ATI Live Review ATI/NCLEX

Question Answer
What will PAD look like? Weak pedal pulses, shiny & cool to touch, & intermittent claudication.
Positioning for PAD? Position the left leg dependently.
Positioning for PVD? Raise leg above the level of the heart.
First thing to do with a transfusion reaction? Discontinue and send blood and tubing to lab.
What will infiltration look like? Swelling, pain at IV site, cool to touch.
NI for infiltration with transfusion reaction? Start new IV and restart transfusion.
Time of suctioning for tracheotomy? 10-15 seconds
Tracheotomy care: Patient education about the ties on dressing? Never untie old ones until you have new ones in place. If you remove ties, patient will have no airway- fatal!
Important to remember about why Physical is most important aspect of Maslow's Hierarchy of needs? If you're dead, then nothing else matters.
Common intervention for oxygen/perfusion problems? IV Fluids.
According to ABC's, you have got to perfuse oxygen. First, you must have what to infuse in the first place? Oxygen
Positioning for dyspnea? Sit them up
What is often the first thing you do- it is quick and efficient? Patient positioning
The ____ the injury, the worse it is. Higher
"____ breathe no more. C5 to stay alive." C4
Patient found at foot of the bed lying on the floor. Initial action? Asses VS & LOC.
According to delegation, are transferring and discharging the same thing? Which can the LPN participate in? No. Transferring.
A patient with multiple skeletal fractures will be expected to have shallow respiration, bloody drainage at pin site, and chest pain with positioning. What would require immediate assessment? Disorientation.
Disorientation and change in LOC are clinical manifestations of what related to neurologic and respiratory systems? IICP & Early hypoxia
What medication should be held prior to ECT? Phenytoin (Dilantin)
What should be the biggest concern related to a patient 1 week post op knee arthroplasty? Blood clots.
NI for knee arthroplasty related to potential blood clots? Mobility & Blood thinners.
Patient has an indwelling urinary catheter and not voided in 8 hours. Priority NI? Perform bladder scan.
What medication should only be used to treat cancer patients or severe diseases caused by overactive immune system such as psoriasis or rheumatoid arthritis? Methotrexate sodium (Methotrexate)
What is the only non-weight bearing form of crutch walking? 3-point gait crutch walking
Which type of partial-weight bearing crutch walking is used frequently with Neuro/CVA patients? 2 & 4-point gait crutch walking
Nursing education for 3-point crutch walking? Stand in the middle of your crutches (tripod position), Advance crutches forward with affected/injured leg, Step beyond crutches with stronger leg. Continue steps in equal length.
Keep arm flexed & back up before sitting in chair.
Nursing education for 4-point gait crutch walking? Right crutch- left foot. Left crutch- right foot.
Nursing education for 2-point gait crutch walking? Right foot with left crutch. Left foot with right crutch.
Why would you be worried about a child on the playground squatting after a game of ball? Tetralogy of Fallot (congenital heart defect) which causes poor oxygen perfusion, thus resulting in hypoxia.
When TPN is administered, there is always a high risk for what? Hyperglycemia
What type of fluid is administered with TPN? Hypertonic solution
What should the nurse monitor every 4-6 hours with TPN administration? Blood glucose
TPN may be given what two routes? PICC line & tunneled catheter
TPN dressing changes are done with what type of asepsis? Surgical
A new TPN bag + a new filter is hung how often? Every 24 hours
TPN is administered primarily to prevent what imblance? Fluid Volume Deficit
What is the biggest concern with DKA patients? Priority nursing intervention? Dehydration. Oxygen, give atleast 1 L of NS and then insulin.
Prolonged vomiting and diarrhea is associated with which two electrolyte imbalances? Hypokalemia & Hyponatremia
Patient education for patient at home taking a diuretic. Watch for what signs? Anorexia, Disorientation, Weakness
For a patient with renal failure, monitor excessive retention or excretion of what two components? Na and K+
With vomiting and gastric suctioning, which electrolyte is primarily lost? Na
What should be restricted in diet to manage FVE? Processed foods
Excessive ketones can cause what complication? Diabetic coma
Nurisng interventions for patient with hyperglycemia? Electrolyte replacement, IV fluid replacement & Rapid- acting insulin.
Nursing Intervention for patient in a diabetic coma? Give insulin
Nursing Intervention for patient in insulin shock? Give sugar
Signs and symptoms of Hyperglycemia? 3 P's, N/V, dull HA, & vertigo, fruity breath, ketones, Kussmaul respirations, tachycardia (trying to perfuse)
Rule of thumb for chronic hypoxia? Give O2, Perfuse O2, Conserve O2.
Order or color in triage? Red-Yellow-Green-Black
What will require immediate follow up with patient with chronic kidney disease? 5 lb. weight gain over past 24 hours, indicating FVE=HF.
Patient with Grave's disease requires immediate intervention when? When temperature begins increasing.
