ATI COMPREHENSION A/B RATIONALES 2013 try this one

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antidepressants
(elavil)
amitriptyline?

pt may not feel better for 7 to 28 days

and may not experience full effect
for 6 to 8 weeks

atrial ventricular
(AV) block look on
EKG?

regular rate between 60-100/min

with extended PR intervals

can pts with hepatitis

a donate blood?

no

4.

car seat?

should be secure with a seat belt

5.

crutch teaching?

instruct pt to hold crutches on the

side opposite the injured leg, when
sitting to improve balance and
prevent falls

does trichomonas
vaginalis increased
the risk for cervical
cancer?

NO

during the initial tx

of acute diverticulitis
what is done?

the pt receives parenteral nutrition

and should be kept NPO

eosinophils?

usually with asthma

following rupture of
the membranes what
is the greatest risk?

fecal cord compression of prolapse,

which is a medical emergency and
obtaining a fetal heart tone is
priority

genital herpes s/s?

fluid-filled vesicular rash in genital

region

Gonorrhea can lead

to?

pelvic inflammatory disease and

tubal scarring and can result in
infertility

12.

graves disease s/s?

difficulty slepping, diarrhea,

increased appetite, heat intolerance

13.

hepatitis A?

fecal-oral route, uncooked food

how are normal

bowel sounds?

high pitched, irregular gurgles that

occur every 5-15 seconds, in a rage
of 5-30 per/min

how can hep B be

contracted?

blood transfusion
sexual contact
sharing IV drug needles

how is mono
(infectious
mononucleosis)
acquired?

direct contact with droplets of saliva

of an infected person

how is nystatin best

absorb?

if given 1 hour before or after a

feeding

how large should the

opening of the stoma
pouch be?

no larger than 1/4 inch

1.

2.

3.

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14.

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27.

28.

29.

30.

how long after giving

insulin should a nurse
check for
hypoglycemia?

4-14 after administration of NPH

(novolin N) insulin

how many grams of

protein does peanut
butter contains?

7g

how much should

infants grow?

1 inch per month, during the first 6

months
they should be able to double their
birth weight between 4-6 months
of age
and gain approximately 150-210
(about 5-7oz) per week

how often is a tetanus

booster?

every ten years

how often is a tetanus

booster
recommended?

every ten years

how should drops be

apply?

the nurse should apply gently

pressure to the inner canthus of the
eye for 30-60 seconds

how should epoiten

alfa be given?

sub Q

how should IM
injections be given?

z tract method

how should the

formula be to prevent
gastric cramping in an
enteral feeding?

administer the formula at room

temp

how to administer ear

drops to children
under 3 yrs?

pull pinna down and back

how to handle of an
infant with HIV?

use disposable diapers, and

discard in separate plastic bags
use bleach solution and gloves to
clean up blood spills
hand washing is important
anyone changing babies diaper
should wear gloves

how to use a cane?

pt should hold cane on the

stronger side of the body
place it forward 6-10 inches and
move his weaker leg forward to the
cane
distributing his weight between the
cane and the stronger leg
then he should move the stronger
leg forward beyond the cane and
distribute his weight between the
cane and weaker leg

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32.

33.

34.

how will ventricular

fibrilation look on ekg?

irregular rate without P waves,

bizarre and variable QRS

how would the nurse

determine progression of
ascites?

abdominal girth should be

measured daily

how would the nurse

explain a procedure to a
school age child?

using simple diagram

if NG tube meets
resistance?

the nurse should rotate the

tube without forcing it past the
area of resistance

IGA?

associated with autoimmune

diseases or chronic infections

36.

IGE?

allergic manifestations,
anaphylaxis, and asthma

37.

IgG?

antibodies to all types of

infections

IGM?

antibodies against ABO blood

groups

in order to maintain
sterile technique what
should the nurse do?

should open all sterile

packages prior to donning
sterile gloves

in respiratory acidosis
what is elevated?

the Paco2 is elevated greater

than 45

41.

lymphocytes?

cancers and malnourished pts

42.

monocytes?

infection and several collagen

disorders

43.

neutrophils?

infection, stress, and

inflammation

44.

nitroglycerin (nitrostat)?

take up to 3 tabs during single

episode
place under tongue
store in original container
discard on expiration date

39.

40.

45.

