ATI Predictor A

kabenate's version from 2016-03-07 18:42

Section 1

Question Answer
What is a kosher diet?No shellfish but yes fish with fins and scales; no pork; no mixing meat with milk, ever;
Woman is post pelvic surgery and asks why she has a foley catheter inserted, what is your response?It avoids stress on the incision site/bladder
Crutches on what side when rising? When walking?Unaffected side when rising, affected side while walking.
Arms at what degrees when hands on crutch rails while standing?30 degrees
What walking gate for stairs?3 point
Normal stoma findingsMoist shiny and pink; mild soap and wager, then dry gently and completely, apply paste if used, apply barrier pastes to creases
Cholecystitis dietNo cheese!! Low fat, low cholesterol (<200), if AST and lipase, any type of bilirubin, WBC, amylase, LDH, are elevated, bad.
Expect what during the latent phase of labor.(0-3, 5-30, 30-45) 0-3cm, contractions mild and moderate, 5-30min. apart/30-45 seconds.
Contractions 3 minutes apart = what phase of labor?Active
Variable decelerations = what? Intervention?Cord compression! Prep for emergency c-section or inducing labor. Also can change position, d/c oxytocin, O2 8-10L/min per mask, perform/assist with vaginal exam, assist with amnioinfusion if ordered
Which of the following is the initial nursing action the nurse should take when late decelerations appear on the fetal monitor? A. Reposition the client in to left-lateral position B. Apply a fetal scalp electrode C. Increase the IV fluid rate D. Perform a vaginal exam to assess dilationReposition client left-lateral position
Best pain management for 8-10 post open cholecystectomy: Demerol, hydromorphone, fentanyl, morphineDemerol, NOT morphine or others. Morphine can cause biliary spasms.
Fontanels close when?Posterior 2-3 months, anterior 12-18 months
Do you report chlamydia, do you need consent, etc.Mandated reporting to CDC, without verbal or written consent
Empty JP drain when? Clean how?Before half full, or every 8-12 hours, NOT 24 hours. Clean with soap and water, NOT antimicrobials or Dakin's etc.
If JP drainage has doubled in last two hours, possible cause?Hemorrhage. So assess, stat CBC, notify physician.
What do bananas, avocado and spinach have in common? If patient on what med, these are good foods?^ K+, so good for hypokalemic patients. If patients on thiazide diuretics (Diuril, Enduron), may be HYPOkalemic, so give these
MAOI's/Nardil, avoid what?cheese!
Cheese is not good with what? Cheese is good for what and why?Nardil/MAOI's! Good for hyponatremia because high in sodium, high in protein
Is drainage at pin sites ok with bucks traction?Drainage ok, note the type, odor, color and amount. Leave crust as a barrier, pin care 3x/day
Phenytoin, SMZ-TMP, command hallucinations = what?Phenytoin toxicity!
If patient has command hallucinations, withhold med?Yes!

