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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

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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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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

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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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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

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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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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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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

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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

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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?

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it is the first stool passed and


it is dark green and viscous

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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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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

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what is abnormal finding


in a TURP?

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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

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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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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

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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

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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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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

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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

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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

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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?

229.

230.

231.

232.

233.

234.

235.

236.

237.

238.

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

239.

240.

241.

242.

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

243.

244.

245.

246.

247.

248.

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

257.

258.

259.

260.

261.
249.

250.

251.

252.

262.

265.
253.

254.

255.

256.

266.

267.

268.

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

270.

271.

272.

273.

274.

275.

276.

277.

278.

279.

280.

281.

282.

283.

284.

285.

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

286.

287.

288.

289.

290.

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