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ATI Comprehensive QUESTION WITH THE BEST
ANSWERS AND RECENTLY UPDATED
Fontanel closing on newborns - Correct answer anterior 12 - 18 months posterior 1 - 2 months Best time to perform bladder scan - Correct answer immediately after void Cholecystitis Diet - Correct answer no cheese! low fat, no fatty/greasy food, low cholesterol, Increase fruit and veggies, Whole grain (Melon) Moro reflex - Correct answer startled; hit surface next to the newborn Position for suppository or enema administration - Correct answer - Sim's/left lateral/Rt. knee to chest Varicella contraindication - Correct answer corticosteroids Dtap contraindication - Correct answer Hx of inconsolable crying Newborn car seat safety - Correct answer Snug harness across axillary. Not across abdomen or neck. Ileostomy what pt expect on appearance - Correct answer - Initial drainage: dark green, odorless.
- Some initial bleeding normal
- Pink or red stoma color normal
- Initial swelling; decreases 2 - 3 weeks later delirium - Correct answer simple orientation and low stimuli
Hep b contraindication - Correct answer Baker's yeast MMR contraindications - Correct answer pregnancy, recent blood transfusion Anorexia nervosa - Correct answer increase in sodium, potassium, chloride, BUN, liver function, cholesterol Bulimia therapeutic nursing care - Correct answer offer small and frequent meals 89% postoperative - Correct answer change to another finger Non rebreather mask - Correct answer Ensure two "flaps" open during exhalation/close during inhalation. Venture mask - Correct answer ensure reservoir bag 2/3 full during inspiration and expiration Thoracentesis position - Correct answer sitting position, arms raised and resting overbed table Chlorpromazine (psychoses) - Correct answer adverse effect (SPASMS/TREMORS) treat benzo (COGENTIN) BENADRYL Variable deceleration - Correct answer cord compression Early decelerations - Correct answer safe Begin prior to peak of the contraction and end by the end of it. they are caused by head compression. no need for intervention if variability is within normal range (6-10) and the FHR is within normal range. Cystic fibrosis - Correct answer DNA mutant gene, sprinkle capsule on food Levothyroxine - Correct answer thyroid, caution with cardiac pts (TACHY ANXIETY) take in morning Levothyroxine toxicity - Correct answer anxiety, chest pain, tachy, hypertension
penis to wash, do not remove yellowish mucus do not use moist towelettes, heals in a couple weeks TB precautions - Correct answer private negative pressure room, N95 mask, wear mask when transported, 4 meds at a time, for up to 6 - 12 months, test exposed family members, sputum culture q2- 3 weeks, 3 negative= noninfectious leukorrhea - Correct answer white discharge from the vagina during early pregnancy MRSA Contact Precautions - Correct answer - keep distance within 3 ft of client
- Private room or share with someone with similar infection (wound infection, herpes simplex)
- double bag dressing gauze.
- PPE: Gloves and Gowns. Metformin common side effect - Correct answer renal kidney failure drawing up insulin - Correct answer NR-RN regular NPH (Clear then cloudy) Interaction between SSRI and st johns warts - Correct answer hypertensions and increased heart rate that can become life threatening. diabetic foot care - Correct answer - Nailcare: Podiatrist, cut nail straight across.
- Wear Clean Cotton Socks/Closed Shoes
- Do not soak feet or wear ointments Used Opioid overdose - Correct answer Naloxone (Narcan) Contraindication during alcohol withdrawals - Correct answer Delirium, accompanied by hallucinations Pt education for amniocentesis - Correct answer supine or rolled towel under right hip, continue breathing normally as needle is inserted, rest 30 min after, increase fluids for 24 hrs after
Indications for fluid depletion - Correct answer thread pulse, hypotensive, tachy, increased resp, cool, clammy, diaphoretic, decreased UOP, thirst Type of stomas - Correct answer single one stoma, loop proximal active distal inactive, divided proximal digestive distal mucus, double barrel sutured together Documentation for ostomy care - Correct answer amount, color, consistency Priority for panic disorder - Correct answer Breathing Technique Education on meds - Correct answer digoxin- 2hrs of meals monitor pulse for 1 min, toxicity, sodium polystyrene- hypokalemia, restrict sodium, epogen- blood twice a week, monitor hypertension, ferrous sulfate-administer following dialysis with stool softner take with food, aluminum hydroxide gel- avoid pts with gi disorders, 2 hrs before/ after dig, Lasix- monitor i&o, bp, weight, report thirst cough Newborn water temp and room temp - Correct answer 120F 97.9-99F Bathing newborn technique - Correct answer Bathe from cleanest to dirtiest - Eyes - Face - Head
- Chest - Arms - Legs
- Groin (last) Newborn reflex shown on day 1 - Correct answer hear voice Immunization recommended for postexposure protection - Correct answer Hep A
