Comprehensive NCLEX-RN ATI review Study Guide 2024

Five rights of delegation - ANSWERSRight person Right task Right circumstance Right direction and communication Right supervision and evaluation Non-delegatable tasks - ANSWERSNursing process Client education Tasks that require nursing judgement (care of unstable patients) LPN delegation - ANSWERSTracheotomy care Suctioning Inserting urinary catheter Checking NG tube patency Medication administration Sterile specimen colection Reinforce client teaching AP delegation - ANSWERSADLs Ambulating Feeding Positioning Vital signs I&Os Autonomy - ANSWERSThe right to make ones own decisions Beneficence - ANSWERSThe obligation to good for others Confidentiality - ANSWERSThe obligation to observe the privacy of another and maintain strict confidence Fidelity - ANSWERSThe obligation to be faithful to agreements and responsibilities, to keep promises Justice - ANSWERSThe obligation to be fair to all people Nonmaleficence - ANSWERSThe obligation to do no harm to others Paternalism - ANSWERSAssuming the right to make decisions for another Veracity - ANSWERSThe obligation to tell the truth Nurses role of informed consent - ANSWERSEnsure the provider gave the necessary information Ensure the client understands the procedure Patient must be competent to sign informed consent Witness the clients signature Notify the provider if clarification is needed Mandatory Reporting - ANSWERSAbuse - vulnerable populations Communicable diseases Malpractice - ANSWERSThe failure of a person with professional training to act in a reasonable an prudent manner within the identified scope of practice Negligence - ANSWERSThe omission to do something that a reasonable person would do or something that a reasonable person would not do Emergency class 1 (red tag) - ANSWERSImmediate threat to life Do not delay care Urgent class 2 (yellow tag) - ANSWERSMajor injuries that require treatment Delay of 30 minutes to 2 hours Non-urgent class 3 (green tag) - ANSWERSMinor injuries that do not require immediate attention Delay of 2-4 hours Expectant class 4 (black tag) - ANSWERSExpected/allowed to die Prepare for morgue TPN - ANSWERSMonitor serum glucose ever 4-6 hours Change dressing every 48 - 72 hours Change IV tubing and fluid every 24 hours If solution is temporarily unavailable, administer 10% dextrose in water to prevent hypoglycemia Acetaminophen (antidote) - ANSWERSAcetylcysteine (antidote) Benzodiazepine (antidote) - ANSWERSFlumazenil (antidote) Curare (antidote) - ANSWERSEdrophonium (antidote) Cyanide poisoning (antidote) - ANSWERSMethylene blue (antidote) Digitalis: (antidote) - ANSWERSDigoxin immune FAB (antidote) Ethylene poisoning (antidote) - ANSWERSFomepizole (antidote) Heparin and enoxaparin (antidote) - ANSWERSProtamine sulfate (antidote) Iron (antidote) - ANSWERSDeferoxamine (antidote) Lead (antidote) - ANSWERSSuccimer (antidote) Magnesium sulfate (antidote) - ANSWERSCalcium gluconate 10% (antidote) Narcotics (antidote) - ANSWERSNaloxone (antidote) Warfarin (antidote) - ANSWERSPhytonadione (vitamin K)(antidote) Calcium channel blockers - ANSWERSSuffix: dipine Causes: arterial dilation and decreased BP For: angina and HTN, verapamil and diltazem can be used for a-fib, a-flutter, svt Precautions: digoxin and beta blockers Contraindication: heart failure, heart block, of bradycardia Side effects: reflex tachycardia, peripheral edema, and toxicity Monitor: BP and HR Do not drink grapefruit juice Do not crush/chew IV administration 2-3 minutes ACE inhibitor - ANSWERSSuffix: pril For: hypertension, heart failure, MI, and diabetic nephropathy Monitor potassium, BP, angioedema Captopril should be taken 1hr before meals ARBS - ANSWERSSuffix: tan For: hypertension, heart failure, MI, and diabetic nephropathy Monitor potassium, BP, angioedema Beta 2 adrenergic agonists - ANSWERSFor: Respiratory Albuterol - short acting (inhaled) for acute bronchospasm, onset 5-15 min Formoterol - long acting/long-term control (inhaled), onset 1-3 min, duration 10hr Salmeterol - long acting/long-term control (inhaled), onset 10-20 min, duration 12hr Terbutaline - long acting/long-term control (oral) Precautions: increased heart rate, tremors, beta blockers will decrease effect, MAOIs will increase effect Antilipemic - ANSWERSSuffix: statin For: reduction of formation of cholesterol precursors Drug interactions: digoxin, warfarin, thyroid hormones, thiazide diuretics, phenobarbital, NASIDs, tetracycline, beta blockers, gemfibrozil, glipizide, glyburide, oral contraceptices, and phenytoin Do not administer with grapefruit juice Glucocorticoids - ANSWERSSuffix: one, ide & ate For: Prevention of inflammatory responses by suppression of airway mucus production Interaction: DM may require higher doses Side effects: insomnia, psychotic behavior, hyperglycemia, peptic ulcer, fluid retention, withdrawal symptoms, increased appetite, risk for infection (prednisone & methotreaxate), risk for osteoporosis (prednisone) Administer medication with meals Do not take with NSAIDs Beta blockers - ANSWERSSuffix: olol For: decreased cardiac excitability, cardiac output, myocardial and oxygen demand Use: primary HTN, angina, tachydysrhythmias, heart failure, and MI Contraindications: AV Block and sinus tachy, asthma, bronchospasms, or heart failure Side effects: nasal stuffiness, bronchospasms Monitor blood glucose with propranolol Do not administer labetalol in same IV as furosemide Do not crush/chew Hold medications if pulse is less than 60 or systolic BP is less than 100 Vasodilators - ANSWERSNitroglycerine, enalaprilat, nitroprusside, hydralazine For: vasodilation of arteries and veins resulting in decreased blood pressure Precautions: hepatic and renal disorders, older adults, electrolyte imbalances Side effects: cyanide toxicity Nitroprusside may not be mixed with any medication Continuious ECG and BP monitoring Insulin - ANSWERSLispro: rapid acting, 15-30 min Regular: short-acting, 30min-1hr NPH: intermediate acting, 1-2hr Insulin glargine (lantus): 70 minutes Do not mix lantus with other insulin's (in syringe) Draw up regular and then NPH Regular insulin is the only insulin given IV (used for DKA) Penicillin - ANSWERSSuffix: cillin Hypersensitivity with possible anaphylaxis Proton pump inhibitors - ANSWERSSuffix: prazole & idine For: prevents/blocks selected receptors within the stomach Side effects: can increase risk for osteoporosis Antiviral - ANSWERSSuffix: vir Acylovir and valacyclovir to be given with food MAOIs - ANSWERSIsocarboxazid, tranylcypromine, phenelzine Avoid foods with tyramine Contraindications: SSRIs, tricyclics, heart failure, CVA, renal insufficiency Side effects: CNS stimulation, orthostatic hypotension, hypertensive crisis r/t tyramine, SSRI's and tricyclics SSRIs - ANSWERSSuffix: pram & ine Avoid alcohol Monitor: agitation, confusion, hallucinations for first 72 hours Side effects: weight gain, fatigue, drowsiness Ginko biloba - ANSWERSUse: improves cerebral circulation Treats: dementia & memory loss Interferes with: Alzheimer treatments Discontinue 2 weeks prior to surgery Seizures are a sign of overdose St. Johns wort - ANSWERSUse: depression, seasonal affective disorder, anxiety Side effect: headache, sleep disturbances, phototoxixcity, constipation Interactions: oral contraceptives, cyclosporine, warfarin, digoxin, CCBs, antidepressants ABX - ANSWERSSuffix: cycline & floxacin Consume at least 3L fluid daily Avoid