ATI Comprehensive Final Quiz, RN Comprehensive Predictor 2019 A, RN Comprehensive Predictor 2019 Form B and C

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ATI Comprehensive Final Quiz, RN Comprehensive Predictor 2019 A, RN Comprehensive Predictor 2019 Form B and C What is a nurses priority action when a patient is experiencing anaphylactic shock whil... e receiving IV medications? -Answer- Priority action: stop the medication infusion The nurse can also: Administer epinephrine; infuse .9% sodium chloride, and elevate the lower extremities to help maintain adequate blood pressure A nurse is caring for a group of clients in a long-term facility. One of the clients is walking in the hallway and bumping into walls and does not respond to his name. which of the following actions should the nurse take first? -Answer- Accompany the client back to his room. What medication is contra indicated while taking St. John's wort? And why? -Answer- Sertraline Taking concurrently puts the patient at risk for serotonin syndrome Both of these are used for Tx of depression Persistent otitis media -Answer- An infection of the middle ear Passive smoking promote adherence of respiratory pathogen's to the lining of the middle ear space which prolongs inflammation and impedes drainage from the ear Exposure to cold weather does not cause otitis media Acarbose (Precose) adverse effects -Answer- Sleepiness, headaches, anemia; the most common adverse effects are gastrointestinal - diarrhea, abdominal distention, cramping, flatulence presbyopia -Answer- impaired vision as a result of aging Can affect one's ability to read the newspaper, the lens is unable to change shape to focus on close up objects Myelomeningocele -Answer- Most severe form of spina bifida in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac and protrude through the spine Neural tube defect pts are at Rx for latex allergy Most common complication of this disorder is UTI Prevention of the development of amblyopia -Answer- A disorder of the eye and which unilateral central blindness occurs as a result of another problem, such as strabismus Parents should patch the unaffected I Strabismus -Answer- Cross eyed Without treatment by 6 years of age this can lead to central blindness (amblyopia) Ethambutol (Myambutol) -Answer- Med for TB, report vision changes immediately Adverse effects: loss of red/green color discrimination due to optic neuritis; d/c if this occurs Isoniazid (INH) -Answer- Antitubercular Adverse effects: hepatotoxicity, peripheral neuropathy, yellowing of the sclera is an indication of jaundice that accompanies liver failure Rifampin (Rifadin) -Answer- Anti TB and Antibiotic Adverse effects: changes in color of bodily secretions to red-orange What is a patient at risk for when they're platelet count is below the reference range? -Answer- Indicates thrombocytopenia, which puts the patient at increased risk for bleeding What should a nurse anticipate with bladder distention in the fourth stage of labor? -Answer- Bladder will fluctuate with palpation Bladder is dull to percussion Uterus will be displaced to the right, is boggy, well above the umbilicus cystitis -Answer- inflammation of the bladder lining, Commonly occurs with UTI Prevention methods: Stay well hydrated, urinate before and after sex, wipe front to back, avoid tub baths Intrauterine device (IUD) -Answer- Small, T-shaped device inserted by a physician inside the uterus to prevent pregnancy Increased risk for a topic pregnancy Does not protect from STI's or HIV Manifestations of retinal detachment -Answer- sudden onset of decreased peripheral or central vision, dark floaters, flashes of light. curtain vision over part of visual field Manifestations of cataract -Answer- Decreased color perception, blurry vision,clouding of the lens of the eye Without treatment leads to blindness Manifestations of Angle-closure glaucoma -Answer- Rapid onset of e severe pain around the eyes and face, reduced vision, colored halos, headaches, sudden onset of elevated IOP Manifestations of macular degeneration -Answer- Gradual, mild to moderate reduction of central vision Nursing actions for a patient in Balanced skeletal traction -Answer- Patient who is in mobile is at risk for constipation, nurse should encourage a high fiber diet and increased fluid intake Active range of motion of the affected limb is not feasible due to limited mobility with the traction apparatus The nurse should not remove the weights after they're in place Nurse should inspect the pin site at least every 8 to 12 hours due to risk of infection Priority assessment for infant experiencing dehydration -Answer- Measure the patient's weight daily; critical for infants and children because fluid accounts for a greater portion of their body weight What is included in an infant Hydration assessment what