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NURSING 254 ATI QUESTIONS & EXPLANATIONS
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WhatinterventionsshouldbemadeforaninfantwithRSV(RespiratorysyncytialVirus) ? Precautions:Standard/contact/droplet Ifavailableanswers:Isolation(orusebulbto suction) Nursing Interventions: **place pt in a private room or cohort patient, suction PRN, maintain humidity andprovideo2, feed smallfrequentmeals, keep headelevated at alltimes, Durationofprecautions:durationof illnessReserve:respiratory secretions NursingConsiderations:Contact/ dropletprecautions;palivizumabforhighriskinfants,followestablishedguidelinesfor administration of ribavirin. Whatisanecessaryinterventionforanewborngettingphototherapy? Answer:underdressthenewborn,everythingoffexceptthediaper(youcanplacesu rgicalmaskalsoto covergenitals). MaternalATIpg. 192 NursingCareforPhototherapy i. Maintaineyemaskoverthenewborn’seyesforprotectionofcorneasandretinas ii. Keep the newborn undressed. For a male newborn, a surgical mask should be
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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[Type the document title] placed (like a bikini),over the genitalia to prevent possible testicular damage from heat and light waves. Be sure to removethemetal strip fromthemask to preventburning. iii. Avoidapplyinglotionsorointmentstotheskin iv. Removethenewbornfromphototherapyevery4hours,andunmaskthenewborn’se yes,checkforinflammationor injury v. Repositionthenewbornevery2hoursto exposeallthebodysurfacestothephototherapy vi. Checkthelamp Phenelzinefoodyoucaneat->MAOImedication Answer:wholebranbread Comprehensivebookpage56: MAOI’s—>Isocarboxazid, Tranylcypromine & PhenelzinePrecautions/Interactions: Avoid foods containing tyramine**Antihypertensiveshaveadditivehypo tensiveeffect ContraindicatedwithSSRI’s,tricyclics,heartfailure,CVA,renalinsuffiency S/ E:CNSstimulation,orthostatichypotension, hypertensivecrisiswithintakeoftyramine ,S SRI’sandtricyclics. TyramineCAUTIONwithMAOI’s:Smokedcheese,smokedmeets,agedcheese,beer,f ish/shrimpsauces.
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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[Type the document title] Clienteducation:
- Therecanbediscomfortinitiallywithdialysateinfusion A patient just had carpal tunnel surgery, what is a necessary intervention by the nurse? Correct answer: ensure the patients hand is elevated at the level above the heart Meg-surgicalpg 458: CarpalTunnel: compressionofthemediannerveinthewristfromswollenorthickenedsy novium,causingpain and numbness. Risk factors: some metabolic and connective tissue disease such as rheumatoid arthritis and DM,Occupationalinjuryfromrepetitivestressofhand(i.e.,computerusers),repetitivespo rts(tennis),useofcomputersandhandhelddevices andgrowthof aspaceoccupying lesion(gangliaorlipoma). Post-operativeCare: i. MonitorV/Sandcheckdressingfordrainage ii. Elevatethehandabovethehearttoreduceswelling iii. Checkneurovascualrstatusoffingerseveryhourandencouragetheclienttomovethemf requently iv. Offerpainmedications ClientEducation i. Handmovementsandheavyliftingmightberestricted4to6weeks ii. Theclientcanexpectweaknessanddiscomfortforweeksormonths iii. Remindtheclienttoreportanychangesinneurovascularstatusincludingincreaseinp aintosurgeonimmediately.
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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[Type the document title] Whatisanadversereactiontoapatientwhoisgivingacoolingblanket? Answer:Shivering Whatisnecessaryinterventionforapatientexperiencingpaniclevelanxiety? Answer:Engagetheclientinphysicalactivity MentalHealthpage i. Panicattackstypicallylast15to30minutes ii. Fourormoreofthefollowingmani’sarepresent:palpitations,SOB,chocking,chest pain,Nausea,feelsofdepersonalization, fearof dyingorinsanity, chillsor hotflashes. iii. Theclientmightexperiencebehaviorchangesand/ orpersistentworriesaboutwhenthenextattackwilloccur. Nursingcare: i. Clientsexperiencingpanic-levelanxietybenefitfromacalm,quietenvironment. ii. Remainwiththeclientduringtheworstoftheanxietytoprovidereassurance iii. Provideasafeenvironmentforotherclientsandstaff iv. Client participation in decision making regarding care.ATIcomprehensivebook pg178: Panic:unabletofocusontheenvironment,mayfeelunreal,cannotprocesswhatishappeni ng,hallucinationsor delusionsmay occur,somaticreports increase. Nursing interventions: maintain calm manner, remain with client, minimize environmental stimuli, useclear and simple statements, use low-pitched voice, listen for themes in communication, attain to physicalandsafety needs. **Encouragegrossmotoractivities,suchaswalking,setlimitsbyusingfirmshortandsimpl
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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- Settimelimits for OCD
- Lengthentimeb/writuals
- Cognitivetherapytoidentifysourceofanxiety
- Thought-stopping to interrupt OCD behaviorSSRI,SNRI’S andAnti- anxietymeds
- Whatistheantidotetodiazep am? Answer: Flumanezil Comprehensive ATIpg Diazepam is a benzodiazepine that increases the efficacy of GABA to reduce anxiety.Benzo’sareusedwithcautioninclientswhohavesubstancedisordera ndliverdisease. S/ E:CNSdepression,paradoxicalresponse(insomnia,excitation,euphoria),withdrawals ymptoms,riskofabuseand potential for overdose.