sun exposure Permanent tooth discoloration if given to children /= 8 Bronchodialoator - ANSWERSSuffix: phylline For: Muscle relaxant of the bronchial smooth muscle. Long term control of asthma Contraindicated: PUD Precaution: caffeine, furosemide, cimetidine, fluoroquinolones, acetaminophen, pheylbutazone (falsely elevated levels) Side effects: irritability, restlessness Toxic: tachycardia, tachypnea, seizures Antiemetics - ANSWERSPromethazine: monitor EPS Metoclopramide: monitor EPS and tardive dyskinesia Ondansetron: monitor headache, EPS, dysrhythmia Scopolamine: monitor for blurred vision Glycopeptide - ANSWERSSuffix: mycin Contraindicated: allergy to corn Administer over 1hr Monitor trough Caution: nephrotoxic and ototoxic Inhaled anticholinergics - ANSWERSSuffix: ium For: preventing acute bronchospasms Not used for acute episodes Education: if using 2 inhaled medications, wait 5 minutes between Fire safety - ANSWERSR - rescue A- alarm C - contain E - extinguish CDC mandatory reporting - ANSWERSHepatitis A, Hepatitis B, Hepatitis C, Measles (Rubeola) Meningococcal, Rubella, Salmonellosis, Shingllosis (dysentery), TB, VRE Contact precautions - ANSWERSGloves/gown C-diff, Hep a w/ fecal incontinence, Herpes simplex, MRSA, Rotavirus, Salmonellosis, Shigellosis (dysentery), staph, VRE Airborne precautions - ANSWERSHerpez zoster (shingles), Measles (Rubeola virus), TB Droplet precaution - ANSWERSMeningococcal, pneumonia, RSV, Rubella Hypokalemia - ANSWERSSigns: muscle weakness, cramping, irritability, confusion, flat or inverted T waves Interventions: monitor rsp status, initiate seizure precautions, monitor ecg & I&Os If the patient is not urinating do not administer K Hyperkalemia - ANSWERSSigns: peaked T waves, centricular dysrhythmias, muscle twitching, paralysis, ascending muscle weakness Interventions: monitor bowel sounds, initiate dialysis, kayexalate, 50% glucose with insulin, calcium gluconate, bicarb, loop diuretics Hypernatremia - ANSWERSSigns: swollen dry tongue, hallucinations, hyperreflexia, pulmonary edema Interventions: daily weights, I&Os, seizure precautions Hypocalcimia - ANSWERSSigns: Prolonged QT interval, trousseaus sign, chvosteks sign, seizures Interventions: seizure precuations, IV calcium replacement (dilute with D5W), orthostatic hypotension Hypercalcemia - ANSWERSSigns: kidney stones, pathologic fx, flank pain, deep bone pain Interventions: isotonic IVF, dialysis, cardiac monitoring Hypomagnesemia - ANSWERSSigns: trousseaus sign, chvosteks sign, aggitation, confusion Interventions: seizure precautions, monitor swallowing Hypermagnesemia - ANSWERSSigns: facial flushing Do not administer to clients with renal failure Toxicity treat with calcium gluconate Metabolic Acidosis - ANSWERSCause: Diarrhea, renal failure, DKA Metabolic Alkalosis - ANSWERSGI suction, blood transfusion, prolonged vomiting Respiratory Acidosis - ANSWERSRSP depression, pneumothorax, airway obstruction, inadequate ventilation Respiratory Alkalosis - ANSWERSHyperventilation, altitude sickness, asthma, pneumonia Bronchoscopy - ANSWERSVisualize larynx, trachea, bronchi Tissue biopsy Foreign body removal Assess gag reflex prior to feeding, NPO 8-12 hours Cor pulmonale - ANSWERSRight sided heart failure caused by pulmonary disease Signs: Cyanotic lips, JVD, dependent edema TB - ANSWERSManifestations: Positive sputum cx for acid-fast bacillus, low grade fever with night sweats, NAAT test for family of a TB patient 3 consecutive negative sputum cultures is negative TB after diagnosis Intervention: avoid food containing tyramine if on INH, rifampin can alter metabolism of certain medications, monitor liver/kidney function Rifampin - turns fluids orange, monitor AST/ALT for