Board Vitals/ATI - NEED to KNOW

Board Vitals/ATI - NEED to KNOW ScienceMedicineNursing sia_simone Save ATI comprehensive predictor STUDY...198 terms h_trtPreview

ATI: BOARD VITALS

34 terms m_c_e_1Preview Adaptive Exam HARD (boardvitals) 111 terms anna_corrine_carollo Preview MS1 98 terms pjo A 4-month-old infant with developmental dysplasia of hip needs which of the following?Pavlik harness - used to prevent hip dysplasia in infants A nurse is teaching a client who has a new prescription for clozapine. Which of the following client statements indicates an understanding of the teaching?I will need to get up slowly from a lying position while taking this medication - orhostatic hypotension is a common finding with this medication clozapine is an antipsychotic medication.The nurse is preparing to irrigate the student's eye. What steps are appropriate in completing the irrigation? Select al that apply

• Perform hand hygiene and put on gloves
• Offer the client a paper tissue
• Place the solution unto the conjunctival sac

When irrigating the eyes, the nurse should perform hand hygiene and wear gloves to prevent the transmission of microorganisms. The nurse should offer the client a tissue or pad the shoulder area to absorb solution as it drains from the eye. The solution should not be directed into the center of the eye because this can harm the cornea.

A nurse is caring for a client with a urinary tract infection who has a new prescription for phenazopyridine (Pyridium.) When providing client teaching about this medication, the nurse will advise the client about which of the following changes in the urine?the urine may be orange in color - Phenazopyridine (Pyridium) is a urinary tract analgesic. It relieves symptoms of cystitis, including burning, urgency, pain, and frequency. The client should be advised that the medication will result in orange urine that may stain clothing. Use of a panty- liner or sanitary pad can prevent damage to clothing. The orange discoloration interferes with urinalysis tests that depend on reaction to color, including tests of urinary ketones, bilirubin, glucose, and protein. The nurse should advise the client to discontinue the medication after the discomfort is relieved. Antibiotics should be continued for the full course prescribed, even if symptoms resolve. Renal function must be monitored during long-term use of this medication, but it is usually only required for 1-2 days when prescribed with the correct antibiotic therapy for cystitis (bladder infection).A nurse is reviewing information with the family of a client who frequently experiences suicidal ideation. Which of the following information should the nurse include?"Share how the client's suicide would be devastating to the client's family." - The family should let the client know how important his well- being is to them. The nurse should encourage the family members to also emphasize the ways in which the client's suicide would be devastating to the family and others.These are strategies that can protect the client from harm and promote a therapeutic relationship for the client and family: -Don't agree to keep secrets.

• Be a good listener, and allow the individual to express any feelings they have.
• Take any threat of suicide seriously, and get professional help quickly.
• Know the numbers for suicide hotlines Contact local mental health centers Provide a safe environment if someone is having suicidal thoughts.
• Remove weapons from the environment.
• Don't leave the person alone.
• Don't show judgment or inflict guilt.
• Try to provide hope and encouragement.

After a nurse performs a mental status examination on an older adult, the previously cooperative client becomes silent when asked to spell "world" backwards. Which response by the nurse is most appropriate at this time?Go on to another mental assessment - After allowing sufficient time for a response, moving on to another area of assessment shows respect for the client; however, the nurse must document the lack of response in the client's assessment.The 1 year old child looks for objects that have been hidden from her. The nurse knows that this action demonstrates the concept of: Permanence - By 12 months of age, a 1-year-old has developed the concept of object permanence and will look for objects that are suddenly hidden from her. Development of grasp, curiosity and transferring objects from one hand to the other are not related to the concept of object permanence.

The cancer most often linked to a diet high in fat is cancer of the:

Colon - Colon cancer is most often linked to high fat diets. Breast and prostate cancers are also associated with high fat diets A client has undergone total hip replacement and returns to the recovery room. What postoperative care should be given by the nurse?Keep pillows between the legs - After total hip replacement, adduction of the affected limb should be prevented either by placing abductor splint or 2 pillows between legs.

A nurse accuses a newly licensed nurse of providing inadequate care for a client who underwent hip arthroplasty. Which of the following responses by the newly licensed nurse demonstrates assertiveness?"I feel as though I met the standard of care. Would you tell me more about your concerns?" - Communicating assertively is expressing thoughts in an open, honest, and direct manner that demonstrates respect for self and others. The use of "I" statements, maintaining eye contact, and congruent verbal and facial expressions are all components of assertiveness skills. The nurse demonstrates respect for the opinion of the other nurse by asking for feedback and the reason for the concerns.A nurse is assisting with the care of a child who is experiencing respiratory failure. Which of the following findings are considered early cardinal manifestations of this condition? (Select all that apply.)

• Tachycardia
• Diaphoresis
• Restlessness

Tachycardia is an early manifestation of respiratory distress. The heart tries to compensate for the lack of perfusion by pumping harder.Diaphoresis is an early manifestation of respiratory distress due to decreased oxygenation and perfusion. Restlessness is an early manifestation of respiratory distress due to decreased oxygenation and perfusion to the tissues.

