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ATI comprehensive predictor 1 Verified answers 2023
Typology: Exams
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APGAR -ANS Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) <>Woman in labor (un-reassuring FHR) -ANS (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! <>Infant with Spina Bifida -ANS Prone so that sac does not rupture <>Prolapsed cord -ANS Knee to chest or Trendelenburg oxygen 8 to 10 L <>Cleft Lip -ANS position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. <>FHR patterns for OB -ANS Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill <>what to check with pregnancy -ANS Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. <>Position of the baby by fetal heart sounds -ANS Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. <>Heroin withdrawal neonate -ANS irritable, poor sucking <>lead poisoning -ANS test at 12 months of age <>pt with leukemia may have -ANS epistaxis due to low platelets <>when a pt comes in and is in active labor -ANS first action of nurse is to listen to fetal heart tones/rate
<>NCLEX answer tips -ANS choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. <>1 tsp -ANS 5 mL <>1 oz -ANS 30 mL <>1 cup -ANS 8 oz <>1 quart -ANS 2 pints <>1 pint -ANS 2 cups <>1 g (gram) -ANS 1000 mg <>1 kg -ANS 2.2 lbs <>I lb -ANS 16 oz <>centigrade to Fahrenheit conversion -ANS F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 <>birth weight -ANS doubles by 6 months triples by 1 year <>early sign of cystic fibrosis -ANS meconium in ileus at birth <>hemophilia is x linked -ANS passed from mother to son <>perform amniocentesis -ANS before 20 weeks to check for cardiac and pulmonary abnormalities <>Rh mothers receive Rhogam -ANS to protect next baby <>anterior fontanelle closes by...posterior by.. -ANS 18 months, 6-8 weeks <>caput succedaneum -ANS diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days <>pathological jaundice occurs: physiological jaundice occurs: -ANS before 24 hours (lasts 7 days) after 24 hours <>placenta previa s/s
<>laparoscopy -ANS CO2 used to enhance visual. general anesthesia. foley. post-- ambulate to decrease CO2 buildup <>PTB -ANS low grade afternoon fever <>pneumonia -ANS rusty sputum <>asthma -ANS wheezing on expiration <>emphysema -ANS barrel chest <>kawasaki syndrome -ANS strawberry tongue <>pernicious anemia -ANS red beefy tongue <>downs syndrome -ANS protruding tongue <>cholera -ANS rice watery stool <>malaria -ANS stepladder like fever--with chills <>typhoid -ANS rose spots on the abdomen <>diptheria -ANS pseudo membrane formation <>measles -ANS koplick's spots <>sle (systemic lupus) -ANS butterfly rash <>pyloric stenosis -ANS olive like mass <>Addison's -ANS bronze like skin pigmentation <>Cushing's -ANS moon face, buffalo hump <>hyperthyroidism/ grave's disease -ANS exophthalmos <>myasthenia gravis -ANS descending musle weakness <>gullian-barre syndrome -ANS ascending muscle weakness <>angina -ANS crushing, stabbing chest pain relieved by nitro <>MI -ANS crushing stabbing chest pain unrelieved by nitro <>cystic fibrosis -ANS salty skin
<>DM -ANS polyuria, polydipsia,polyphagia <>DKA -ANS kussmal's breathing (deep rapid) <>Bladder CA -ANS painless hematuria <>BPH -ANS reduced size and force of urine <>retinal detachment -ANS floaters and flashes of light. curtain vision <>glaucoma -ANS painful vision loss. tunnel vision. halo <>retino blastoma -ANS cat's eye reflex <>increased ICP -ANS hypertension, bradypnea,, bradycarday (cushing's triad) <>shock -ANS Hypotension, tachypnea, tachycardia <>Lymes disease -ANS bullseye rash <>intraosseous infusion -ANS often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist. <>sickle cell crisis -ANS two interventions to prioritize: fluids and pain relief. <>glomuloneprhitis -ANS the most important assessment is blood pressure <>children 5 and up -ANS should have an explanation of what will happen a week before surgery <>Kawasaki disease -ANS (inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. <>ventriculoperitoneal shunt -ANS watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees <>3-4 cups of milk a day for a child? -ANS NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA <>MMR and varicella immunizaions -ANS after 15 months!
<>Digitalis -ANS increases ventricular irritability ----could convert a rhythm to v-fib following cardioversion <>Cold stress and the newborn -ANS biggest concern resp. distress <>Parathyroid relies on -ANS vitamin D to work <>Glucagon increases the effects of? -ANS anticoagulants <>Sucking stab wound -ANS cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a closed pneumo or tension pneumo! <>chest tube pulled out? -ANS occlusive dressing <>PE -ANS Needs O2! <>DKA -ANS acetone and keytones increase! once treated expect postassium to drop! have K+ ready <>Hirschprung's -ANS diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools <>Intussusception -ANS Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements <>laboring mom's water breaks? -ANS first thing--worry about prolapsed cord! <>Toddlers need to express -ANS independence! <>Addison's -ANS causes sever hypotension! <>pancreatitis -ANS first pain relief, second cough and deep breathe <>CF chief concern? -ANS Respiratory problems <>a nurse makes a mistake? -ANS take it to him/her first then take up the chain <>nitrazine paper -ANS turns blue with alkaline amniotic fluid. turns pink with other fluids <>up stairs with crutches? down stairs with crutches? -ANS good leg first followed by crutches(good girls go to heaven) crutches with the injured leg followed by the good leg. <>dumping syndrome? -ANS use low fowler's to avoid. limit fluids
<>TB drugs are -ANS hepatotoxic! <>clozapine, Clozaril -ANS antipsychotic anticholinergic <>clozapine s/e -ANS weight gain, hypotension, hyperglycemia, agranulocytosis <>dehydration -ANS -hypovolemia