liver function, nephrotoxic drug Ethambutol - loss of red/green color distinction Acute pulmonary embolism - ANSWERSFactors: chrinc a-fib, long bone fx, PVD, DVT, sickle cell anemia, central venous catheter, Signs: dyspnea, tachypnea, tachycardia, diaphorisis, restlessness, chest pain, hemoptysis. Fat emboli: petechia over chest and axilla Interventions: manage airway, pain medication, heparin Low pressure alarm - ANSWERSIndicates low volume Associated with tube disconnection, cuff leak, or tube dislodgement High pressure alarm - ANSWERSIncreased pressure Associated with increased secretions, kinking of tube, pulmonary edema, client coughing/biting tube Apnea alarm - ANSWERSNo spontaneous breathing within a preset time period Crohn's disease - ANSWERSDiet: low residual, low fiber diet Foods: cream of wheat, puffed rice cereal, canned green beans Colostomy - ANSWERSEmpty when 1/3 - 1/2 full No lotions Cranberry juice and yogurt hide odor Change and clean every 5-10 days (have also seen 3-7) Hepatitis A - ANSWERSFecal-oral route Person to person Food/water contamination Report to CDC Signs: flu like symptoms Hepatitis B - ANSWERSSexually transmitted Sharing needles Needle sticks Report to CDC Signs: RUQ pain, anorexia, N/V, dark urine, light stools, jaundice Hepatitis C - ANSWERSBlood-to-blood Illicit IV drug sharing Sexually transmitted Report to CDC Signs: asymptomatic, cirrhosis Osteoarthritis - ANSWERSRisk factors: age, female, metabolic disease, obesity, smoking Manifestations: pain which is diminished after rest, pain that increases after activity Medications: NSAIDs. corticosteroids, topical analgesics, glucosamine, chondroitin Rheumatoid arthritis - ANSWERSChronic and progressive autoimmune disorder Risk factors: female Manifestations: morning stiffness, pain at rest, pain with movement, bilateral joint inflammation, decreased range of motion Intervention: ice/heat for comfort Medications: NSAIDs. corticosteroids, methotrexate, leflunomide, hydroxychloroquine Gouty arthritis - ANSWERSRisk factors: excessive alcohol intake, high intake of foods with purines (organ meats, yeast, sardines, spinach) Manifestations: excruciating pain and inflamation in one or more small joints Diagnosis: serum uric acid = y mg/dL Intervention: bed rest during acute episodes, increase fluid intake to 3L daily Medication: colchicine, allopurinol, NSAID's, corticosteroids Diabetes insipidus - ANSWERSDeficient antidiuretic hormone due to disorder of the posterior pituitary gland resulting in the inability of kidneys to conserve water Cause: head trauma, tumor, surgery, radiation, CNS infection, malignant tumors, railure of renal tubules Signs: decreased urine specific gravity (/= 1.001), increased urinary output, ice water cravings, dehydration SIADH - ANSWERSExcessive release of antidiuretic hormone resulting in the inability to excrete and appropriate amount of urine thus developing fluid retention and dilution of hyponatremia Cause: neoplastic tumors, head injury, meningitis, respiratory disorders, and some medications Intervention: restrict water (500-1000mL/daily), monitor I&O's and client weight, initiate seizure precautions Medication: tolvaptan Addison's disease - ANSWERSHyposecretion of adrenal cortex hormones caused by an autoimmune disease, TB, histoplasmosis, adrenalectomy, tumors and HIV Hint: you need to ADD cortisol Signs: weakness, fatigue, N/V, hyperpigmentation, hypotension with increased heart rate, salty food cravings Intervention: monitor BP and heart rhythm, electrolytes, low urine output Addison's Crisis - ANSWERSCharacterized by hypotension, tachycardia, tachypnea, pallor Secondary to infection, trauma, surgery, pregnancy, emotional stress Medication: