ATI Comprehensive – Flashcards
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When to withhold Heparin?
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The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced or the infusion withheld until the aPTT returns to the therapeutic range.
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What does Valproic Acid treat?
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Valproic acid is used to treat certain types of seizures (epilepsy). This medicine is an anticonvulsant that works in the brain tissue to stop seizures. Valproic acid is also used to treat the manic phase of bipolar disorder (manic-depressive illness), and helps prevent migraine headaches.
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What should be tested for Valproic Acid?
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Liver enzymes
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What does Chlorpromazine treat?
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It can treat mental illness, behavioral disorders, tetanus, blood disorders such as porphyria, and severe nausea and vomiting. It can also reduce anxiety before surgery.
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What is contraindicated to eat with a MAOI?
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Tyramine (i.e. cheeseburger)
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What does an orienter do?
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Noting the progress of the group toward assigned goals is the task of the orienter.
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Colostomy care...what should the nurse do with the skin barrier?
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The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds.
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A nurse is caring for a child who has sickle cell anemia and is having a vaso-occlusive crisis. Which of the following interventions should the nurse implement first?
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Increase IV fluids.
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Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?
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aPTT Prior to adjusting the client's continuous heparin infusion, the nurse should review the client's activated partial thromboplastin time (aPTT). The expected reference range for the aPTT is 40 seconds. Clients who are receiving continuous heparin therapy should have an aPTT of 60 to 80 seconds, which is 1.5 to 2 times of the expected aPTT level. The nurse should increase or decrease the heparin infusion according to this value.
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A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?
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Droplet The nurse should initiate droplet precautions for this client by placing the client in a private room and wearing a surgical mask when caring for the client.
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A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?
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The nurse should instruct the client to check the functioning of the oxygen equipment daily. The nurse should instruct the client to wear clothing made with cotton fabrics rather than synthetic or woolen fabric when the oxygen is in use. The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the mucous membranes, because products containing oils are flammable when near oxygen. The nurse should teach the client to store full oxygen tanks in an upright position because this will prevent injury to the client and family.
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A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
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Pink, frothy sputum A client who has manifestations of pulmonary edema can have pink, frothy sputum due to fluid leaking across the pulmonary capillaries and into the lung tissue.
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A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan?
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The nurse should plan to initiate a protective environment for a child who has severe immunodeficiency. The nurse should administer granulocyte colony-stimulating factor to the child to promote the production of granulocytes in the bone marrow to help fight infection. A child who has severe immunodeficiency should eat a high-calorie, high-protein diet to provide adequate nutrients to rebuild WBCs and fight infection.
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A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.
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The nurse should first inspect the client's abdomen to assess skin integrity and symmetry. Next, the nurse should perform auscultation. Because palpation and percussion can alter bowel sounds, the nurse should auscultate prior to these steps. After auscultation, the nurse should percuss the client's abdomen for tympany, dullness, absence, or flatness of resonance. Lastly, the nurse should palpate the abdomen for tenderness, pain, or the presence of a mass.
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A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching?
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The nurse should instruct the parents to administer the medication every 8 to 12 hr as prescribed to maintain blood levels. Shake the medication bottle well before each dose is given. Store the medication in the refrigerator. Report diarrhea to the provider immediately. Diarrhea can be a manifestation of pseudomembranous colitis. The nurse should instruct the client to discard any unused medication after 14 days.
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A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make?
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Broccoli is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli does not contain tyramine. Yogurt is correct. Yogurt is a food that contains little or no tyramine. Pepperoni pizza is incorrect. Pepperoni is a fermented meat that is high in tyramine content. Cream cheese is correct. Cream cheese is a food that contains little or no tyramine. Bologna is incorrect. Bologna is a fermented meat that is high in tyramine content.
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A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?
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A three-point gait allows the client to be mobile without bearing weight on the affected extremity. The client should wear rubber-soled shoes when using crutches. When walking upstairs, the client should advance the unaffected leg first. When walking downstairs, the client should advance the crutches and the affected leg first and then follow with the unaffected leg.
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A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes a decreased urinary output. Which of the following actions should the nurse take?
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Decreased urine output and bladder spasms indicate internal obstructions of the catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the provider if the obstruction does not clear.
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A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?
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Heat loss by conduction is a loss of heat between the newborn's skin and the cooler surfaces beneath it. Using a protective cover prevents contact with the scale, which prevents the loss of heat through conduction.
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A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?
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The nurse should recognize that floating dark spots are a manifestation of a detached retina due to bulges, folds, or holes in the affected retina.
