ATI Practice A Flashcards
If a patient is on Heparin and has a DVT what is a nursing intervention?
Elevate the legs
Does walking increase the risk of a PE if the patient has a DVT?
no
What is a good intervention for patients with cancer to reduce the risk of pulmonary stasis?
The patient will walk for short distances Throughout the day.
How often should a patient that is immunocompromised wash their toothbrush in the dishwasher?
Once a week, not every month
How often should a patient in mechanical restraints be assessed?
Every 15-30 minutes
What is a nurse’s responsibility during the disaster response stage?
Performing a rapid needs assessment
What is a nurse’s role during the preparedness stage of a disaster?
Identifying the roles of disaster workers
What foods should someone eat if they need a uric acid-based diet for urinary calculi formation?
Citrus fruits and avoid foods that contain purine
What is an adverse effect that should be told to the provider if a patient is taking estradiol?
Headaches- it can be an indication of thromboembolic strokes
If a patient is taking lorazepam and their RR is 6 and BP 90/44 what medication should the nurse give?
Flumazenil (benzodiazepine receptor antagonist)
What is the antidote for cholinesterase inhibitors?
Atropmin
Why is a reddened and tender heel on a patient with a fiberglass cylinder cast concerning?
It is a sign of a pressure injury
What is a nursing intervention for cranial nerve II deficit?
Clear objects from the client’s walking area because this causes damage to the optic nerve which leads to falls
What is a concerning sign of a hemolytic transfusion reaction?
Low back pain
What should a patient report to the provider if they are taking Warfarin?
A change in color in their stools
When should a patient get lab draws after starting warfarin?
Within the first 5 days of taking the medication
How can a nurse establish trust in the orientation phase with a client whose partner recently died?
Establish the termination date of therapy
What is an example of doing root cause analysis for falls?
Investigate environmental factors that might be contributing to client injury during these hours
What substance can be used to clean surfaces to protect from Hepatitis A?
Hydrogen peroxide
What is Nystagmus?
Involuntary eye movements and muscle spasticity
What is an early manifestation of lithium toxicity
Confusion
If a client has a K+ level of 3.4 what are some manifestations?
Muscle weakness and decreased DTR
What are some manifestations of abruptio placentae?
Persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding
What is sublimination?
Displayed when a client substitutes socially unacceptable behavior for acceptable behavior
What is displacement?
Transferring emotions of a particular situation to another non threatening situation
What is denial?
Suppression of emotions
What is regression?
Childlike pattern of behavior
What food is high in Vitamin A?
A raw carrot
What should the water temperature be set at if someone has a newborn
At or below 120 F
How far apart should crib slats be for an infant
2.25 in
What Precautions are used for a patient with herpes simplex virus?
Contact
What are some common side effects of amitriptyline?
Dry mouth and constipation
What does an axillary temperature of 36.2 C (97.2 F) indicate?
Cold stress
Why would a newborn receive vitamin K?
Prevents bleeding
What are the manifestations of digoxin toxicity?
Nausea, anorexia, abdominal pain, bradycardia, and visual changes
What UA results would indicate acute glomerulonephritis?
Protein in the urine because of increased glomerular permeability which allows protein to filter through
What color tag would a client with significant head trauma and agonal respirations have?
A black tag- they are likely to not survive
What should a parent do for a child who has gastroenteritis?
Oral rehydration; soft or puréed foods can be given along with the oral rehydration therapy to replace fluids lost from diarrhea
What is a physiological change associated with aging?
Decreased lung expansion due to decreased mobility of the ribs
What is an intervention for a patient 4 hours postpartum with a boggy uterus and heavy lochia bleeding?
Massage the uterus to expel clots- results in decreased bleeding
What medication can be given to a patient with a closed-head injury with mechanical ventilation to decrease intracranial pressure?
Mannitol- osmotic diuretic
What is an expected assessment finding for cardiac tamponade?
Pulse paradoxes- systolic BP is 10 mmHg or greater on expiration than inspiration along with jugular vein distention, bradycardia, and hypotension
What places a patient at risk for pressure injuries in a long term care facility?
Recent weight loss because of decreased nutrients for the skin and tissues
What is an illness that is a nationally notifiable infectious condition?
Food borne botulism- needs to reported to the CDC
What is a manifestation of the acute phase of Kawasaki disease?
Fever unresponsive to antipyretics
If a school-aged client is taking cyclophosphamide and they have neuroblastoma, what is a what for them to prevent hemorrhagic cystitis?
Maintain hydration with liberal fluid intake
What are the symptoms of autonomic dysreflexia
Severe headache and nasal congestion