hydrocortisone (prevents crisis) Cushing's disease/syndrome - ANSWERSHypersecreation of glucocorticoids Cause: hyperplasia of adrenal cortex or pituitary gland tumor Manifestations: upper body obesity with thin extremities, moon face, buffalo hum, feck fat, osteoporosis, hyperglycemia, hypernatremia, hypokalemia, hyocalcemia, slow growth rate in children Intervention: monitor for infection, prevent falls, treat hyperglycemia, assess BP and heart rate Diabetic keto acidosis - ANSWERSOccurs in type 1 diabetes Blood glucose level 300 - 800 ABG: metabolic acidosis Signs: ketone uria, Kussmaul's respirations Intervention: regular insulin, blood glucose should decrease ~100mg/dL each hour Medication: glucose and insulin at same time to maintain rate of reduction Hyperglycemic hyperosmolar state - ANSWERSOccurs in type 2 diabetes Blood glucose is = 600 Signs: not seen with ketosis, altered mental status Intervention: replace lost fluids Medication: insulin Atrial fibrillation - ANSWERSCharacteristics: HR 120-200bpm, irregular ventrical rhythm, no clear p waves, QRS comples less than 0.12 seconds Medication: coumadin/warfarin 3rd degree heart block - ANSWERSCharacteristics: p waves are not consecutively followed by a QRS complex; p wave could be present followed by additional p wave r/t no ventricular activity Ventricular tachycardia - ANSWERSPulse = cardiovert No pulse = defibrillation Characteristics: 'saw tooth', 140-180bpm, irregular rhythm, p waves are typically not seen, QRS complex is wide Ventricular fibrillation - ANSWERSCPR - there is no pulse Characteristics: no recognizable waves or patterns Cause: most common MI TURP - ANSWERSEnlargement of the prostate, enlarged section removed Intervention: monitor continuous bladder irrigation (expect bloody drainage). encourage 3L fluid/daily, frequent irrigation prevents clots TURP syndrome signs: hyponatremia, confusion, bradycardia, hypo/hypertension, N/V, visual changes Increased ICP - ANSWERSContributing factors: head injury w/ subdural or epidural hematoma, CVA, cerebral edema, brain tumor, hydrocephalus, meningitis Manifestations: changes in LOC, headache, Cushing's triad, ineffective thermoregulation Intervention: monitor vital signs, keep HOB 30-45, avoid coughing/sneezing/straining/suctioning, administer O2, decrease environmental stimuli Medication: mannitol Avoid: opiates and sedatives Cushing's triad - ANSWERSSigns: hypertension with widening pulse pressure, bradycardia, and irregular breathing (Cheyne-stokes respiration) Autonomic dysreflexia - ANSWERSSudden severe HTN triggered by noxious stimuli below damage of spinal cord Causes: impaction, bladder distension, pressure points, ulcer, pain Manifestations: hypertension with bradycardia, headache, flushing, goose bumps, sweating, nasal congestion Guillan Barre - ANSWERSAscending muscle weakness Intervention: respiratory monitoring Myasthenia gravis - ANSWERSDescending muscle weakness Intervention: respiratory monitoring Early signs: ocular involvement (dyplopia) Interventions: plan activity early in day to prevent fatigue, provide eye care Parkland Formula - ANSWERS4mL/kg/% burn 1/2 of dose given during the first 8 hours 1/2 of dose given for the remaining 16 hours Superficial burn - ANSWERSAppearance: pink to red, tender, no blsiters, mild edema, no eschar Superficial partial thickness burn - ANSWERSAppearance: red to white with blisters, mild to moderate edema, no eschar Deep partial thickness burn - ANSWERSAppearance: red to white with moderate edema, no blisters, soft/dry eschar Full-thickness - ANSWERSAppearance: red to tan, black, brown, white, no blisters, severe edema, hard inelastic eschar May or may not be painful Deep full-thickness - ANSWERSAppearan