Pt complaints of cramping - Correct answer decrease infusion rate Location for drainage bag of catheters - Correct answer bed frame below level of bladder ventilator alarms - Correct answer low: disconnection high: kink, suction Glascow Coma Scale - Correct answer 15: Good 3: severe Pressure ulcer strategies - Correct answer reposition bed q 2hr, chair q 1hr, apply barrier cream and moisture absorbing pads Immunization: booster every 10 years - Correct answer DTP HPV vaccine - Correct answer 3 doses given starting at age 11 - 12 How to measure Fundal Height - Correct answer top of symphysis pubis to top of fundus Calcular due date - Correct answer Day of LMP - 3 months + 1 yr & 7 days Contraindicated immunizations during pregnancy - Correct answer - Varicella - Zoster - MMR True labor vs False labor - Correct answer true- pain in lower back; regular rhythmic contractions; increased intensity with ambulation false-discomfort at abdomen; no lower back pain; contraction stop with ambulation or position change Deceleration - Correct answer early head compression late uteroplacental insufficiency variable cord compression
interventions in late variable deceleration - Correct answer left lateral side laying oxygen C-section Normal FHR - Correct answer 120 - 160 Nursing car boggy uterus - Correct answer void, massage top of fundus with fingers reassess q 15 min Nursing care engorgement - Correct answer moist heat for 5 in before breastfeeding, ice compresses after feeding to reduce swelling and discomfort Nursing care mastitis - Correct answer continue breastfeeding and take antibiotics as prescribes Narcotic antidote - Correct answer Naloxone (Narcan) Anemia Lab - Correct answer RBC 4.20-4. BUN and creatinine - Correct answer 10 - 20, 0.9-10. sodium - Correct answer 136 - 145 Potassium - Correct answer 3.5-5. Chloride - Correct answer 96 - 106 Magnesium Sulfate Toxicity - Correct answer calcium gluconate Magnesium toxicity - Correct answer Absent or decreased deep tendon reflexes Respiratory depression Cardiac arrest Decreased urine output Mom Rh-, baby Rh+ - Correct answer Give Rhogam
Variable decelerations - Correct answer cord compression, prep for c section, change position, d/c oxytocin Follow initial nursing action for late decelerations - Correct answer left lateral position Demerol - Correct answer best pain management post op cholecystectomy Do you report chlamydia - Correct answer mandated reporting to CDC w/out consent JP Drain - Correct answer empty 1/2 full Q 8 hrs clean with soap and water JP Drainage doubles in two hours - Correct answer think hemorrhage assess start cbc Notify MD Foods high in potassium - Correct answer • Avocado o Bananas o Cantaloupe o Carrots o Fish o Mushrooms o Oranges o Potatoes Pork, Beef, Veal o Raisins o Spinach o Strawberries o Tomatoes MAOI Nardil - Correct answer avoid cheese food for hyponatremia - Correct answer cheese high in sodium and protein Drainage pin sites - Correct answer document COCA,
leave crust pin care TID Phytoin SMZ-TMP - Correct answer command hallucination- phytoin toxicity Command hallucinations - Correct answer An individual hearing voices that direct the person to take action. without meds Methergine risk - Correct answer treats postpartum hemorrhage, risk for: hypertension, check bp, watch n/v headache 2 years of age presentation - Correct answer round soft abdomen 3 years immunizations - Correct answer dtap, ipv, mmr, varicells, influenza 3 year normal - Correct answer 2 - 3kg y, 2.5- 3 in y, picky eaters, initiative vs guilt, imaginary friends, ride tricycle, jump off bottom step, stand on one foot for a few seconds First thing to do with newborn - Correct answer ABC, Dry off Terminally ill patient - Correct answer anticipatory Client involved in MVA severe internal bleeding - Correct answer 5% dextrose in LR Hypovolemic shock - Correct answer 5% Dextrose in LR Family asks to pray with you - Correct answer refer to spiritual services Blood transfusion - Correct answer look at HGB increase 1 - 2 per unit of blood Antibiotic in TPN line - Correct answer NOTHING GOES IN TPN TPN infusion line - Correct answer change q 24 hr
ventricular tachycardia - Correct answer widened QRS 3 month old - Correct answer graham crackers, flex and tuck Febrile cooling blanket - Correct answer shivering is adverse reaction Dig toxicity - Correct answer - 3.2 is possible Report in preterm labor - Correct answer severe headache; hypertensive crisis tuna - Correct answer high in protein and potassium anemic - Correct answer decrease milk increase iron craniotomy things to report - Correct answer aphasia, HOB increase 30 Prednisone - Correct answer not long term, risk for infection Losing 1lb in a week - Correct answer - 500 calories a day Bad sign with newborn - Correct answer disapproval diet glomerulonephritis - Correct answer low sodium, water restriction dehydrated peds - Correct answer do not give gingerale, fruit juice, or water postop colon resection - Correct answer monitor treat pain&evaluate pain relief, provide wound care using surgical aseptic technique, advise the client to use stool softners to prevent straining priority infection for amniotomy - Correct answer fever/infection