46.

dehydration
report decreased urine output
infant may sleep longer
should be kept on a regular feeding schedule
of every 3-4 hrs
may have loose green stool

post
bronchoscopy
care?

pt should not eat until gag reflex is checked

blood in sputum is expected
have a ride home
report horseness or wheezing

a pregnant pt
who is
bleeding is
always?

priority

a pregnant pt
with edema of
the ankles do?

avoid prolonged standing, to wear support

hose, and rest through out the day with
legs/hip elevated

premature
atrial
contractions
look on EKG?

irregular rate with ectopic atrial beats

earlier than expected

pt with anxiety
disorders
demonstrate?

obsessive behavior

pt with
dementia
demonstrate?

difficulty finding correct words to use

54.

RA s/s?

bilateral pain and swelling in fingers and

joints with stiffness in morning, finger
joints are erythematous and warm to touch

55.

SIADH?

is caused by excessive release of an

antidiuretic hormone (ADH) as a result pt
retains water creating a dilutional
hyponatremia

s/s of
coarctation of
the aorta?

unequal upper and lower extremity pulses

57.

stoma care?

use mild soap

apply skin sealant
cut it 1/8 to 1/16 larger than the size
measure it at least once a week

58.

TPN?

withdrawal look out for hypoglycemia

(shakiness and diaphoresis)

59.

turp care?

monitor pt for fluid volume over load

remind pt that they will feel urge while
catheter is in place
calculate urinary out put every 2 hours
measure pain level every 2-3 hours
pt should get up to a chair asap, risk for dvt

what are
cherry
angiomas?

bright red, raised spots (expected skin

changes with aging)

48.

35.

38.

phototherapy
risks?

47.

nursing interventions for

pts in hypovolemic shock?

place pt in trendelengurg
position
elevate legs to promote venous
return to heart
increase IV fluids
keep pt warm

nursing interventions for

pts with vein ligation and
stripping?

elevate feet (recliner is

appropriate)
perform ROM
walk 5 to 10 min/hr while
awake for first 24 hrs
the nurse should wrap legs
with an elastic bandage for
prevention of clots

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50.

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53.

56.

60.

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64.

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67.

what are dm type

2 manifestations
of
hyperglycemia?

increased urination and thirst

what are dm type

2 manifestations
of hypoglycemia?

tremors
cold, clammy skin

what are early

manifestations of
aids?

persistent fever
swollen glands
diarrhea
weight loss
fatigue

76.

what are early s/s

of
hyperglycemia?

anorexia
dry mouth
urinary frequency

77.

what are early s/s

of hypoglycemia?

drowsiness
clammy skin
diaphoresis
blurred vision

what are
expected findings
in hemodialysis?

elevated temp
weight loss
decreased bp

what are
hyperthyroidism
findings?

tachycardia

what are
hypothyroidism
findings?

cold intolerance
constipation
brittle hair

what are
interventions for
a salem sump
tube?

the most common ng tube it is a double

lumen (two-channeled) it irrigates the
stomach and removes fluid and gas from
stomach.
-pt should be reposition every 2 hours to
promote emptiying of stomach content
-set suction 80-100
-never clamp air vent
pt should be NPO

74.

75.

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79.
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69.

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73.

what are left

sided heart
failure s/s?

dizziness

what are normal

findings after a
colonoscopy?

abd cramping
fatigue
passage of liquid stools

what are nursing

interventions for
pts with
dementias?

should encourage verbal praise

do not exceed 20 mins in tub
may not be able to follow direction
they should not disrobe until right before
entering the bath to prevent chilling

what are pt with

preclampsia at
risk for?

seizures

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81.

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84.

85.

86.

87.

what are right sided

heart failure s/s?

edema
ascites
anorexia

what are risk factors

for colorectal cancer?

obesity
high consumption of alcohol
cigaret smoking
high protein diet
older pt
fam hx of colon cancer/ polyps
hx of gastrectomy and
inflammatory bowel disease

what are sinus

tachycardia look on
EKG?

regular rate greater than 100/min

normal P and QRS waves

what are some risk for

fall findings?

the pt walks barefoot

medications stored on top shelf

what are some side

effect for theophylline
(theo-dur)?

is used to prevent wheezing,sob,

chest tightness in asthma
irregular pulse and dysrhythmias
seizures
anxiety
urinary frequency
anorexia
n/v
diarrhea

what are s/s of a

detached retina?

photopsia= bright flashes of light

what are s/s of

anaphalictic
reactions?

