2023 Virtual ATI Comprehensive Predictor Assessment New, Exams of Nursing

Download 2023 Virtual ATI Comprehensive Predictor Assessment New and more Exams Nursing in PDF only on Docsity! 2023 Virtual ATI Comprehensive Predictor Assessment New Latest Version Updated with All Questions and Answers Best Studying Material Delegation for effective task management. -------- Correct Answer --------- A nurse is responsible for providing clear directions when a task is initially delegated and for periodic reassessment and evaluation of the outcome of the task. RNs must delegate tasks so that they can complete higher level tasks. RNs may delegate to other RNs, PNs or APs. PNs may delegate to other PNs or APs. Predictability of outcome: Is this routine, or is this new, is there potential for complications Potential for harm: Is the client stable? Risks? Aspiration, Bleeding Complexity of Care: Does the delegatee have the license to perform the task, and the training? Need for problem solving: Does this require the nursing process? Assessment skills or judgment Level of client interaction: Is there psychosocial support needed? TO PN -------- Correct Answer --------- Monitoring findings Reinforcing client teaching Tracheostomy Care Suctioning NG tube patency Enteral Feedings Insert Catheter Administering Meds TO AP -------- Correct Answer --------- ADLs Bathing, Grooming, Dressing, Toliet Ambulating Feeding Positioning Routine tasks Bed making Specimen Collection, I and Os Vitals For stable clients Concepts of management—Strategies to identify solutions to community health problems -------- Correct Answer --------- Planning Organizing: Controlling: Directing: Staffing: Planning: -------- Correct Answer --------- What needs to be done, and who is going to do it Organizing: -------- Correct Answer --------- Lines of authority, communications, and where decisions are made Directing: -------- Correct Answer --------- Influences and motivates people to perform Controlling: -------- Correct Answer --------- The evaluation of performance and unit goals to ensure outcomes are met Staffing: -------- Correct Answer --------- Adequate staffing, and staffing mix Characteristics of managers: -------- Correct Answer --------- Hold formal positions of authority and power, Possess clinical expertise, Network with members of the team, Coach subordinates, Make decisions for the organization: Resources, Budget, Hiring, and Firing Conflict Management between health care workers -------- Correct Answer --------- Autonomy: -------- Correct Answer --------- The ability of the client to make personal decisions, even when those decisions might not be in the client's own best interest Beneficence: -------- Correct Answer --------- Care that is in the best interest of the client Fidelity: -------- Correct Answer --------- Keeping one's promise to the client about care that was offered Justice: -------- Correct Answer --------- Fair treatment in matters related to physical and psychosocial care and use of resources Nonmaleficence: -------- Correct Answer --------- The nurse's obligation to avoid causing harm to the client Veracity: -------- Correct Answer --------- The nurse's duty to tell the truth Examples when an incident report should be filed: -------- Correct Answer --------- Medication errors, Procedure/treatment errors, Equipment related injuries/errors, Needlestick injuries, Client falls, Visitor/Volunteer injuries, Threat made to client or staff, Loss of property. Necessary Loss: -------- Correct Answer --------- A loss related to a change that is part of the cycle of life Actual Loss -------- Correct Answer --------- : Any loss of a values person, item or status Perceived loss: -------- Correct Answer --------- Any loss that is not obvious to others Maturational or developmental loss: -------- Correct Answer --------- Any loss expected of life. (Child leaving for college) Situational loss: -------- Correct Answer --------- Any unanticipated loss caused by an external event (home loss by tornado) Anticipatory loss: -------- Correct Answer --------- Experienced before the loss happens Stages of grief -------- Correct Answer --------- Denial, Anger, Bargaining, Depression, Acceptance. Advance directives: -------- Correct Answer --------- Legal documents that direct end of life issues Living Will: -------- Correct Answer --------- Directive documents for medical