conference. Therefore, the nurse should report that the client’s appetite has diminished over the last week. Plan of care after thoracentesis for a client who has pleurisy: Instruct the client to avoid deep breathing during the procedure • It is important for the client to avoid deep breathing during a thoracentesis to avoid puncture of the pleura First step in successfully implementing staffing changes: form a staff task force to investigate current staffing issues • Using the stages of change, the first action the nurse manager should take is to form a staff task force to investigate current staffing issues. Valproic Acid diagnostic tests: serum liver enzyme levels • Valproic acid may cause hepatic toxicity • Anticonvulsant/Anti-epileptic: treats seizures and also treats mood disorders and helps prevent migraine headaches. Digoxin Toxicity Manifestation: Nausea • Treats certain heart rhythm problems (atrial fibrillation). Also used to treat heart failure, usually in combination with a diuretic (water pill) and an angiotensin-converting enzyme (ACE) inhibitor. This medicine is also called digitalis.Quad Cane – Need for further instruction: places the cane on the affected side of the body • The cane should always be placed on the unaffected side of the body. Amitriptyline (Depression Medication) Understanding of discharge instruction: I should watch for common reactions like dry mouth and constipation • These are anticholinergic effects common when taking amitriptyline, a tricyclic antidepressant. Fluoxetine (Prozac) symptoms to report and monitor: Tremor • Fluoxetine can cause serotonin syndrome within 2 to 72 hours after starting treatment. • The client can experience tremors, agitation, confusion, anxiety, and hallucinations. Chlorpromazine teaching: “Sip fluids frequently throughout the day” • Phenothiazine/ Antiemetic • Clients taking chlorpromazine may experience dry mouth. Sipping fluids throughout the day can minimize dry mouth • Treats mental disorders, severe behavior disorders, severe hiccups, severe nausea and vomiting, and certain types of porphyria. Also used before and after surgery to relieve anxiety. Indications for Rh immune globulin administration: An O negative woman following a spontaneous abortion • The O negative mother following a spontaneous abortion may have been carrying an Rh positive fetus and should receive Rh (D) immune globulin1 day post-op hip arthroplasty priority to report to the provider: dressing saturated with sanguineous drainage • The greatest risk to the client is excessive bleeding; therefore, a saturated dressing is the priority finding for the nurse to report Theophylline toxicity symptom: Anorexia • Anorexia is an expected finding of theophylline toxicity Vitamin K is routinely given to newborns to prevent bleeding IV Cefazolin w/ 0.9% sodium chloride: piggyback the cefazolin into the 0.9% NaCl infusion • Cephalosporin antibiotic: treats serious infections caused by bacteria. Also prevents infection after surgery Checking FHR near the end of 1st trimester: place the scope midline just above the symphysis pubis and apply firm pressure Client experiencing a wound evisceration 1. Stay with the client and call for help 2. Cover the client’s wound with saline soaked gauze: to keep the internal organs moist 3. Place the client in a supine position with the hips and knees bent: to relieve pressure from the open wound 4. Take the clients vital signs: to assess for changes in hemodynamics Thrombocytopenia patient care and teaching: avoid venipunctures when possible and tell the patient to avoid nose blowing • Deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury.Pneumonic for Crutches Cane Opposite Affected Leg Fat Emboli Symptoms (fracture complication) • Petechiae or rash over chest: caused by embolization of skin capillaries or thrombocytopenia • Conjunctival hemorrhage • Snow storm of chest x-ray: patchy infiltrates