increased respiratory effort

hypotension
bronchoconstriction (laryngeal
stridor)

what are s/s of

atorvastatin (lipitor)
side effects?

muscle weakness which can lead to

rhabdomyolysis, report muscle
cramps, pain or tenderness

what are s/s of

circulatory overload
transfussion
reaction?

bounding pulse and hypertension

what are s/s of

diabetes insipidus?

polydipsia
polyuria

what are s/s of

diabetic ketoacidosis?

increased blood glucose levels

positive urine acetone
a low bicarbonate levels

what are s/s of febrile

transfussion
reaction?

chills

what are s/s of

hemolytic
transfussion
reaction?

lower back pain

what are s/s of icp?

restlessness
change in LOC

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90.

91.

92.

93.

what are s/s of IV

infiltration?

pallor surrounding the

infusion site

what are s/s of macular

degeneration?

loss of peripheral vision

what are s/s of thyroid

storm?

fever
hypertension
pain
tachycardia

106.

107.

what are strategies for

teaching adolescents?

collaborative process/
problem solving

what are strategies for

teaching preschoolers?

role playing/ short stories

what are strategies for

teaching school age
children?

discussing and participating

in hands on demonstration

what are strategies for

teaching toddlers?

picture books and simple

words

what are the

characteristics of a pt with
dependent personality
disorder?

they have problems making

everyday decision without
input from others

what are the risks for

colorectal cancer?

obesity
high consumption of alcohol
cigarette smoking
high protein diet (red meat)
fam hx of colon cancer
hx of gastrectomy and IBS

108.

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105.

112.

113.

114.

what are unexpected

finding after a
colonoscopy?

guarding- can indicate bowel

perforation

what can a pt with

thickened liquids have?

oatmeal

what can hydromorpone

cause?

urinary retention

what can long term use of

corticosteroids induced?

osteoporosis

what can reduce the anti

hypertensive effect of anti
hypertensives?

ibuprofen (advil) or any

NSAIDS

119.

what can visual

disturbances indicate?

preeclampsia

120.

what can you not give to a

pt with thickened liquids?

no ice chips
no water
no icepops

what causes acromegaly?

excessive production of
somatropin (growth
hormone) after closing of the
epiphyses

what color is the

meconium?

115.

116.

117.

118.

it is the first stool passed and

it is dark green and viscous

121.

122.

what color should

peritoneal fluid not look
like?

cloudy or opaque, this might

means infections

what diet should the

child with nephrotic
syndrome be in?

low sodium diet to assist with

diuresis of extracellular fluid

what do do for a child

with juvenile idiopathic
arthiritis?

use heat therapy prior to

physical activities because it
promotes exercise
they should attend school as
much as possible
promote exercise
eat a well balanced diet

what does a change in

color mole indicate?

indicates skin cancer

what does advance

directives contain?

written instructions regarding

end of life care

what does an elevated

GFR indicate?

an acute inflammatory process

pt will need thermal
interventions (heat or cold)

what does
benzodiazepines
(lorazepam/ativan)
causes?

lethargic and somnolent

what does bethanechol

(urecholine) causes?

it stimulates urinary out put

what does concave shape

nails indicate?

emphysema, prolonged
hypoxemia

what does histamine

release causes?

increases mucus secretions

bronchospasms
bronchial constriction

what does ketoacidosis

causes?

dehydration by s/s of n/v

what does metoprolol

affect?

heart rate is a beta adrenergic

antagonist

what does parathyroid

hormone regulates?

calcium

what does pts with

delirium demonstrate?

a fluctuating LOC often at

night or in am

what does pt with COPD

have?

increased metabolism due to

work of labored breathing
they have dry mouth/thick
mucus
constipation
decreased peristalsis

what does serum amylase

has to do with?

pancreatitis

what does the use of

cardiac catherization
required?

that the pt have normal renal

functions for excretion of the
dye

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129.