Incorrect Answers:

• Stupor behavior is an advanced manifestation of respiratory failure related to oxygen deprivation of the cerebral tissue.
• Cyanosis is an advanced late manifestation of severe hypoxia.

Vital Concept:

Cardiac arrest can cause respiratory failure. During respiratory failure, the lungs cannot adequately exchange carbon dioxide and oxygen. This results in hypoxemia and increased carbon dioxide retention. It is imperative that the nurse recognize the early signs of respiratory failure to improve oxygenation status. The classic cardinal signs of respiratory failure are restlessness, tachypnea, tachycardia, and diaphoresis.Respiratory failure is diagnosed by physical examination and laboratory results, such as arterial blood gases. Treatment for respiratory failure includes CPR intubation, oxygen, repositioning, and careful observation and monitoring.A nurse is caring for a client with heart failure who takes a diuretic. The client has had an ECG (electrocardiogram) performed and it demonstrates U waves. This should alert the nurse to check laboratory values for which of the following electrolyte abnormalities?Hypokalemia - U waves in the electrocardiogram indicate hypokalemia. Hypokalemia is generally defined as a serum potassium level of less than 3.5 mEq/L (3.5 mmol/L) and is associated with development of U waves on ECG.

Vital Concept:

Hypokalemia may result from inadequate potassium intake, increased potassium excretion, or a shift of potassium from the extracellular to the intracellular space. The most common cause of hypokalemia is increased excretion. Increased excretion can occur with vomiting, diarrhea, or as a result of medications, including diuretics, amphetamines, and other stimulants. It also occurs in clients with Cushing syndrome.The Licensed Practical Nurse (LPN/LVN) is working on a pediatric unit and is assigned to care for a 10-year-old boy who has leukemia. The client is no longer eating or drinking, oral needs have been discontinued because the client is unable to swallow them and urine output is negligible.The physician expects that the client will expire within the next 24 hours. The client is semi-conscious and is moaning. Facial grimacing is also apparent. The client's blood pressure is low and his respirations are 8 per minute. The parents ask the LPN/LVN to administer an opioid because the client is moaning and appears to be in pain. What should the LPN/LVN do?Administer the prescribed prn medication - The client should be given pain medication. Their respirations are acceptable and are likely to increase due to pain. Client respirations are unlikely to drop to an unacceptable range (less than 8BPM) while they are experiencing pain.

A nurse is collecting data on a client who has COPD and finds absent breath sounds in the left lower lobe and dyspnea. Which of the following actions should the nurse take first?Administer oxygen to the client. - The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to administer oxygen to increase oxygenation and improve gas exchange. A client who has COPD can develop a spontaneous pneumothorax due to rupture of an air-filled bleb. The nurse should immediately check the client's airway for patency, apply oxygen, check the client's vital signs, including pulse oximetry, and ensure IV access to administer fluids and medications. The client will require diagnostic studies, such as ABGs, chest X-rays, ECGs, and CBCs, to determine the cause of the absent breath sounds. The client might require insertion of a chest tube to drain air from the intrapleural cavity, re-establish negative pressure, and re-expand the lung. The client might also experience pleuritic pain and anxiety and require an analgesic or antianxiety medication. The nurse should frequently check the client's vital signs and monitor the client's breath sounds.A nurse is teaching a client who is at 24 weeks of gestation and scheduled for an amniocentesis procedure. Which of the following client statements indicates an understanding of the teaching?"I must urinate prior to the procedure." - During an amniocentesis, a needle is inserted through the maternal abdomen and there is a risk for puncture. The client's bladder should be empty prior to the procedure to allow for better visualization of the gestational sac and to reduce this risk.

Incorrect Answers:

• During an amniocentesis, the client should be in a supine position with a wedge placed under her right hip to move the uterus off of the vena

cava. A drape should be placed over the client so that only her abdomen is exposed.

• The client does not need to be NPO for 24 hr prior to the procedure.
• During an amniocentesis, the client should be conscious and awake. There is no indication for sedative use for this procedure.

Vital Concept:

Amniocentesis is an invasive procedure performed to evaluate the amniotic fluid for fetal chromosomal abnormalities and fetal lung maturity.The client should be instructed to empty her bladder prior to the test to decrease the risk for puncture. The client should be in a supine position.Ultrasonography is used to visualize the fetus and allow the provider to safely insert the needle through the abdomen. The amniotic fluid is aspirated and then examined after the procedure Which of the following symptoms can be related to a reaction to contrast medium?

• Hoarseness
• Wheezing
• Cyanosis
• Dyspnea
• All the above

A 34 year old male is admitted to the hospital with a diagnosis of pheochromocytoma. Which of the following symptoms would the nurse not expect to see during an attack?Bradycardia - This is a catecholamine producing tumor of the adrenal gland. Most are benign, however the tumor synthesizes the catecholamine's epinephrine and norepinephrine, which stimulates beta receptors. This stimulation causes tachycardia, peripheral vasodilation, diaphoresis, and postural hypotension due to decreased blood flow to the brain.