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A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?
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The nurse should instruct the client to void because an empty bladder decreases the risk of a bladder puncture and minimizes the client's discomfort from the need to void.
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A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?
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The nurse should report any indications of respiratory distress such as nasal flaring, retractions, and grunting.
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A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
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A client who has active TB should wear a surgical mask while being transported to prevent transmission of the disease.
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A nurse is preparing to mix haloperidol lactate 5 mg/mL and diphenhydramine 25 mg/1.5 mL to administer IM for a client who is agitated. Which of the following actions should the nurse plan to take?
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The nurse should avoid administering more than 1 mL of medication into the deltoid site. Both haloperidol and diphenhydramine should be administered deep into a large muscle mass. The nurse should plan to use a 2-in needle for an IM injection of the combination of the 2 medications. The nurse should inject air into each vial to be used when mixing medications for administration. This action ensures the nurse can easily withdraw the medication when needed and that medication in the syringe is not pulled back into the vials.
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Normal Magnesium Level
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1.5-2.5 mEq/L
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A nurse is caring for a client who has a magnesium level of 2.5 mEq/L. Which of the following interventions should the nurse plan to take?
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The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest.
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A nurse is caring for a client who has gastrointestinal bleeding and an NG tube in place. While performing gastric lavage, which of the following actions should the nurse take?
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The nurse should ask the client to lie on the left side because this position limits the flow of the instilled solution out of the stomach and prevents aspiration. When performing gastric lavage, the nurse should instill 200 to 300 mL of the solution the facility's protocol specifies (sterile water, tap water, or 0.9% sodium chloride irrigation).
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A nurse is caring for a client who is receiving hemodialysis with an arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care?
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The nurse should auscultate the AV fistula in the affected extremity every 4 hr for a bruit to assess for patency.
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A nurse is teaching self-administration of insulin to a client who has a new prescription for a short-acting and intermediate-acting insulin. Which of the following actions by the client indicates an understanding of the teaching?
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When mixing insulin, the client should withdraw the short-acting insulin before the intermediate-acting insulin. This prevents contaminating the short-acting insulin with the protein in the intermediate-acting insulin. The nurse should recognize the client understands the teaching when he pinches the skin prior to injecting the insulin. This allows better access to the subcutaneous tissue. In order to access subcutaneous tissue, the client should insert the needle at a 45° to 90° angle.
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Hospice care includes...
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Hospice care includes providing bereavement services after a family member's death.
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A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider?
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The nurse should report this sodium level because it indicates hypernatremia. Clients who have kidney disease often retain sodium and require sodium-restricted diets.
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Which site should the nurse tap to elicit a positive Chvostek's sign?
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he nurse should assess for a Chvostek's sign by tapping the client's facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that indicates hypocalcemia.
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A nurse is caring for a client who asks about taking ginseng to improve her appetite. The nurse should identify that ginseng can decrease the effectiveness of which of the following client medications?
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The nurse should identify that timolol is an ophthalmic antiglaucoma medication. Ginseng can decrease the effectiveness of this medication. Therefore, the nurse should instruct the client to speak with the provider prior to taking the supplement.
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A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?
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Constipation, dry mouth, alterations in taste, rashes, pruritus, and edema.
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A nurse is assessing a client who has depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?
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Constipation, urinary retention, dry mouth, and blurred vision.
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A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?
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Weight gain, coughing at night.
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A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?
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The nurse should instruct the client that she will need to fast the night before the test to prevent inaccurate test results.
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A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?
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Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. Therefore, the nurse should initiate fall precautions for the client.
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A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss?
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A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration.
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A nurse is caring for a multiparous client following a vacuum-assisted birth. The nurse should assess the client for which of the following possible complications related to the birth method?
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The nurse should assess the client for maternal complications associated with vacuum-assisted birth such as perineal, vaginal, or cervical lacerations.
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A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect in the client's urine?
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Increased glomerular permeability allows protein to filter into the urine. Therefore, this is an expected finding in a client who has glomerulonephritis.
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A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?
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The nurse should teach the client that a drop in body temperature of approximately 0.25° C (0.5° F) commonly occurs immediately prior to ovulation.
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A nurse is providing teaching to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?
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Children who have autism spectrum disorder respond well to a reward system, which can provide structure and expectations for behavior.
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A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
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The nurse should delegate providing gastrostomy feedings through the client's established gastrostomy tube to an AP, because this task is within the AP's scope of practice.