Section 2

Question Answer
Methergine risk? What does it do?Treats postpartum hemorrhage by inducing uterine contractions, reducing hemorrhage. HYPERTENSION is a risk, so CHECK BP prior to administration, watch for n/v, headache,
High pressure alarm, do what?Assess for kinks, client biting, excess secretions (suction), pulmonary edema, etc. Notify provider
Low pressure alarm, do what?Assess for leaks, displacement. If can't find anything wrong, MANUALLY VENTILATE AND CALL RESPIRATORY STAT, do NOT LEAVE ALONE
2 years of age, presentation of arms longer than torso, or round and soft abdomen?Round and soft abdomen, NOT arms longer than torso
3 years of age normals; immunizations?2-3kg/yr, 2.5-3in./yr., picky eater, initiative vs. guilt, imaginary friends, ride tricycle, jump off bottom step, stand on one foot for few seconds. DTaP, IPV, MMR, varicella, influenza
First thing to do with a newborn: Take temperature, weigh, dry...Dry
Terminally ill patient only wants family, not friends with them. Type of grief?Anticipatory, not dysfunctional, normal, or disenfranchised.
A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which IV solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase BP? 1. 5% dextrose in lactated Ringer's 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.225% sodium chloride (1/4 normal saline) 4. 0.45% sodium chloride (1/2 normal saline)5% dextrose in LR
Give what for hypovolemic shock5% dextrose in LR
Client's family asks you to pray with them. Response?Refer to spiritual services
After a blood infusion, will you look at hub, hct, BP, or HR for changes?Hgb! 1-2 point increase per unit of blood.
Can you give an antibiotic in a TPN infusion line? What can you add to a TPN infusion line?NO! Nothing!
Change a TPN infusion line every 24 hours, or how often?Yes! Every 24 hours
Can client's family change dressing daily? Tie tubing to neck?No, every 8 hours! Yes, square knot with 1-2 finger widths,
TPN, slow down infusion before ending, d/c until new bag ready?No, don't d/c or change rate, don't change flow rate!
Hip arthroplasty, what to watch out for?Peripheral pulses! So cool and weak, 1+ peripheral pulses, sign to call provider.
Mom engorged, don't do what?Don't self express milk! Ice packs, support bra all ok.
Rifampin, isoniazid, phenytoin, what's up?INH/Isoniazid increases phenytoin toxicity, meaning ataxia and hallucinations may present. Decrease phenytoin dosage. Hepatotoxicity possible with rifampin.
Palpate fontanels by 2-3 years?No! Bulging fontanels could mean ^ ICP, meningitis.
First priority for DKA patientsESTABLISH VENOUS ACCESS, before ANYTHING.

Section 3

Question Answer
DKA patient drops glucose from 450 to 250, do what? Measure glucose, temp, what, and how often?Measure glucose & potassium hourly, provide IV glucose at 250 to prevent hypoglycemia.
Patient has L1-L2 paralysis, lives with spouse, bathroom and bedroom on 2nd floor. Needs PT, respite, speech therapy, what?Needs occupational and physical therapy, but social services is number one for help with home adaptation!
Highest risk to patient is bed tray left in room, tray table at end of bed, restraints tied to bed rails?Restraints to bed rails! This is inappropriate.
Infant has scaly spots, erythemic papillae, and something on lips. Report which to physician?Lips!
A woman comes in to you and says she is on contraception and wants to get pregnant. What is she at risk for?If IUD, then ectopic pregnancy!
Infant has substernal heaves, expect what?O2, suction, Survanta for surfactant, vent. support
aPTT normal25-35
Platelets normal150-400
aPTT 30 and platelets 200, what's wrong?Nothing
Can you delegate an LPN to check NG tube placement? Can they provide first feeding after CVA?Yes, according to book; not clear, but assume no, because high risk scenario
Ventricular tachycardia/Vtach = what ECG?WIDENED QRS
What can a 3-month old eat, carrots, grapes, graham crackers, or popcorn?Graham crackers
Dehydration = what v/sLow BP, high HR, metabolic acidosis (low pH, high bicarb). postural hypotension, H&H, BUN and other elevated
Glucose reaches 250 on insulin, give what? Isotonic, hypotonic, hypertonic, dextrose?Dextrose to prevent hypoglycemia.
Bend at waist to pick up, or tuck pelvis and flex abs?Flex and tuck, NEVER bend at waist
Give patient cooling blanket when febrile, what is sign of adverse reaction?Shivering
Can digoxin toxicity occur with 3.2 potassium?Yes
130/86 BP, severe headache, what would you report in preterm labor to provider?Severe headache!! HYPERTENSIVE CRISIS
S/S of magnesium sulfate toxicity? 2 main interventionsurine output < 30, RR < 12, no deep patellar tendon reflexes, decreased LOC, cardiac dysrhythmias. IMMEDIATELY D/C, give CALCIUM GLUCONATE
Tuna good for what, bad for what?High in protein AND potassium, so watch out.
If anemic, increase or decrease milk, and give iron or no?Decrease milk as it interferes with iron absorption, and they need iron; give iron!

Section 4

Question Answer
Report what after a craniotomy?Aphasia, because this means increased ICP r/t increased bleeding which is the highest risk. Keep HOB at 30
Prednison 10 months, ok? Watch for what?Long term not recommend, never change dosage, watch for osteoporosis, AVOID LARGE CROWDS due to ^ risk for infection