Download ATI PN Comprehensive Predictor LATEST UPDATES 2024 and more Exams Medicine in PDF only on Docsity!
Do not delegate - Correct answer What you can EAT E-evaluate A-assess o T-*teach Addison's & Cushings - Correct answer 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? - Correct answer Elevate veins, D-Angle Arteries APGAR - Correct answer 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 - Correct answer MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip - Correct answer private room, neg pressure with 6 - 12 air exchanges/hr mask & respirator N95 for TB Droplet precautions - Correct answer 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 - Correct answer 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 - Correct answer Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism - Correct answer 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) - Correct answer (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC - Correct answer Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) LOC - Correct answer Level of Consciousness
AKA (above knee amputation) - Correct answer elevate for first 24 hours on pillow. position prone daily to maintain hip extension. BKA (below knee amputation) - Correct answer foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina - Correct answer area of detachment should be in the dependent position dependent position - Correct answer supported administration of enema - Correct answer pt should be left side lying (Sim's) with knee flexed. supratentorial - Correct answer (incision behind hairline on forhead) e After supratentorial surgery - Correct answer elevate HOB 30 - 40 degrees HOB - Correct answer head of bed infratentorial - Correct answer (incision at the nape of neck) After infratentorial surgery - Correct answer position pt flat and lateral on either side. During internal radiation - Correct answer on bed rest while implant in place Autonomic Dysreflexia/Hyperreflexia - Correct answer S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! Shock - Correct answer bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) Head Injury - Correct answer elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis (when outflow is inadequate) - Correct answer turn pt from side to side BEFORE checking for kinks in tubing
Lumbar Puncture - Correct answer After the procedure, the pt should be supine for 4 - 12 hours as prescribed. Myesthenia Gravis - Correct answer worsens with exercise and improves with rest Myesthenia Gravis - Correct answer a positive reaction to Tensilon---will improve symptoms Cholinergic Crisis - Correct answer Caused by excessive medication ---stop giving Tensilon...will make it worse. Liver biopsy (prior) - Correct answer must have lab results for prothrombin time Myxedema/ hypothyroidism - Correct answer slowed physical and mental function, sensitivity to cold, dry skin and hair. Grave's Disease/ hyperthyroidism - Correct answer accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. Thyroid storm - Correct answer increased temp, pulse and HTN Post-Thyroidectomy - Correct answer semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypo-parathyroid - Correct answer CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hyper-parathyroid - Correct answer fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypovolemia - Correct answer increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1. Hypervolemia - Correct answer bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's
Pheochromocytoma - Correct answer hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) Tetrology of Fallot - Correct answer DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Autonomic Dysreflexia - Correct answer (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) FHR patterns for OB - Correct answer Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill what to check with pregnancy - Correct answer Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. Position of the baby by fetal heart sounds - Correct answer Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. Ventilatory alarms - Correct answer HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc ICP and Shock - Correct answer ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp
Cor pumonae - Correct answer Right sided heart failure caused by left ventricular failure (edema, jugular vein distention) Heroin withdrawal neonate - Correct answer irritable, poor sucking brachial pulse - Correct answer pulse area on an infant lead poisoning - Correct answer test at 12 months of age Before starting IV antibiotics - Correct answer obtain cultures! pt with leukemia may have - Correct answer epistaxis due to low platelets when a pt comes in and is in active labor - Correct answer first action of nurse is to listen to fetal heart tones/rate for phobias - Correct answer use systematic desensitization NCLEX answer tips - Correct answer choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. ARDS and DIC - Correct answer are always secondary to another disease or trauma In an emergency - Correct answer patients with a greater chance to live are treated first Cardinal sign of ARDS - Correct answer hypoxemia Edema is located - Correct answer in the interstitial space, not the cardiovascular space (outside of the circulatory system) the best indicator of dehydration? - Correct answer weight---and skin turgor heat/cold - Correct answer hot for chronic pain; cold for accute pain (sprain etc)
1 pint - Correct answer 2 cups 1 g (gram) - Correct answer 1000 mg 1 kg - Correct answer 2.2 lbs I lb - Correct answer 16 oz centigrade to Fahrenheit conversion - Correct answer F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 Angiotenson II - Correct answer In the lungs...potent vasodialator, aldosterone attracts sodium. Iron toxicity reversal - Correct answer deferoxamine S3 sound - Correct answer normal in CHF. Not normal in MI After endoscopy - Correct answer check gag reflex TPN given in - Correct answer subclavian line pain with diverticulitis - Correct answer located in LLQ appendicitis pain - Correct answer located in RLQ Trousseau and Chvostek's signs observed in - Correct answer Hypocalcemia never give K+ in - Correct answer IV push DKA is rare - Correct answer in DM II (there is enough insulin to prevent fat breakdown) Glaucoma patients lose - Correct answer peripheral vision.
Autonomic dysreflexia - Correct answer patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T- 7 or above) Spinal shock occurs - Correct answer immediately after injury multiple sclerosis - Correct answer myelin sheath destruction. disruptions in nerve impulse conduction Myasthenia gravis - Correct answer decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. Gullian - Barre syndrome - Correct answer ascending paralysis. watch for respiratory problems. TIA - Correct answer transient ischemic attack....mini stroke, no dead tissue. CVA - Correct answer cerebriovascular accident. brain tissue dies. Hodgkin's disease - Correct answer cancer of the lymph. very curable in early stages burns rule of Nines - Correct answer head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1% birth weight - Correct answer doubles by 6 months triples by 1 year if HR is <100 (children) - Correct answer Hold Dig early sign of cystic fibrosis - Correct answer meconium in ileus at birth
there is pain, but no bleeding (board like abd) bethamethasone (celestone) - Correct answer surfactant. premature babies five interventions for psych patients - Correct answer safety setting limits establish trusting relationship meds least restrictive methods/environment SSRI's - Correct answer take about 3 weeks to work