stroke pt priority therapy - Correct answer speech/ABC's best to orient - Correct answer - follow nurse informed consent - Correct answer - parent of minor, spouse relative, court ordeed rep, legal guardian impaired nurse - Correct answer report to charge nurse veracity - Correct answer med error PCA pump, PRN morphine - Correct answer walking talking pain management Singulair - Correct answer - once daily at bed time Peak gentamicin - Correct answer - 30 min after giving IM or after IV finished, trough before next dose Lithium level - Correct answer 0.4-1. Lithium toxicity - Correct answer slurs speech, NVD, thirst, polyuria, muscle weakness Central line push resistance - Correct answer do not push Pt with anthrax - Correct answer strip down Beta Blockers - Correct answer **** DO NOT give with ASTHMA, BRONCHIAL CONSTRICTIVE DISEASE!!!**** "LOL" Antenolol, metoprolol. labetolol Antihypertensive. Blocks beta-adrenergic receptors in heart, decreases excitability of the heart, reduces caridac workload and O2 consumption. Lowers BP. Check BP before giving (hypotension)
histrionic personality - Correct answer flirty and seductive Shizo findings - Correct answer - memory deficit, difficulty concentrating, disordered thinking, poor problem solving and decision making CA- 125 for ovarian cancer - Correct answer hard 2 beat after biopsy Post op care for diabetes - Correct answer vitamin C Flush central line - Correct answer 10 CC Abnormal Pap smear - Correct answer cervical cancer trying to get pregnant - Correct answer after stops may take a while Chlamydia mom and baby - Correct answer Zithromax, amoxicillin and erythromycin Decontamination radiaton - Correct answer soap and water disposable towels insulin, rotate sites or no? - Correct answer do not rotate site Valproic acid - Correct answer Liver failure/ jaundice Implementing staff changes - Correct answer - investigate issue with task force Consent from ED to do surgery - Correct answer - get official interpreter Heavy lochia boggy fundus - Correct answer - give oxytocin Autism ati - Correct answer Lack of responsiveness Frequent variable decels - Correct answer turn on left side first Post EGD - Correct answer cool, clammy skin= perforation
Cytoxan for neuroblastomas in toddlers - Correct answer hydrate liberally Risk for diabetes insipidus - Correct answer - monitor for polyuria Postpartum, immediate action - Correct answer boggy uterus, massage fundus Cushings Disease - Correct answer moon face, increased cortisol Memory Loss - Correct answer ICP Equation for calculating pulse pressure - Correct answer SBD-DBP = PP Trough - Correct answer 1 hour prior to next dose Overhydration - Correct answer tachycardia, bounding pulses, hypertension, tachypnea, increased CVP, confusion, muscle weakness, wt gain, ascites, dyspnea, crackles Hyponatremia - Correct answer hypothermia, tachycardia, rapid thread pulse, hypotension, ortho hypotension, headache, condusion, decreased DTR, hyperactive bowel sounds Hypernatremia - Correct answer hyperthermia, tachycardia, rapid thread pulse ortho hypotension, restlessness, irritability, muscle twitching, reduced to absent DTR, hyperactive bowel sounds Hyperkalemia - Correct answer slow/irregular pulse, hypotension, restlessness, irritability, flaccid paralysis, N/V/D, hyperactive bowel sounds Hypokalemia - Correct answer hyperthermia, weak irregular pulse, hypotension, resp distress, muscle cramping, pvc's, bradycardia, decreased mobility Complications hypophysectomy - Correct answer bleeding and nasal drainage csf leak, assess nuero condition q hr for 24 hr and q 4hr after Nursing intervention for preventing delays in healing - Correct answer encourage fluid intake 2 - 3L increase protein, keep serum albumin level above 3.
- tension pneumothorax, - sucking chest wound,
- prolonged clamping of the tubing
- kinks in the tubing or obstructing After a rhinoplasty - Correct answer frequent swallowing is a sign of hemorrhage (TWICE PICTURE QUESTION - Correct answer stage 1 lyme disease 200lb person wants to lose 15lb what percent body weight is that?? - Correct answer Preventing phlebitis - Correct answer rotate site Q 72 hours or by policy avoid lower extremities hand hygiene surgical asepsis Care for frostbite - Correct answer - never rub!
- remove person from cold
- skin to skin contact for minor frostbite
- water bath(98.6-106F) - tetanus What does glaucoma look like through patients eyes - Correct answer Google picture of tree Scoliosis Assessment - Correct answer - instruct pt to bed at the waist w arms reaching toward toes
- inspect and palpate down the spine using thumb and forefinger
- inspect the spine again with client standing
- Expected findings: no tenderness with spinal vertebrae that are midline To avoid contractures - Correct answer frequent position changes things to report during first trimester - Correct answer bleeding
leakage of fluid contractions Preventing infection in immunocompromised pt - Correct answer - dont place stuff on floor
- dont shake linens
- clean least soiled area first
- use plastic bag for moist contaminated items
- empty all liquids used into drain Contraindication of acupuncture - Correct answer herpes zoster Primary Prevention - Correct answer
