ATI Comprehensive Exam|140
Complete Questions and Answers
For cataract extraction surgery, what are the protocols? - --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? - --
assess pain
-THEN you can educate, turn patient, give PRN analgesic
-What happens during true labor? - --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)? - --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? - --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? - --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? - --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? - --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? - --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? - --
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? - --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? - --at
risk for fat embolism syndrome
-PRIORITY FINDING
-What is important about newborn safety? - --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? - --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? - --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? - --SHOULDNT write detailed
notes
-What are the steps of trach care for a child? - -1. Take out inner cannula
2. Remove soiled dressing
3. Clean stoma
4. Replace collar
-What is important regarding NPH and regular insulin? - --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? - --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?
- --oranges
-AVOID meats, alcohol, chicken
-What is the first action a nurse should take when discharging a client who
was abused? - --develop a safety/escape plan
-THEN provide info about social services and support groups
-What is the priority for children with cystic fibrosis? - --hemoptysis over
250 ml/24 hours indicates risk for brain hemorrhage
-What are main manifestations of vaso occlusive crisis? - --hematuria
(occlusion of kidneys)
-swelling of hands and feet
-visual disturbances (NOT hearing disturbances)
-What are manifestations of autonomic dysreflexia? - --facial flushing
-nasal congestion
-headache
-What is true about methadone? - --can keep taking when pregnant
-can develop dependency
-can cause sedation
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