treatment per the client's wishes Health Care Proxy/Durable Power attorney: -------- Correct Answer --------- A document that appoints someone to make medical decisions when the client is no longer able to do son on his own behalf. Rest and Sleep—Promoting Sleep Factors that interfere with sleep -------- Correct Answer --------- Illness: Can require more sleep or disrupt sleep Current life events: Traveling or work hours change Emotional stress: Anxiety, fear, grief Diet: Caffeine consumption, heavy meals before bedtime Exercise: Promotes sleep if at least 2 hours before bedtime Fatigue: Exhausting or stressful work makes falling asleep difficult Sleep environment: Too light, wrong temp or too noisy Medications: Some can induce sleep, some can interfere Bedtime routine, Limit waking clients, Promote quiet, Help with hygiene, CPAP, Sleep products Limit alcohol, caffeine and nicotine at least 4 hours before bedtime. Limit fluids 2-4 hours before bed time Engage in muscle relaxation if anxious or stressed Narcolepsy -------- Correct Answer --------- Exercise regularly, Eat small meals high in protein, Avoid sitting too long/warm environments /alcohol, Avoid accidents, driving or heights, Take naps when drowsy, Take stimulants Medication effecting urinary output Indications for use of diuretics -------- Correct Answer --------- Management of blood pressure Excretion of edematous fluid related to heart failure, Kidney and Liver disease Prevention of kidney failure Emergency Response Plan -------- Correct Answer --------- Facility Protocols: Appropriate client for discharge in event of community disaster First discharge or relocate ambulatory clients requiring minimal care. Next, make arrangements for continuation of care for clients who require some assistance which could be provided in the home or tertiary care facility Do not discharge or relocate clients who are unstable of require continuing nursing care and assessment unless they are in imminent danger. Discharge on the fact that some will likely be able to stay Handling Hazardous and Infectious materials Cancer treatment options: Implanted internal radiation device -------- Correct Answer ---- ----- Follow protocol for proper removal of dressings and bed linens from the room Waste products should not be touched by anyone Place the client in a private room and keep the door closed as often as possible Place a radiation warning sign on the door Wear a dosimeter film badge that records personal amount of radiation expose Pregnant nurses or children should not come into contact with the client or radiation source Limit visitors to 30 min visits and maintain 6 feet from the source Wear a lead apron while providing care keeping the front of the apron facing the radiation source Keep a lead container in the client's room if the delivery method could allow spontaneous loss of radioactive material. Tongs should be available for placing material into this container Brachytherapy: -------- Correct Answer --------- This can be placed in vagina, abdomen or IV with radionuclide iodine which is absorbed by the thyroid. Standard Precautions---- -------- Correct Answer --------- 1. All body fluids, except sweat 2. Nonintact skin and mucous membranes 3. These apply to all clients regardless of condition 4. If hands are not viably soiled alcohol hand rub should be used 5. Antimicrobial soap should be used if hands are soiled or contaminated with spores 6. Remove gloves and complete hand hygiene between each client 7. Masks, eye protection, and face shields are required when care might cause splashing or spraying of body fluids 8. This client does not require a private room unless they are unable to maintain appropriate hygienic practices Isolation Guidelines: -------- Correct Answer --------- 1. Hand hygiene and the use of barrier precautions 2. These precautions apply to every client, regardless of the diagnosis 3. Change PPE after contact with each client and between procedures with the same client, if in contact with large amounts of blood or blood fluids (compromising the PPE) 4. Higher risk for loneliness explain the reason for isolation and provide sensory stimulation Airborne Precautions -------- Correct Answer --------- 1. Private room 2. Masks and respiratory protections (N95 for TB) 3. Negative pressure airflow exchange of at least 6-12 exchanges per hour 4. If splashing or spraying