130.

what do you do if an
order is questioned?

the nurse should record

seeking clarification from the
provider

what do you do when

inserting a urinary
catheter, and urine is
seen in the tubing?

the catheter should be advance

another 2.5-5 cm to ensure
that the balloon is inflated in
the bladder

what do you do with a

boggy uterus?

promote involution of the

uterus, massaging the fundus
because of hemmorhage

what foods are rich in

iron?

red meats, liver

what foods to avoid with

diverticulitis?

corn, strawberries, whole

grain bread

what happens in passive

ROM?

the pt does not actively

participates
the nurse should support the
pts extremities distal and
proximal to the joints to
facilitate passive ROM

what helps pt with acute

manic?

step by step direction

what is a bladder scan?

it is a non invasive procedure,

and pt should not experience
discomfort
not a sterile procedure
no consent necessary
LOWER ABD CRAMPING
BLOODY URINE WITH
LARGE CLOTS
INCREASED BLADDER
SPASMS

132.

what is a bronchoscope?

a tube that allows the doctor to

see in the lungs and airways
and remove objects

133.

what is actinic keratosis?

a pre-malignant lesion
flat, scaly area with red edges

what is addisons
disease?

hormone deficiency caused by

damage to the outer layer of the
adrenal gland
they need diet high in salt,
carbs, and protein
low in potassium

134.

135.

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141.

142.

143.

144.

what is abnormal finding

in a TURP?

131.

138.

145.

146.

147.

148.

149.

150.

151.

what is a early s/s of

hepatitis A?

anorexia

152.

what is a food high in

potassium?

cantaloupe

153.

what is a late s/s of

hepatitis A?

pale feces
dark urine
jaundice

154.

155.

what is a low sodium

food?

canned peaches

what is a manifestation
of type 2 DM?

infection and poor wound

healing

what is an abnormal
finding 24 hrs after
surgery?

low HGB

what is an appropriate
behavior of a pt with hx
of violence?

pt will avoid violence provoking

situations

what is an effective
method of bowel
retraining?

anal stimulation with a gloved

finger after the evening meal, it
will help stimulate the
gastrocolic reflex

what is an expected PR
interval?

should be 0.12 to 0.20 seconds

it should be one P wave prior to
each QRS complex
an expected QRS duration is 0.04
to 0.10 second
an expected ventricular rate of 60
to 100/min

what is an indication of
hydration status?

mucus membranes

what is an indication of
peripheral venous
disease?

brown pigmentation around

ankles

what is an initial s/s of

wound infection?

erythema (redness) at incision

site

what is an inportant
thing to ask when pt
having cardiac
catherization?

if pt allergic to iodine

what is a normal s/s of

aging?

presbyopia= difficulty focusing

on close objects

what is a positive way

of dealing with a
terminal illness?

"remembering things they used to

do together"

what is a sign that a

newborn has finished
eating?

a slowed suck/swallow pattern is

a sign that the newborn is
finished eating

what is a skin cancer

prevention?

pts should use sunscreen that

protects against uva and uvb

what is a s/s of an
extravasation?

tissue sloughing

what is a s/s of
anorexia nervosa?

amenorrhea
acrocynosis

what is a s/s of bulemia

nervosa?

hemoptysis

what is a s/s of
circulatory over load?

crackles, sob, jugular vein

distention, cough

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172.

what is a s/s of
phlebitis?

redness along the vein

what is
displacement?

transfer of feelings to a less

threatening person

what is early lyme

disease
characterized by?

fever
influenza like manifestation
erythema migrans
distinct progressive circular rash (or
bulls eye rash)

what is expected
24 hrs after
surgery?

hypo active bowel sounds

pain

what is given for

long term alcohol
abuse?

disulfiram (antabuse), which is an

adversion therapy

what is high
sodium foods?

wheat crackers
lean ham
cottage cheese

what is
hyperactive?

every 3 seconds or greater

what is
hypoactive?

infrequent less than 5/min

what is indication
of peripheral
arterial disease?

intermittent, leg muscle pain

what is inhibit
with spinal cord
damage at T1 and
T2?

it inhibits function below the waist

what is
intellectualization?

a logical aproach

what is karposi
sarcoma KS?

associated with aids it looks like

hyperpigmented multicentric lesions
that can be firm, flat, or nodular

what is late s/s of

ICP?

widening pulse
decerebrate posturing

what is
montelukast
(singular) for?

a leukotriene modifier, and is taken on

a regular basis, once a day, and not
prn, and is not used for exercise
induced asthma

what is normal
after taking a
nitroglycerin
(nitrostat) tab?

h/a
change positions slowly
it should be kept in original, dark
colored bottle to avoid light exposure

what is normal
findings in a turp?

yellow urine with red sediment

what is pcp
(pneumocystis
carininii
pneumonia?

it exist as part of the normal flora of

the lungs, the infection results from
an impaired immune system
pt may need a bronchoscopy with
biopsy of lung tissue

173.

