ATI Extra

Pregnant Clients with a BMI greater than 30 should plan to gain

5-9.1 kg (11-20 lb)

Pregnant clients with a phi of 25-29.9 should plan to gain

6.8 to 11.3 kg (15-25lb)

Peak of PO morphine

60 to 90 minutes

A patient in active labor experiencing hypotension following epidural placement

Increase fluids Give 10-12 L of oxygen Place client in a lateral position Administer a vasopressor to increase maternal blood pressure

Values for a child with nephrotic syndrome

Increased platelets Decreased Sodium Increased cholesterol levels

RIFLE: No urine output without renal replacement therapy for more than 3 months

Indicated end stage kidney disease

RIFLE: No urine output for 12 hr

Indicated failure

RIFLE: No urine output without renal replacement therapy for 4-12 weeks

Indicates Loss

RIFLE: <0.5 mL/kg of urine output for 12 hrs

Indicates injury

Moro Reflex

Infant reflex where a baby will startle in response to a loud sound or sudden movement. Gone at 3-4 months

Breathing techniques for a client with emphysema : Pursed lip breathing

"When I breath out through pursed lips, my airways don't collapse between breaths" The client should first inhale slowly through the nose then exhale slowly through pursed lips, sitting or walking with tightened abdominal muscles

Injury to temporal lobe

- difficulty understanding language and speaking - difficulty recognizing faces - difficulty identifying/ naming objects - problems w/ short and long term memory - changes in sexual behavior - increased aggressive behavior

IV solution for hypovolemic shock

.9% sodium chloride

Pregnant Clients with a BMI of 18.5 to 24.9 should plan to gain

11.3 to 15.9 (25-35lb)

Pregnant Clients with a BMI less than 18.5 should plan to gain

12.7 to 18.1kg (28-40lb)

Vocab of 10 or mote words

18 months

Follow and complete simple commands

2 years old

State name/ refer to self by name

2 years old

When and how to screen for congenital heart disease in infants

24 to 48 hrs after birth with a pulse oximeter If the nurse performs the screening prior to 12 hrs after birth acrocyanosis might alter the results

Name a color

30 months/ Toddler

Client with SLE taking prednisone should monitor for

Infection, Hyperglycemia, Myopathy, weight gain

Premature infant risk

Intraventricular hemorrhage , Hypoglycemia, hypothermia

A nurse at a pediatric clinic is assessing a 5- mouth- old infant during a well-child visit. Which of the following findings should the nurse report to the provider? A.) Head lagging when the infant is pulled from a lying to a sitting position B.) Absence of startle and crawl reflexes C.) Inability to pick up a rattle after dropping it D.) Rolling a from back to side

A.) Head lagging when the infant is pulled from a lying to a sitting position At the age of 5 month, the infant should have no head lag when pulled to a sitting position: therefore the nurse should report this finding to the provider

A nurse is caring for a client who is experiencing an acute gout attack. The nurse should anticipate a prescription from the provider for which of the following medications? A.) Naproxen B.) Pegloticase C.) Probenecid D.) Allopurinol

A.) Naproxen NSAIDS are first choice treatment for reliving the manifestations of an acute gout attack Pegloticase is IV therapy for Chronic gout Probenecid can exacerbate an acute gout attack Allopurinol is the medication of choice for clients who have chronic tophaceous gout

Buspirone

Antianxiety

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following examples should the nurse use to illustrate a suggestive finding? A.) Bruising of both knees with sutures on 1 B.) Arm cast for a spiral fracture of the forearm C.) Consistent bedwetting at nap time D.) Frequent, vague reports of a stomachache or a headache

B.) Arm cast for a spiral fracture of the forearm Spiral fractures occur from the twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury

A nurse is caring for a client who is In labor and received meperidine for pain 1 hr ago. Which of the following should the nurse take? A.) Assess the clients reflexes B.) Assess the newborn for respiratory depression C.) Assess the client for bradycardia D.) Assess the newborn for signs of opiate withdrawal

B.) Assess the newborn for respiratory depression Meperidine should not be giving to clients who are expected to deliver within 4 hrs of medication administration. The medication crosses the placenta and causes respiratory depression in the newborn which peaks 2-3 hrs after administration. Narcan is ineffective in reversing Meperidine can cause tachycardia, nausea, vomiting , dizziness and altered mental status

