ATI Capstone Board-Vitals review

ATI Capstone Board-Vitals review Leave the first rating Students also studied Terms in this set (26) Science MedicineNursing Save ATI comprehensive predictor STUDY...198 terms h_trtPreview ALTERNATE FORMAT Safe and Effec...48 terms caro0522Preview Virtual ATI PN Capstone Orientation...

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shan_sferragamo02 Preview Boardv 81 terms tku A nurse is monitoring a neonate an hour after an uncomplicated spontaneous vaginal delivery. The

following are normal findings:

- Respiratory rate: 30-60/minute

- Heart rate: 110-160/minute

- Systolic blood pressure: 60-80 mm Hg

- Diastolic blood pressure: 40-50 mm Hg

- Temperature: 97.7-99.5 F (36.5-37.5 C) axillary

• Pink or acrocyanotic skin color without jaundice.
• Mongolian spots, which are bluish purple pigmented

spots usually found on the back, shoulders, or buttocks.

• Vernix (a thick, waxy covering to the skin)
• Milia (tiny, pearly-white, firm raised bumps on the face)
• Fine, soft hair (lanugo) that may cover the scalp, forehead, cheeks, shoulders,

and back.A nurse is working in a busy urban emergency department. The following clients have a right to be informed about all aspects of their care and to participate in making decisions about that care.

• A 17-year-old female client who presents with a positive

pregnancy test and vaginal bleeding

• A 60-year-old client with hypertension, diabetes, and

chest pain who is seen in an urgent care setting

• A 40-year-old client with peritonitis admitted to the ICU

with impending respiratory failure requiring urgent intubation and mechanical ventilation

• An 89-year-old client with multi-infarct dementia and

pneumonia who is disoriented to place and time A client who is cognitively impaired retains their client rights, but a surrogate may be designated to act on the client's behalf to exercise those rights in the client's interest.

• for example. An 34-year-old client with severe mental illness who has been

ruled incompetent and is a ward of their parents

A nurse is placing a peripheral intravenous catheter. The following are measures that can reduce the risk of a catheter-related infection.

• Clean the site with 70% alcohol solution or

chlorhexidine by rubbing vigorously back and forth over the insertion site in the venous flow direction. Scrub for 30 seconds and allow to dry for at least 30 seconds.

• Apply an occlusive transparent dressing over the site

after insertion. Securely tape the hub

• inspected at least every 8 hours and the catheter should

be replaced if signs of infection.

• Remove the catheter no more frequently than every 72-

96 hours (and if necessary).If there is excessive hair at the insertion site, it can be clipped. Shaving is not recommended.Clean gloves are used when inserting a peripheral IV catheter, but central venous catheters and arterial lines require sterile gloves. Hand hygiene must be performed before and after palpation of the site and before and after insertion of the catheter.A nurse is preparing to assist in a surgical procedure. The following steps are in the correct order for performing a surgical scrub.

• Open the scrub brush package.
• Moisten the surgical brush.
• Wet the hands and arms thoroughly.
• Scrub the nails, fingers, hands, wrists, and forearms.
• Rinse the soap from hands and arms.
• Turn off the water and discard the brush.
• Hold the hands away from the body with the hands

above the level of the elbows.A nurse is preparing for a head to toe assessment. The following are the correct order of the steps for performing a pupillary light reflex test during a vision screening.

• Observe the client's eyes to determine if the pupils are

equal

• Shine a penlight into the client's right eye to constrict

the pupil

• Check the left eye to see if it constricts equally
• Remove the light and observe the pupils for dilation.
• Repeat the procedure on the left eye.

Both pupils should constrict briskly when a light source is applied to one eye.Abnormalities can be caused by a mass effect in the brain with rising intracranial pressures. A fixed and dilated pupil can indicate uncal herniation or compression of the third cranial nerve.A nurse is caring for a client who is receiving a tube feeding and develops diarrhea, cramps, and abdominal distention. The following interventions are most appropriate.

• Change the feeding apparatus every 24 hours
• Slow the administration rate
• Use a diluted formula, gradually increasing the volume

and concentration

• Anticipate changing to a lactose-free formula

About 50% of diarrhea in clients receiving tube feedings is caused by sorbitol- containing medications. The nurse should assess for other possible causes.Other medications that may cause diarrhea include those containing magnesium, nonsteroidal anti-inflammatory drugs, histamine 2 blockers, proton pump inhibitors, and antibiotics.Diarrhea is defined as > 200 mL of stool per 24 hours.