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177.

178.

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180.

what is
pediculosis
capitis
management?

store child's clothing in a separate cubicle at

school
boil brushes and combs in water for 10 mins
dry bed lines and clothing in a hot dryer for
at least 20 mins

what is
primary
therapy for a
pt with JRA?

preservation of joint function

what is
priority in a
child with
sickle cell
crisis?

oxygenation

what is
priority in a
pt with
anorexia
nervosa?

record amount of food pt consumes

weight daily
restrict exercing

what is
priority in
palliative
care?

pharmacological pain management

what is
projection?

attribute her faults to others

what is
psycho-motor
learning?

have the pt demonstrate back the procedure

what is
raynaud
disease?

a disorder of the blood vessel that supply

blood to the skin and causes the distal
extremities and the tip of nose and ear to feel
numb/cool in response to cold temps or
stress s/s: tingling, swelling, painful
throbbing attacks may last mins to hours
the pt should not smoke

181.

182.

183.

184.

what is
scleroderma?

is a chronic disease with skin changes

causes thickening, hardening, or tightening
of the skin, blood vessels, and internal
organs

what is some
skin care for
pts on
radiation
therapy?

pat area when drying

use hand to wash
do not use sunscreen

what is
splitting?

a primitive ego defense mechanism that

places people in good/bad categories

what is s/s of
herpes zoster
(shingles)?

results from reactivation of a dormant

varicella virus, inflammation of the dorsal
root ganglion.
localized vesicular lesions unilateral
localized, nodular skin lesions

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199.

200.

201.

202.

what is the babinski reflex?

stroke sole of the foot

upward, toward the great
toe

what is the cause autonomic

dysreflexia?

bladder distention

what is the clinical

manifestation of
disequilibrium?

restlessness and
decreased level of
consciousness

what is the common cause of

hyperthyroidism?

graves disease

what is the first action in an

infiltrated IV?

to d/c the saline lock

what is the first action when

IV pump alarm is beeping?

to observe the iv site for

infiltration or phlebitis

what is the first action when

preparing to do a dressing
change?

to determine the pts level

of pain

what is the first thing a pt with

prosthesis do?

applied immediately the

prosthesis after waking

what is the first thing you

should do with excessive
lochial discharge?

perform a fundal
massage

what is the glascow coma

scale?

motor response

what is the greatest risk for a

thyroidectomy?

hypocalcemia with
tingling around the
mouth

204.

205.

206.

207.

208.

209.

what is the greatest risk to a pt

receiving hemodialysis?

disequilibrium syndrome
as a result of rapid loss
of fluids and decrease
bun

what is the greatest risk with a

thyroidectomy?

hypocalcemia leading to
tetany by s/s of tingling
around mouth

what is the moro reflex?

203.

startle the infant by

clapping hands`

what is the nurse

responsibility of the nurse
when witnessing the pts
signature on an informed
consent?

that the pt is fully

informed and
understands the
procedure befor signing
the consent form

what is the palmer grasp

reflex?

place an object in the

palm of infant hand

what is the play mode in

toddlers?

parallel play with each

child performing similar
activities

what is the position for an

enema?

left lateral

210.

211.

212.

213.

214.

215.

216.

what is the stepping

reflex?

hold infant upright and allow

one foot to touch tables surface

what kind of lubricant

should be used during
NG tube insertion?

water- based lubricant NOT

petroleum jelly

what kind of mask

should pt with COPD
use?

a venturi mask

what might cause dry

skin in older adults?

a decrease in elasticity of the

skin which is an expected
change associated with aging

what must be done in

bucks traction?

the pt must be in proper

alignment
boots are secured by 3 straps,
around pt leg
weights must hang freely
footplate is resting 15.24 cm
(6inches) from the footboard

what not to do when

breastfeeding?

is not necessary for the entire

areola be in the mouth
each feeding should start at the
opposite breast
do not push back of newborns
head-toward the nipple

what places a newborn at

risk for respiratory
depression?

administration of an opioid
analgesic
exa: fentanyl (sublimaze)

what position is best for

COPD pt?

orthopnea position because it

increases lung expansion

what promotes drainage

of stomach content in
tubes/pumps?

turning pt every two hours

what promotes venous

return?

using sequential compression

device

what pt should not take

cephalexin (Keflex)?

pts with PCN allergy

what reduces exposure

to allergens?

use a dehumidifier/ NOT

humidifier
no carpet
bed linens should be washed
weekly in hot water
dont apply repellent to skin

what should a pregnant

pt with odorless vaginal
mucus do?

practice good hygiene, use

perineal pads

what should a pregnant

pt with urgency and
frequent urination do?

should perform kegel exercises

217.