A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? A.) Pallor B.) Jaundice C.) Absence of hair on legs D.) Poor nailed capillary refill

C.) Absence of hair on legs Indicates poor arterial circulation to that area. Pallor can indicate hematologic disorders but pigment loss is common with aging and can also indicate anemia. Jaundice can indicate hyperbilrubinmia but is also common with aging Nail beds can indicated arterial insufficiency but are common with aging

Medication risk for hearing loss

Chronic us of salicylates

Expected findings of continuous ambulatory peritoneal dialysis

Clear pale yellow drainage, abdominal fullness (A low flowers position can reduce the pressure)

RAST testing for season allergies

IgE

Grandiose Delusion

a person's false belief that he or she possesses great wealth, intelligence, or power

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction A.) Sudden hemoptysis B.) Acute diarrhea C.) Frontal headache D.) Acure Confusion

D.) Acute confusion Manifestations of MI in clients 65 and older include acute confusion, nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpations and fatigue. Hemoptysis indicates GI bleed Diarrhea indicates gastroenteritis Frontal headache indicates fluid overload

Injury to the frontal lobe

Difficulty making decisions and situational reactions

Injury to the brainstem

Difficulty with respiratory effort

Side effect of baclofen

Muscle weakness, dizziness, drowsiness and nausea Hypotension, constipation, increased sweating

Autonomic dysreflexia

Neurological emergency in clients that have a spinal injury above T6 Can be triggered by a full bladder or distended rectum Flushing above injury (at face & neck), pallor below Hypertension Bradycardia Headache

If an infants temp is low you should

Obtain their glucose levels Infants who become cold attempt to generate heat through increased muscular and metabolic activity. this process increases glucose consumption and puts the newborn at risk of hypoglycemia

Adverse effect of cisplatin

Ototocicity which can cause tinnitus

Adverse effect of naloxone

Pain, cardiac manifestations, nausea and vomiting

Client on warfarin

Should carry a medical alert ID card as they are at an increased risk for bleeding Avoid aspirin and ibuprofen PT and INR labs daily the first 5 days and then twice weekly for 1-2 weeks Avoid food with vitamin K : Dark leafy vegetables

Injury to the hypothalamus

Difficulty with temperature control

Signs of increased ICP

Hypertension, bradycardia, widening pulse pressures (Pt. with icp should be hyperventilated) Dialted pupils

A stage 3 pressure ulcer will heal by

Secondary intention

Osteomalacia/rickets

Vitamin D deficiency

Wrinkle Korsakoff Syndrome

Will exhibit neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor, dipole, and memory loss. Result of alcohol use disorder

Menieres disease

disorder of inner ear causing vertigo, tinnitus, and hearing loss

Somatic Delusion

false belief that one's appearance or part of one's body is diseased or altered

spondylolisthesis

forward slipping of one vertebra over another

nephrotic syndrome

group of clinical signs and symptoms caused by excessive protein loss in urine

Placenta Previa

implantation of the placenta over the cervical opening or in the lower region of the uterus Painless, bleeding The fundal height measures greater than gestational age

glomerulonephritis

inflammation of the glomeruli of the kidney Perioribital edema, elevated blood pressure

diabetes insipidus (DI)

insufficient secretion of antidiuretic hormone (vasopressin) Dry inside Polydipsia and polyuria Increased thirst and urination -Large amounts of urine with a very low specific gravity

Elevated AST and ALT

liver disease/ Hepatic toxicity

macular degeneration

progressive damage to the macula of the retina Loss in the center of the visual field

Common side effects of Buspirone

Dizziness, tachycardia, palpations, drowsiness

Infant contraindications for breastfeeding

Galactosemia -Cannot metabolize lactose

angle closure glaucoma

Rapid onset of elevated IOP -Emergency, severe pain around the eyes and face, reduced vision, colored halos, headaches

Manifestations of renal toxicity

Polyuria and proteinuria

Moderate Dehydration in an infant

Tachypnea, flat or sunken fontanel, increased hr, decreased urinary output

Extrusion Reflex

Thrusting tongue movements that automatically push food out of the mouth Absent by 4 months