- Whatistheproperfoodselectionforaclientwith kosherdiet? answer:scrambledeggwithmilk **Kosher is no mixing of meat and dairyComprehensivepg 27
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DietaryRestrictions:foodisrequiredtobekosher(judaism).Milkandmeatcannotbeserve datthesamemealorpreparedonthesamedishes.Porkandshellfishprohibited.Fastingrequ iredonYomkippur. Lactose intolerance is common among Jews and European origin.OtherDiets to befamiliarized with:
- Buddhism:VegetarianDietyw/noalcohol
- Catholicism:Ash Wednesday
- Christian Science:Abstain fromalcohol
- Hinduism:VegetarianDiet,noBeeforPork,righthandforeatingandlefthandfo rtoilingandhygiene
- Islam:FoodmustbeHalal(lawful),Nopork,alcohol,andsomeshellfishareprohibited.
- Mormon:Noalcohol,coffee,andtea
- SeventhdayAdvent:Vegetariandiet,withnoalcohol,coffee and tea Whatisaproperinterventiontopromotevoidinginapregnantwomenhavingdifficult? Answer:Massagethefundus Encourage the client to empty her bladder frequently every 2-3 hours to prevent possibledisplacementoftheuterusandatony,measuretheclient’sfirstfewvoidingaft erdeliver,encouragetheclient toincreasefluid intake,catheterizeifnecessary forbladderdistention. Comprehensive ATI pg 213Bladder
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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i. Teachtheclientaboutmeasurestoimprovetolerancetoactivity,suchasalternati ngperiodsofactivitywith periods of rest
15. TBtestwithpositiveresult: Induration10mm 16. What to tell a new mother 1 day post op?answer: when flying,usea carseat
- Whatisagooduseofusingrestraints? answer:cleftlipinfantwithanelbowimmobilizer. Post op: i. Keepinfantpainfree(analgesics) ii. Avoidsucking(nospoonsorforks) iii. Elbowrestraints**
- Whatshouldthenursetellaclientwho’stakingprednisoneandhasasthma? Answer:“thismedicationmayincreaseriskforinfection” Prednisoneusedfor10daysormorecanresult in:
- Suppressionofadrenalglandfunction
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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- Boneloss
- Hyperglycemiaandglycosuria
- Myopathy
- Pepticulcerdisease
- **infection:adviceclienttonotifytheproviderifearlymani’sofinfectionoccur (sorethroat,weakness,malaise)
- Disturbancesoffluidandelectrolytes
- Hiparthroplastywhattoinstallordoathome? Answer:Railsin theentryway ofthehouse
- Audit Question: After a patient is discharged they want to see the care providedanswer:Outcomeaudit
- Outcomeauditsdetermineswhatresultsoccurredduetonursingcareprovided.
- Structureaudit:evaluatestheinfluenceofelementsoutside/separateofclients- staffinteraction
- Processaudit:howcarewasprovided
- Retrospectiveaudit:After theclientreceives care
- Concurrent:whiletheclientreceivescare
- Prospective:predictsfutureofclientcare
- Bestsourceofcalcium?
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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- A nurse is providing teaching to an older adult client about method to promote nighttime sleep. Whichofthefollowing instructions should thenurseinclude? Answer:eatalightsnackbeforebedtime
- A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of thefollowingplaces theclientat rick foraspiration? Answer:HistoryofGERD (gastroesophagealrefl uxdisease)ComprehensiveATI pg GERD: A condition in which the lower esophageal sphincter does not close properly, allowing stomachcontentsto back up into theesophagus. Contributingfactors: olderadults,obesity,smoking,heavyalcoholuse,ingestionofveryla rgemeals,obstructivesleep apnea. Mani’s: Dyspepsia,**regurgitation,eructation,flatulence,coughing,hoarseness,wheez ing… NursingInterventions: i. LimitoreliminatefoodsthatdecreaseLESpressure: ex:Limitchocolate,caffeine,friendandorfattyfoods,alcohol,carbonatedbev,spicyandac idicfoods. ii. 4to6small mealsperday iii. Eatslowlyandchewthoroughly vi.Eatingnothingforatleast 3hoursbeforegoingto bed. Meds: Histamine blockers:famotidine, ranitidine/Antacids/ PPI’s: omeprazole.
