ATI comprehensive predictor 2 Exam Questions With Answers Graded A

Do not delegate - What you can EAT E-evaluate A-assess T-teach Addison's & Cushings - Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia Better peripheral perfusion? - EleVate Veins, DAngle Arteries APGAR - Appearance (all pink, pink and blue, blue (pale) Pulse (100, 100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) Airborne precautions - MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip - private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB Droplet precautions - spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precaution - MRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves Skin infection - VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism - S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) Woman in labor (un-reassuring FHR) - (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC - Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) After lumbar puncture and oil based myelogram - pt is flat SUPINE (prevent headache and leaking of CSF) Pt with heat stroke - flat with legs elevated during Continuous Bladder Irrigation (CBI) - catheter is taped to the thigh. leg must be kept straight. After Myringotomy - position on the side of AFFECTED ear, allows drainage. After Cateract surgery - pt sleep on UNAFFECTED side with a night shield for 1-4 weeks after Thyroidectomy - low or semi-fowler's position, support head, neck and shoulders. Infant with Spina Bifida - Prone so that sac does not rupture Buck's Traction (skin) - elevate foot of bed for counter traction After total hip replacement - don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Prolapsed cord - Knee to chest or Trendelenburg oxygen 8 to 10 L Cleft Lip - position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. To prevent dumping syndrome - (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. AKA (above knee amputation) - elevate for first 24 hours on pillow. position prone daily to maintain hip extension. BKA (below knee amputation) - foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina - area of detachment should be in the dependent position administration of enema - pt should be left side lying (Sim's) with knee flexed. After supratentorial surgery - (incision behind hairline on forhead) elevate HOB 30-40 degrees After infratentorial surgery - (incision at the nape of neck) position pt flat and lateral on either side. During internal radiation - on bed rest while implant in place Autonomic Dysreflexia/Hyperreflexia - S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! Shock - bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) Head Injury - elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis (when outflow is inadequate) - turn pt from side to side BEFORE checking for kinks in tubing Lumbar Puncture - After the procedure, the pt should be supine for 4-12 hours as prescribed. Myesthenia Gravis - worsens with exercise and improves with rest Myesthenia Gravis - a positive reaction to Tensilon---will improve symptoms Cholinergic Crisis - Caused by excessive medication ---stop giving Tensilon...will make it worse. Liver biopsy (prior) - must have lab results for prothrombin time Myxedema/ hypothyroidism - slowed physical and mental function, sensitivity to cold, dry skin and hair. Grave's Disease/ hyperthyroidism - accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. Thyroid storm - increased temp, pulse and HTN Post-Thyroidectomy - semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypo-parathyroid - CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hyper-parathyroid - fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypovolemia - increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity 1.030 Hypervolemia - bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity 1.010. semi fowler's Diabetes insipidus (decreased ADH) - excessive urine output and thirst, dehydration, weakness, administer Pitressin SIADH (increased ADH) - change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics hypokalemia - muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia - MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes Hyponatremia - nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids Hypernatremia - increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. Hypocalcemia - CATS Convulsions, Arrythmias, Tetany, spasms and stridor