ATI COMPREHENSIVE PREDICTOR
what to check with pregnancy - Never check the monitor or machine as a first action. Always assess the patient first. Ex..
... [Show More] listen to fetal heart tones with stethoscope.
Position of the baby by fetal heart sounds - Posterior --heard at sides
Anterior---midline by unbilicus and side
Breech- high up in the fundus near umbilicus
Vertex- by the symphysis pubis.
Ventilatory alarms - HOLD
High alarm--Obstruction due to secretions, kink, pt cough etc
Low alarm--Disconnection, leak, etc
ICP and Shock - ICP- Increased BP, decreased pulse, decreased resp
Shock--Decreased BP, increased pulse, increased resp
Cor pumonae - Right sided heart failure caused by left ventricular failure (edema, jugular vein distention)
Heroin withdrawal neonate - irritable, poor sucking
brachial pulse - pulse area on an infant
lead poisoning - test at 12 months of age
Before starting IV antibiotics - obtain cultures!
pt with leukemia may have - epistaxis due to low platelets
when a pt comes in and is in active labor - first action of nurse is to listen to fetal heart tones/rate
for phobias - use systematic desensitization
NCLEX answer tips - 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.
ARDS and DIC - are always secondary to another disease or trauma
In an emergency - patients with a greater chance to live are treated first
Cardinal sign of ARDS - hypoxemia
Edema is located - in the interstitial space, not the cardiovascular space (outside of the circulatory system)
the best indicator of dehydration? - weight---and skin turgor
heat/cold - hot for chronic pain;
cold for accute pain (sprain etc)
When pt is in distress....medication administration - is rarely a good choice
pneumonia - fever and chills are usually present. For the elderly confusion is often present.
before IV antibiotics? - check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose.
COPD and O2 - with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe.
Prednisone toxicity - Cushings (buffalo hump, moon face, high blood sugar, HTN)
Neutropenic pts - no fresh fruits or flowers
Chest tubes are placed - in the pleural space
Preload/Afterload - Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart.
CABG - Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart.
Unstable Angina - not relieved by nitro
RBC - females 4.2-5.4 million
males 4.7-6.1 million
decrease RBC - anemia
WBC - 5,000-10,000
elevated WBC - infection
decreased WBC - immunosuppression
Iron - females 60-160 mcg
males 80-180
elevated iron - hemochromatosis, iron excess
liver disorder, magaloblastic anemia
decreased iron - anemia or hemorrhage
platelets - 150,000-4000,000
increased platelets - malignancy or polycythemia vera
decreased platelets - autoimmune disease
bone marrow suppression or enlarged spleen
Hbg - females 12-16
males 14-18
decrease Hgb and Hct - anemia
Hct - females 37%-47%
males 42-52%
anemia in children
S & SX: - pallor, brittle spoon shaped nails
irritability, muscle weakness
systolic heart murmur, enlarged heart, HF
iron supplements - give 1 hr before or 2 hr after antacid to prevent malabsorpt
N/D and constipation common at start of therapy
use straw for liquid iron to prevent staining of teeth
aPTT - 1.5-2X control range of 30-40 seconds
test clotting factors and monitor heparin therapy
increased aPTT - hemophilia
disseminated intravascular coagulation DIC
liver disease
PT - 11-12.5 seconds, 85-100%
increased PT time - evidence of deficiency or clotting
decreaed PT time - evidence of vit K excess= bleed out
acute hemolytic blood transfusion reactions - **low back pain, TACHYcardia, HYPOtension [Show Less]