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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- A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of thefollowinginterventions should thenurseincludein theplan? Answer:implementfrequentrestperiods Mania:anabnormallyelevatedmood,whichcanalsobedescribedasexpansiveorirritable ,usuallyrequireshospitalization. Manicepisodes lastat least 1week. AcuteManicphase:one-to-onesupervisioncanbeindicatedforclientsafety. i. Provideasafeenvironmentduringtheacutephase. ii. Assesstheclientregularlyforsuicidalthoughts,intentions,andescalatingbehavior. iii. Decreasestimulationwithoutisolatingtheclientispossible.Insomecertaincases,secl usionmightbetheonly way to safely decreasestimulationfor theclient. iv. **Implementfrequentrestperiods(Mentalhealthpg.76)
- A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine.Which of the following findings should the nurse identify as a contraindication to the administration ofclozapine? Answer:WBCCount2,900/mm Mentalhealthpg79andComprehensivepg Schizophrenia: Theclienthaspsychoticthinkingorbehaviorpresentforatleast 6months.Areasoffunctioning, including school or work, self-care, and interpersonal relationships are significantlyimpaired. Clozapine isasecond-generation/atypicalantipsychotic MonitorforAgranulocytosis:noneutrophils(decrease inwbc’sto fight infection)
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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HypertensioninPregnancy: hypertensivediseaseinpregnancyisdividedintoclinicalsub sets:gestationalhypertension; mild and severe preclampsia; eclampsia; hemolysis, elevated liver enzymes and lowplatelets(HELLP) syndrome. i. PregnancyHypertensionsign:Vasospasm ii. GestationalHypertention(GH):Begingsthe20thweekofpregnancy a. Presentsw/ elevatedbpof140/90orgreaterontwooccasions,atleast4hoursapart,within1week. b. ThereisNOproteinuria c. Givingbirthcorrectsit! iii. Mildpreclampsiais GH+addition ofproteinuriaof 1or2+. vi. Severepreeclampsia:BP160/110orgreaterin2separateoccasions6hoursapartonbedre st. A. Proteinuria>3+(dipstick) B. Oliguria C. Serumcreat>1.1mg/dL D. Extensiveperipheraledema*** v.Eclampsia:severepreclampsiaplusseizureactivity
- A nurse is caring for a client who is 33 weeks gestation following an amniocentesis. The nurse shouldmonitorthelucentfor which of thefollowingcomplications? Answer: Contractions Co
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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mprehensive pg 196Amniocentesi s a. Earlypregnancy
- Geneticwork-upforfetalanomalies(downsyndrome,trisomy18/13)
- Detect thepresenceofAChEin neuraltubedefects(NTDs)
- Performedat14-16weeks b. Latepregnancy
- Assessfetallungmaturityandfetalwell-being.
- L:Srationof2:1Indicatesfetallunchmaturity C.NursingIntervention
- preop:explainprocedureandriskstoclientandobtainconsent
- EnsureclienthasapatentiV
- Posop:monitorFHR,signsoflabor,vaginalbleeding/ hemorrhage,administerRho(D)immuneglobulinif clientis Rh-negative D.Educationoncomplications:bleeding,contractions***,s/sofinfection 28.Thenurseiscallingforaninfantwhohascoarctationoftheaorta.Whichof thefollowingshouldthenurseidentify as an expected finding? Answer:Weakfemoralpulses Comprehensivepg CoarctationoftheAorta:Narrowingofthelumenoftheaorta,resulting inobstructionofbloodflowfromtheventricle.
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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a. Mani’s: twitching, cramping, muscle weakness, fatigue, slurred or nasal speech with difficultyformingwords(dysarthria),difficultlychewingandswallowing(dysphag ia),overactivedeeptendonreflex,fatigue, eventual respiratory compromise. Interventions:Implementaspirationprecautionsandalternatemethodsofcommunication ifneeded***
- SawPalmettocontraindications? Answer:Anticoagulantmedications contraindicated (Heparin,Warfarin, NSAIDS, aspirin) Comprehensivepg SawPalmetto(Serenoarepens) a. Purporteduses:treatsandpreventsbenignprostatichypertrophy b. S/E:Headacheandalteredlatelyfunction c. Herb/medinteractions:additiveeffectwithanticoagulants** d. NursingConsiderations:allow4-6wksforfulleffects,discontinueusepriortosurgery.
- A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which ofthefollowingactions bythenurseindicatesa break insurgicalaseptictechnique? Answer:Surgicalgownthenmaskoder Fundamentspg Surgical Asepsis refers to the use of precise practices to eliminate all micro-
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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organisms from an object orarea and prevent contamination. It applies to parenteral medication administration, insertion of urinarycaths,surgical procedures (etc).
- Gown (1st)
- Mask
- Goggles/faceshield
- Gloves(last)
- ManifestationsofMagnesiumtoxicity Answer:UrinaryRetention
AntidoteforMagnesiumsulfate:calciumgluconate10% Therapeuticlevels:4-8mg/dL ToxicDruglevels:greaterthan9mg/dL Toxicitys/ s:cardiacdsyrthymias,outputlessThant30ml,RRlessthan12,absentreflexesanddecrea sedLOC. Mag.Sulfateisatocolyticdrugusedforpretermlabor,CNSdepressanttopreventseizure inpreeclampsia NursingInterventions: a. Preterm
- MonitorcontractionsandFHR
NURSING 254 ATI QUESTIONS & EXPLANATIONS
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