does it determine? -Answer- Checking for absence of tears, palpating the fontanelles excess skin turgor Assessing these factors determines degree or severity of an infants dehydration Priority action for a patient who had a seizure and is unconscious -Answer- Priority action: CHECK AIRWAY PATENCY (airway always first) A nurse can then assess the patient for injuries perform a neurological exam and measure the patient's vital signs once an airway is established Vaginal yeast infections during pregnancy -Answer- Hormonal changes of pregnancy change the acidity of the vagina, making used infections more common Clozapine (Clozaril) -Answer- Atypical Antipsychotic Tx of schizophrenia Adverse effects: urinary retention, orthostatic hypotension, agranulocytosis Fever is an early indication of possible depletion of WBCs or agranulocytosis; WBC count should be checked tympanostomy tube placement -Answer- placement of a tube in the tympanic membrane to relieve symptoms caused by fluid buildup Most children do not need tubes from more than one year; usually fall out on their own between 6 to 12 months after insertion Should wear air plugs to prevent contaminated or soapy water from entering the ears Hearing impairment common with otitis media and can continue after tubes are in place Thrombocytopenia precautions -Answer- Thrombocytopenia is a low platelet count, common after bone marrow transplant's Patients are at increased risk for bleeding Prevention: avoid hard foods No fresh flowers because patient is in protective isolation Use of an electric shaver Do not blow nose or insert objects into nares Lactose free calcium sources -Answer- One cup of collard greens provides about the same amount of calcium equivalent to 8 ounces of milk Ventriculoperitoneal shunt placement discharge teaching -Answer- Patient at increased risk for infection especially 1 to 2 months after placement; parents should report fever, vomiting, seizure activity, decreases in responsiveness which all are indications of infection A minimal amount of fluid is redirected from the ventricles to the abdomen by the shunt and is absorbed readily into the peritoneum Older children should wear a helmet during physical activity to decrease risk for injury, Helmet is not necessary for infants Chronic use of oral glucocorticoids high doses by children can result in what? -Answer- Slowed linear growth Children should be prescribed inhaler glucocorticoids in order to deliver the anti-inflammatory agent directly to the local target area resulting in a decrease risk of adrenal suppression (which leads to slowed linear growth) Abdominal aortic aneurysm (AAA) -Answer- aorta that becomes abnormally large, ballooning outward *triple A= triple the size* Indications of a rupturing AAA: Sudden and increasing lower abdominal and back pain (indication that the aneurysm is extending down word and pressing on the lumbar sacral nerve roots) Indications of Shock including decreased BP and increased pulse Right sided heart failure -Answer- *RIGHT= EVERYTHING ELSE BUT LUNGS Fluid backs up into heart Manifestations: S3 gallop, peripheral edema, jugular vein distention Left sided heart failure -Answer- *LEFT =LUNGS Fluid backs up into lungs Manifestations: crackles in lungs, dyspnea, pulmonary edema (d/t blood cannot get out of pulmonary circulation) Nurse should expect to see oliguria during the day because of decreased blood flow to the kidneys Varenicline (Chantix) -Answer- Smoking cessation Adverse effects: changes in mood, n/v, altered sense of taste, skin rash Rx factors: ↑risk depression/suicide; priority nursing action is to monitor for any mood changes Colorectal cancer primary, secondary, tertiary prevention methods -Answer- Primary prevention: Smoking secession, there is an association between ling-term smoking in colorectal cancer Dietary teaching on the benefits of a diet high in cruciferous vegetables, which helps prevent the development of the disease Secondary prevention: Screening exams starting at age 50 promotes early detection of the disease Tertiary prevention: information about ostomy appliances and care, an action to minimize the effects of long-term disease or disability Patient education for EEG therapy -Answer- EEG electrodes only monitor brain activity, they do not stimulate Patient should not drink any beverages that contain caffeine the day of the test, patient should not fast because hypoglycemia can affect diagnostic results Patient should shampoo their hair before the procedure and refrain from putting any styling products on it afterwards to promote adherence of the electrodes to the scalp Short term memory loss does not occur after an EEG (common after electroconclusive therapy) Doxycycline (Vibramycin, Doryx) -Answer- Tetracycline antibiotic [Show More]

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