is possible wear full face protection 1. -------- Correct Answer --------- Private room Droplet Precautions -------- Correct Answer --------- 1. A private room or room with clients with the same disease a. Ensure that clients have their own equipment 2. Masks for providers and visitors Contact Precautions -------- Correct Answer --------- 1. A private room or room with the same illness 2. Gloves and gown worn by caregivers, and visitors 3. Disposal of infectious dressing material into a simple non porous bag without touching the outside of the bag. Vector based Transmission: -------- Correct Answer --------- Animals or insect's transmission: Ticks ---Lyme disease, Mosquitoes--- West Nile and Malaria Post-Partum Physiological Adaptations Pertussis booster recommendations -------- Correct Answer --------- This vaccine is recommended for women who have not previously received it. Administration prior to discharge or ASAP in the post-partum period is recommended Skin infections/infestations Expected findings of pediculosis capitits -------- Correct Answer --------- Intense itching, Small, red bumps on the scalp, Nits (White specks on the hair shaft) Use of restraints/ Safety Devices Place pressure on the inner corner of the eye Medication Administration Bipolar: Teaching about mood stabilizers -------- Correct Answer --------- 1. Monitor plasma lithium levels during treatment, at least 5 days after starting and after any dosing changes until therapeutic level has been achieved then every 1 to 3 months 2. Blood for monitoring should be obtained in the morning usually 12hrs after the last dose 3. Maintenance level range is between 0.4 and 1.0, Greater than 1.5 can be toxicity 4. Hemodialysis may be indicated for toxic lithium levels 5. Monitor CBC, serum electrolytes, renal function tests, and thyroid function tests 6. Advise clients to take lithium as prescribed 7. Taking lithium with food can help decrease gastric distress 8. Advise clients that effects take 7 to 14 days 9. Encourage clients to adhere to lab appts 10. Emphasize the high risk of toxicity due to the narrow therapeutic range 11. Provide nutritional counseling, Stress the importance of adequate fluid and sodium intake 12. Instruct clients to monitor for manifestations of toxicity and when to contact the provider 13. Clients should withhold medication and seek medical attention if experiencing diarrhea, vomiting or excessive sweating 14. Conditions that cause dehydration such as exercising in hot weather, or diarrhea, put client at risk for lithium toxicity Intravenous Therapies Assessing the IV site -------- Correct Answer --------- Infiltration or extravasation Pallor, local swelling at the site, decreased skin temperature around the site, damp dressing, slowed rate of infusion Phlebitis or thrombophlebitis Edema, throbbing, burning or pain at the site, increased skin temperature, erythema, a red line up the arm with a palpable band at the vein site, slowed rate of infusion Hematoma Ecchymosis at the site Fluid overload Distended neck veins, increased blood pressure, tachycardia, SOB, crackles in the lungs, edema, additional finding varying with the IV solution Cellulitis Pain. Warmth edema, induration, red streaking, fever, chills, malaise Catheter embolus Missing catheter tip on removal, severe pain at the site with migration, absence of findings if no migration Hematoma -------- Correct Answer --------- Ecchymosis at the site Fluid overload -------- Correct Answer --------- Distended neck veins, increased blood pressure, tachycardia, SOB, crackles in the lungs, edema, additional finding varying with the IV solution Cellulitis -------- Correct Answer --------- Pain. Warmth edema, induration, red streaking, fever, chills, malaise Catheter embolus -------- Correct Answer --------- Missing catheter tip on removal, severe pain at the site with migration, absence of findings if no migration Pharmacological Pain Management Post-operative nursing care: Prevention of complications -------- Correct Answer --------- Some complications of surgery are -------- Correct Answer --------- 1. Hypovolemic shock 2. Paralytic ileus 3. Wound dehiscence or evisceration 4. Deep vein thrombosis 5. Airway obstruction 6. Hypoxia 1. -------- Correct Answer --------- Hypovolemic shock 2. -------- Correct Answer --------- Paralytic ileus 3. -------- Correct Answer --------- Wound dehiscence or