Ace-inhibitors end with? -pril
Antivirals end with? -vir
Antifungals end with? -azole
Antilipidemics end with? -statin
ARB's end with? -sartan
CCB end with? -dipine
Erectile dysfunction end with? -afil
Histamine blockers end with? -dine
PPI's end with? -prazole
What are appropriate client identifiers prior to administering medications? Photo ID, full name & hospital assigned ID #.
What to do instead of laxatives to decrease constipation? Stool softeners, increase fiber & fluids, exercise
Immediate intervention if what is observed with patient who received epidural analgesia? Decreased LOC
Where does all the blood go when patient is experiencing hypoxia? Vital organs. -Brain does not need to live, it needs to stay alive!
Nutritional education for Dumping Syndrome? No liquids for 1 hour before or after eating, lie flat after eating, small frequent meals
Nutritional education for gastric resection? No milk, no sweets, no sugars
Universal blood recipient? AB
Universal donor? O-
S+S of Allergic reaction? itching, hives, rash, swelling
S+S of Anyphylaxis reaction? SOB, angioedema, tachycardia, flushing
Febrile reaction often seen in patients who are ___? Immunosuppressed
Hemolytic reaction often seen in patients who are ___? Pregnant (back pain). Received the wrong blood. Rh-incompatibility.
DDAVP intranasal (Desmopressin) is given with which two complications? DI and Hemophilia
What major things lead to SCPC? Dehydration, susceptibility to infection & anemia
Sickle cells tend to hang up on each other where, causing pain? At the joints
Patient is radioactive with which type of radiation? Internal.
NI for internal radiation therapy? No children, no pregnant women, visitors may only stay for 30 minutes and 6 feet away.
Priority intervention with external radiation? Protect the skin. Mild soap and water, pat dry. No ointment unless px by radiologist.
Positioning after cardiac procedure? Supine
NI after cardiac procedure? Apply pressure, Assess 5 P's (Perfusion) and sometimes pupils. Bilateral- always compare injured with non-injured
What ER medication to give with bradycardia? Atropine
"V-tach and awake… meds I'll take." (Amiodarone)
"V-tach and nap… zap zap zap." (Cardiovert)
V-tach, unconscious and pulseless. NI? Defibrilator
What does cardioversion do? Synchronizes rhythm
Signs and symptoms of Hypoglycemia? TIRED. Tremors, Irritability, Restless, Excessive hunger, Diaphoresis.
What complication is similar to DKA, but is seen with T2 DM and does not have acidosis? HHS
DM patient is unconscious. NI? Give Glucagon IV/SQ or 25-50 mL of IV D50W.
Which diabetic medication do you give regardless of if patient is throwing up? Long- acting insulin
As sugar starts to increase with DM patients, monitor for? Ketones
What is the leading cause of renal transplant? DM
Painful swallowing, hoarse voice and blood tinged sputum are all expected findings following what procedure? Bronchoscopy
When should the NTG patch begin effective treatment? Within 1 hour of application.
How long should a patient wear a NTG patch? 12-14 hours/day
Celecoxib (Celebrex) is a non steroidal anti-inflammatory COX-2 inhibitor indicated to relieve manifestations caused by rheumatoid arthritis and oseoarthris in adults. An allergy to ___ is contraindicated? Sulfonamide
Adverse reaction of Lactulose? Diarrhea
If burn is located around the mouth, what should you prepare for? Intubation
UO for a burn patient should be? 0.5 x kg = mL/hr
Parkland formula? 4mL x kg x %TBSA = fluid resuscitation
If drainage is present, you will need a ___ dressing? Moist
If drainage is not present, you will need a ___ dressing? Dry
What is the tall-tale sign of a fat embolus? Petechiae
Patient with fat embolus who is distressed needs __? Oxygen
What is needed to prevent injury and promote healing with fractures and traction? Rest
How long should ice be applied? 20-30 minutes for the first 24 hours.
___ fractures to help control swelling and decrease bleeding? Compress
Immobility is a high risk for what GI complication? Constipation
What are the 2 types of traction? Skin & skeletal
How should plaster cast dry? Air dry
Signs and symptoms of compartment syndrome? Pain unrelieved by position or medication, cyanosis, tingling, paralysis
Pin care associated with what type of traction? Skeletal
In the presence of wound drainage, implement what precautions? Contact
Pin site care should include? Use cleaning agent. Start close to pin and go out. Leave the crust. Never adjust.
The buttocks is raised off the bed with ___ traction? Bryant
No bowel sounds can be indicative of ___? Peritonitis
Monitor for ___ affects with Amitriptyline (Tricyclic)
Given for depression.
Anticholinergic
Chlorpromazine therapeutic effect? Decrease hallucinations.
Chron's disease diet should include what in relation to fiber and protein? Low fiber, high protein.
Headache, bradycardia, HTN and dilated pupils are CM of ___? IICP
Monitor for ___ with Mannitol? Hyponatremia
What is an adverse effect of Mannitol? Hypotension
What supplies are needed for a chest tube? Oxygen, sterile water, occlusive dressing, & hemostat clamps.
What is the purpose of pressure support ventilation (PSV)? Maintains a preset amount of pressure during spontaneous ventilation to decrease the work of breathing.