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228.

what should a pt do with

incentive spirometer?

they should elevate the

cylinder by inhaling deeply
assume semi fowlers or
high fowlers position

what should a pt on suicide

precautions be told to do?

sign a no harm contract aka

no suicide contract

what should a pt with active

TB been transported wear?

a mask

what should a pt with

cardiac catherization
experience?

they should drink adequate

fluids
may need to cough during
test
may experience a feeling of
heat "hot flash"
only need bed rest for 4-6
hours

what should a pt with DM

and influenza report?

temp higher than 101.5 or

greater for 24 hours

what should a pt with

leukemia and stomatitis
eat?

a cold, soft, bland, and

liquid foods to prevent
further irritation to the oral
mucosa
exa: oatmeal and
applesauce

what should a pt with

peripheral vascular disease
do?

walk until feel pain, rest for

3 min and continue until
tired
should sit with legs in a
dependent position

what should a with

hemonymous hemionopsia
with right visual field, what
will help pt eat better?

the pt should turn head to

the right to see all food on
tray

what should be avoided

with a mastectomy?

avoid raising elbow above

the shoulder until drain are
removed
avoid abduction
return to work in 4 to 6 wks
resume driving in 7 to 10
days

what should be done to a pt

with anxiety?

what should be done to pts

with expressive aphasia?

what should be done with a

pen rose drain?

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they will have trouble

concentrating therefore the
nurse should speak to the pt
using simple sentenses
give them a picture board, or
pen and paper, because pt
cannot verbally express
needs or wants
should use simple
statements
and speak normal voice
a safety pin is placed at the
distal end of the drain

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what should be done

with nitroglycerin
(nitrostat)?

if pt continues to have pain after

taking 1 tab, they should call 911
and take a second tab

what should be done

with pts with closed
head injury?

should be log roll

only suction on prn basis
maintain HOB at least 30 degrees
do not use an incentive spirometer
ICP might go up

what should be
included in a stool
specimen?

visible blood, pus, or mucus

what should be
priority when a pt
with ketoacidosis
come to hospital?

administer a 0.9 % sodium

chloride becauses it replaces
sodium looses

what should be used

to clean the inner
cannula of a
tracheostomy?

sterile hydrogen peroxide

what should
peritoneal fluid in
dialyses look like?

bloody, clear, straw color

what should pt avoid

before a colonoscopy?

NSAIDs because it increases risk

for bleeding

what should pt with

COPD do?

should perform pursed- lip

breathing
alternate activities with rest
eat high protein snacks
practice relaxation techniques

what should pt with

cystic fibrosis eat?

a diet high in calories

what should pt with

gastritis eat?

a well balanced diet, they should

keep a record of foods that cause
discomfort, pts can modify their
diet accordingly

what should pt with

leukemia not have in
the room?

fresh flowers

what should the nurse

avoid when placing
ekg lodes?

avoid scar tissue

what should the nurse

consider when using
an interpreter?

the nurse should ensure that the

interpreter and the pt speak the
same dialect and share similar
cultural norms and practices

what should the nurse

do after a pt has have
a ECT
electroconvulsive
therapy?

the pt should be reoriented

frequently

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what should the

nurse do when a pt
feels lightheaded
and begins to fall?

spread feet apart and extend one leg

for the pt to slide down while
lowering the pt to the floor

what should the

nurse do when
removing a pt IV
catheter?

the nurse should maintain the

catheter parallel to the vein to reduce
the risk of trauma to the vein

what should the pt

do after taking iron
preparation?

pt should rinse mouth immediately

after taking med

what should the pt

do with the pouch
removing it?

they should empty the pouch to avoid

spilling the effluent on to the skin

what should the pt

with a colostomy
avoid?

the use of moisturizers, which will

decrease the adherence of the pouch
to the skin

what should the pt

with a desentization
injection do?

must remain in clinic atleast 30

minutes

what should the pt

with SLE skin
lesions do?