evisceration 4. -------- Correct Answer --------- Deep vein thrombosis 5. -------- Correct Answer --------- Airway obstruction 6. -------- Correct Answer --------- Hypoxia Airway Obstruction -------- Correct Answer --------- Swelling or spasm of the larynx or trachea, mucus in the airway or relaxation of the tongue into the nasopharynx Nursing Considerations: for airway obstruction -------- Correct Answer --------- Monitor for choking, noisy irregular respirations, decreased ox stats, cyanosis Implement a head tilt, chin lift, to open the airway Keep emergency equipment at the bedside in the PACU Notify the anesthesiologist, elevate head of bed if not contraindicated, provide oxygen, and plan for reintubation with endotracheal tube Hypoxia -------- Correct Answer --------- Decrease in ox stats Nursing Considerations: Monitor ox stat and admin ox as prescribed Encourage coughing and deep breathing to prevent atelectasis Position client with head of bed elevated and turn every 2hr to facilitate chest expansion Decrease in ox stats -------- Correct Answer --------- Nursing Considerations: Monitor ox stat and admin ox as prescribed -------- Correct Answer --------- Encourage coughing and deep breathing to prevent atelectasis -------- Correct Answer -- ------- Position client with head of bed elevated and turn every 2hr to facilitate chest expansion -------- Correct Answer --------- Hypovolemic shock -------- Correct Answer --------- Post op shock can result from a massive loss of circulating blood volume Nursing Considerations: Monitor for decreased blood pressure and urinary output, increased heart and respiratory rates, narrowing of pulse pressure, and slow cap refill Administer oxygen Place the client in a supine position with legs elevated Administer IV Fluids and vasopressors as prescribed Post op shock can result from a massive loss of circulating blood volume -------- Correct Answer --------- Nursing Considerations: -------- Correct Answer --------- 100kcal/kg/day for 3-6 months Breast milk and formula provide 20kcal/oz Carbos should make up 40-50% of the newborn's total caloric intake. Lactose is the most abundant carb in breast milk and formula At least 15% of calories must come from fat Protein: 2.25 to 4 g/kg/day Solids should not be introduced until 6 months of age Newborns should be breastfed every 2-3hrs Awaken the newborn at least every 3hrs, during the day and every 4hrs at night Breastfeeding should occur 8 to 12 times within a 24hrs window Monitor lochia for color, amount. Consistency and odor, -------- Correct Answer --------- Monitor Vital signs, Encourage Breastfeeding, Early and frequent ambulation, Frequent Voiding -------- Correct Answer --------- D&C can be necessary to remove retained placental fragments -------- Correct Answer -- ------- Inversion of the uterus -------- Correct Answer --------- Assess for an inverted uterus -------- Correct Answer --------- -------- Correct Answer --------- Visualize the introitus -------- Correct Answer --------- Perform a pelvic exam -------- Correct Answer --------- Maintain IV Fluids -------- Correct Answer --------- Administer Oxygen Stop oxytocin if it is being administered at the time uterine inversion occurred -------- Correct Answer --------- Avoid excessive traction on the umbilical cord -------- Correct Answer --------- Anticipate surgery if nonsurgical interventions and management are unsuccessful -------- Correct Answer --------- Retained Placenta -------- Correct Answer --------- Nursing Care: Monitor the uterus for fundal height, consistency, and position -------- Correct Answer --------- Monitor lochia for color, amount, consistency, and odor. -------- Correct Answer --------- Monitor vital signs -------- Correct Answer --------- Maintain or initiate IV fluids -------- Correct Answer --------- Provide oxygen at 2-3L/min per nasal cannula -------- Correct Answer --------- Anticipate surgical interventions, such as a D&C or hysterectomy, if post-partum bleeding is present and continues -------- Correct Answer --------- Lacerations and hematomas -------- Correct Answer --------- Assess Pain -------- Correct Answer --------- Visually or manually inspect the vulva, perineum and rectum for lacerations and or hematomas -------- Correct Answer --------- Assess an episiotomy for extension into a third- or fourth-degree laceration -------- Correct Answer --------- Evaluate