A nurse is caring for an elderly client with rheumatoid arthritis. The following are instructions the nurse should provide.-A warm bath or shower upon arising or at bedtime and application of warm, moist compresses to affected joints several times a day promotes muscular relaxation, reduces pain, and relieves morning stiffness. Gentle massage may also promote relaxation.

- Common symptoms of RA are: pain and swelling in

fingers and toes, sleep disturbance, fatigue, painful or swollen joints, altered mood, and limited mobility.

• A firm mattress or bedboard is preferable to a soft

mattress to keep the body in alignment.

• Elevation of bed linens with bed cradle reduces

pressure on painful joints.The nurse should first focus on relieving pain; then on preventing joint deformity; next, work on preserving joint function; and last, maintaining usual ways of accomplishing tasks, or teaching the client how to accomplish tasks if new ways are necessary.Current RA treatment recommendations focus on early aggressive therapy. For example, clinicians should initiate DMARDs (preferably methotrexate) immediately after diagnosis, with the goal of achieving remission or low disease activity.Methotrexate is associated with hepatotoxicity and bone marrow suppression.A charge nurse is teaching a group of new staff members about hepatitis B. The following are instructions the nurse should include in the teaching.

• After a needle stick, administer Hepatitis B vaccine and

hepatitis B immune globulin as post-exposure prophylaxis for all unvaccinated individuals.- A neonate develops hyperbilirubinemia and phototherapy is initiated. The following are actions the nurse should include in the plan of care for an infant receiving phototherapy.

• Give additional fluids every two hours, because

insensible and intestinal fluid losses increase during phototherapy; extra fluids prevent dehydration.

• The eye shields should be on the baby whenever she is

under the phototherapy lights.

• The baby should not be covered with a blanket; this

prevents the phototherapy lights from reaching the skin.Unconjugated bilirubin is a neurotoxin that can cross the blood-brain barrier, leading to significant brain damage. Phototherapy treatment for jaundice is performed by exposure of skin to a light source, which converts unconjugated bilirubin molecules into water-soluble molecules that can be excreted by in urine and stool.

Symptoms of rubeola generally include:

• A high fever, photophobia, and Koplik's spots (white

patches on the mucous membranes in the mouth).

• Clinical manifestations include fever, and cough,

followed by a generalized rash

• The rash associated with rubeola often starts on the

face and moves downward over the body.

• Rubeola may include nasal congestion and other cold

symptoms.- Rubeola, or measles, is a viral illness that results in a viral exanthem, which refers to a rash or skin eruption.

A nurse is teaching a new graduated nurse about an anaphylactic reaction. The following the nurse should include n the teaching.

• Anaphylaxis is a life-threatening immune reaction to a

foreign antigen. Common antigens that cause anaphylactic response are found in peanuts, shellfish, certain medications such as antibiotics, and latex products.

• Signs and symptoms of anaphylaxis include

angioedema, dyspnea, hives, flushing, back pain, and feelings of impending doom.

• The first priority when examining the client is to assess

the client's airway, breathing, circulation, and level of consciousness.

• The second priority may be administer epinephrine.

A nurse is caring for a client with a diagnosis of nephrotic syndrome. The nurse should provide the following teaching to the client.

• Expect a decreased serum protein.

A decreased total serum protein occurs as extensive amounts of protein are excreted from the body through the urine. Clients may develop hypocalcemia.

• Key laboratory findings in nephrotic syndrome include

albuminuria (protein in the urine); hyperlipidemia; hypoalbuminemia (low serum albumin); and edema.A nurse is caring for a client who was just admitted to the emergency department with a severe burn injury. The following are appropriate interventions the nurse should take.

• Question an order for potassium supplementation.

Potassium is the major intracellular cation and it is released by damage to cells, increasing the serum potassium concentration. Supplementation of potassium in clients who have sustained burns can result in toxic levels.

• Plasma expanders are given with lactated Ringer's,

water, and dextrose solutions depending on client needs.