it affects any organ in the body is a

chronic autoimmune disorder, pt
should monitor body temp and report
any elevations promptly
apply moisturizer after bathing the
lesions with warm water

what should you do

when catheterizing
a male pt?

pt should be place in supine position

penis should be at 90 degree angle
retract the foreskin and clean the
glans prior to catherization

263.

what should you do

when evaluating an
infant?

the nurse should measure ht/wt

separately, and not combine

264.

what should you do

when given
enoxaparin
(lovenox)?

it should be injected SUBQ

do not aspirate
do not massage
do not inject in same area

what should you do

with postmortem
care?

always check about religious

practices prior to body preparation in
order to honor fam wishes

what should you

teach a pt about
exercising?

they should warm up for atleast 5

mins first

what technique
should be NG tube
insertion?

clean technique

what to avoid with

theophylline
(theochron)?

avoid caffeine due to tachycardia

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269.

what to do first
when IV pump is
alarming?

observe the IV site for phlebitis

what to do for
restrains use?

observe skin condition before applying

restrains
use a quick release knot to secure the
restraints
belt restrains should be placed over pts
waist
able to insert two fingers under
restraints
do not use all four side of rails to
restrain pt

what to do when
addressing pt
dilemma?

determine the facts related to dilema

identify possible solutions
consider clients wishes

what to do with a
child with
rotavirus?

the diaper should fit snuggly

avoid using a rectal thermometer
apply skin barrier
they are NOT contagious

what to do with a
colonoscopy?

should not take NSAIDS 1 week prior

should be NPO 6-8 hours before

what to do with
ankle sprain?

check for pedal edema

wrap with a compression dressing
apply ice
elevate

what to do with a
stage 5
alzheimers
diasease pt?

increase stress level, provide a variety of

foods that the pt is able to eat by
himself to maintain independence

what to do with
magnesium
toxicity?

give calcium gluconate

s/s of toxicity: loss of deep tendon
reflex
respiratory depression
oliguria
if left untreated can lead to cardiac and
respiratory arrest

what to do with
spleenectomy?

promoting lung aeration is important

what to eat with

peptic ulcer?

no soda
eat as normal as possible
eat 5-6 small meals a day

what to give prior

to an NST?

administer 4 oz (120 ML) of orange

juice to stimulate fetal movement

what to look for in

HCTZ
(Hydrodiuril)?

flunctuation in weight
encourage increase of potassium
should be taken with food or right after
a meal

what to monitor
with timolol
(Timoptic)?

a decreased in BP

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what to report with

albuterol (proventil)?

tremors

what to teach with

hepatitis B?

pt should use own utensils and

dishes
avoid tylenol (acetaminophen)

what will facilitate

understanding in a pt
with anxiety?

the use of short, concise sentenses

because they have difficulty
concentrating

what will the child

need prior to an IV
urography (IVP)?

the child will need to have a

soapsud enema administered
before the procedure to assist in
visualization of the kidneys,
ureters, and bladder

what would indicate

an active peristalsis?

the presence of bowel sounds

what would you see

with dehydration?

low potassium levels

wheel chair
precautions?

use a gell- filled seat cushion

limit time to 2 hours at a time
avoid donut-shaped pads
shift weight every 15 minutes

when are liver

enzymes elevated?

in pts with HELLP

when can a child with

varicella(chickenpox)
return school?

the child can return to school when

the blisters are dry and no longer
drained (scabbed over)

when inserting an NG
tube?

the nurse should insert the tube

into the airway that is patent and
has greater airflow

when should a
colostomy bag be
changed?

when is 1/3 -1/2 full

when should a
newborn repeat the
hearing test if they
fail the first time?

in 3 months

when should keflex

(cephalexin) not be
given?

if pt has PCN allergy

when taking care of a

pt with meningitis
what should the
nurse wear?

a surgical mask within 3 feet ot the

pt to prevent exposure

when taking iron

supplement what
would counteract
with constipation?

eating raw fruit and vegetables

when would a pt on
antidepressant
(amitriptiline) feel
the effect?

10-14 days and experience full

effect for 4-8 weeks

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291.

where do we do blood
draws?

in the antecubital fossa

where should a cane be

placed?

held in the hand of the

stronger side of body

where should drops be

instill into?

into the conjuctival sac

where should the chest tube

be placed?

below the level of the pts

chest

where would a pt with

acute cholecystitis feel
pain?

RUQ radiating to back

who are at greater risk for

std?

females because of increased

vascularity to the vagina