A nurse is caring for a client who has a new diagnosis of oral candidiasis after taking tetracycline for 7 days. The nurse should recognize that candidiasis is a manifestation of which of the following adverse effects? A.) Allergic Response B.) Superinfection C.) Renal Toxicity D.) hepatoxocity

B.) Superinfection A superinfection can develop from fungal overgrowth due to the antibacterial effect of tetracycline. Manifestations include soreness of mouth and a swollen tounge While tetracycline can cause hepatotoxicity manifestations include jaundice not oral candidiasis

A nurse is developing a plan of care for a client who has alcohol use disorder. Which of the following medications should the nurse plan to administer? A.) Methadone B.) Varenicline C.) Buprenorphine D.) Diazepam

D.) Diazepam Used to minimize manifestations Methadone and buprenorphine for opioid use Varenicline for nicotine withdraw

How to administer eye drops

Drop the eye medication into the lower conjunctival sac to avoid placing the drops on the cornea and causing damage. Gental pressure should be applied for 30-60 seconds at the nasolacrimal duct. The dropper should be help 1 to 2 cm from the lower conjunctival sac to protect the cornea of the eye

Babinski reflex

Reflex in which a newborn fans out the toes when the sole of the foot is touched Present until 1 year Persistence might indicate neurological deficits

Omeprazole

Should be taken no more than 1-2 months, take in the morning before breakfast, adverse effects including diarrhea nausea/ vomitting and headaches

Postpartum contractions

The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract

Cataract

clouding of the lens of the eye

Indication of progestin deficiency

amenorrhea A client who takes a combination OC and has a progestin deficiency can have amenorrhea. Increasing the OC dose of progestin can result in a more regular menstrual cycle.

A nurse is assessing a client who is receiving a transfusion of packed red blood cells. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? A.) Severe hypertension B.) Low body temperature C.) Sudden Oliguria D.) Decreased Respirations

C.) Sudden Oliguria This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. Along with hypotension, fever and tachypnea

reference delusion

belief that certain gestures, comments are directed towards them or because of their personal actions

Persecutory delusions

beliefs of being targeted by others

A nurse is assessing an older adult client. Which of the following findings should the nurse report to the provider. A.) Decreased cough reflex B.) Decreased urinary bladder capacity C.) Decreased sebum production D.) Decreased spinal column Movement

D.) Decreased spinal column movement: An onset of lower back tenderness and restricted spinal column movement which can indicate a compression fracture due to osteoporosis -A decreased cough reflex is a physiological change that can occur with aging. This change can increase the clients risk of infections such as pneumonia and bronchitis

A nurse is caring for a client who is 12 hrs post following a Toal hip arthroplasty. Which of the following medications should the nurse anticipate administering to the client to prevent deep vein thrombosis (DVT) A.) Aspirin B.) Warfarin C.) Ticagrelor D.) Enoxaparin

D.) Enoxaparin ----Warfrain has a delayed onset is prescribed for long term prophylaxis

Manifestations of hypertension

Epistaxis (nosebleed) Headache, dizziness, facial flushing, fainting

DTaP Immunization

Give first at 2 months, then at 4 and 6 moths, 15-18 months and 4-6 years old

How to provide cast itching relief

Hair dryer on a cool setting or an empty 60mL plunger syringe

Manifestations of bladder trauma

Hematuria, blood loss at the urinary meatus, pelvic pain, anuria

aPTT monitors

Heparin therapy

A surgical incision will help by

Primary intention

Stepping Reflex

Reflex that causes newborn babies to make little stepping motions if they are held upright with their feet just touching a surface Disappears by age of 4 weeks

Risk factor for necrotizing enterocolitis (NEC) in newborns

Respiratory distress syndrome Preterm birth Low birth weight and intrauterine growth restriction Asphyxia, gastrointestinal infection, polycythemia

Iatrogenic HAI

Result from diagnostic or therapeutic procedures -Infection acquired from a diagnostic procedure

When should you not give varenicline

The client has a history of depression Varenicline can cause mood changes and thoughts of suicide

Indomethacin

tocolytic for preterm labor