lochia -------- Correct Answer --------- Continue to assess vital signs and hemodynamic status -------- Correct Answer --------- Attempt to identify the source of the bleeding -------- Correct Answer --------- Assess the provider with repair procedures -------- Correct Answer --------- Use ice packs to treat small hematomas -------- Correct Answer --------- Administer pain medication -------- Correct Answer --------- Encourage sitz baths and frequent perineal hygiene -------- Correct Answer --------- Health Promotion and Maintenance -------- Correct Answer --------- -------- Correct Answer --------- Development Stages + Transitions Burns: Dressing Change on a school age kid Minor Burns -------- Correct Answer --------- Stop the burning process -------- Correct Answer --------- Cover the burn with a clean cloth to prevent contamination -------- Correct Answer -------- - Cleanse with mild soap and tepid water -------- Correct Answer --------- Do not remove blisters -------- Correct Answer --------- Use antimicrobial ointment -------- Correct Answer --------- Apply dressing -------- Correct Answer --------- -------- Correct Answer --------- Nonadherent:Fine-mesh gauze -------- Correct Answer --------- Hydrocolloid: Occlusive dressing Provide Warmth -------- Correct Answer --------- Treat additional medical care -------- Correct Answer --------- Provide analgesia -------- Correct Answer --------- Check immunization status: Administer tetanus cassine if it has been more than 5 years -------- Correct Answer --------- Educate the family to avoid using greasy lostions on burns -------- Correct Answer -------- - Educate to monitor for manifestations of infections -------- Correct Answer --------- Major Burns -------- Correct Answer --------- Maintain airway and ventilation -------- Correct Answer --------- Provide humidified 100% supplemental oxygen -------- Correct Answer --------- Monitor vitals -------- Correct Answer --------- Maintain cardiac output -------- Correct Answer --------- -------- Correct Answer --------- Provide hydrotherapy Once or twice a day -------- Correct Answer --------- Use mild soap or detergent to gently wash burns, and then rinse with tepid water Encourage active range of motion during hydro therapy -------- Correct Answer --------- Monitor for cold stress and hypothermia -------- Correct Answer --------- Health promotion -------- Correct Answer --------- -------- Correct Answer --------- Disease Prevention Infection: Client assignment for pregnant personal -------- Correct Answer --------- Contagious or has an infectious disease, Any male patient taking finasteride/dutasteride (for BPH) because of the teratogenic effects, -------- Correct Answer --------- A patient with radiation or chemotherapy. -------- Correct Answer --------- Health Promotion -------- Correct Answer --------- -------- Correct Answer --------- Lifestyle Changes Contraception: Triage clients on different types of birth control IUD: -------- Correct Answer --------- Maintain effectiveness for 1-10 years -------- Correct Answer --------- -------- Correct Answer --------- Can be inserted immediately after abortion, miscarriage, childbirth and breastfeeding Contraception can be reversed with immediate return to fertility -------- Correct Answer -- ------- -------- Correct Answer --------- Does not interfere with spontaneity Safe for breastfeeding mothers -------- Correct Answer --------- -------- Correct Answer --------- Decreased menstrual pain and less bleeding Can increase the risk of PID, ectopic pregnancy and can be expelled -------- Correct Answer --------- -------- Correct Answer --------- Does not protect from STIs Risk of bacterial vaginosis, uterine perforation or uterine expulsion -------- Correct Answer --------- -------- Correct Answer --------- Must be removed in the event of pregnancy Implantable progestin: -------- Correct Answer --------- -------- Correct Answer --------- Avoid trauma to the area of implantation Effective continuous contraception for 3years -------- Correct Answer --------- -------- Correct Answer --------- Reversible Can be used by mothers that are breast feeding -------- Correct Answer --------- -------- Correct Answer --------- Does not protect against STIs Irregular and unpredictable menstruation -------- Correct Answer --------- -------- Correct Answer --------- Provide adequate fluid replacement