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ATI Predictor Practice
Terms in this set (126)
-- Upper left quadrant pain (abdominal pain)
Absent bowel sounds
(indicative of paralytic ileus.
(H) amylase + (H) Lipase
Liver enzymes elevated
Glucose may be elevated - (L) insulin
N/V, jaundice, (H) WBC
: 3.5-5 (slow changes in protein)
: 23-43 (better indication of malnutrition - for acute changes in protein)
Urine Specific Gravity
Oral glucose tolerance test
: <5%; pre-diabetes: 5.7-6.4%; DM: >6.5%
: 10-15 mm Hg
: 35-45 mm Hg
: 4-7 L/min
: 0.43-2.33 mcg/mL (elevated = clot formation occurred--> pulmonary embolism occurred)
: 0% (30-170 units/L); elevated 4-6 hrs; lasts 3 days
: <0.03 ng/L; elevated @ 3hrs; lasts 7-10 days
: <0.2 ng/L; elevated @3-5hrs; lasts 14-21 days
: <200 mg/L
: 35-80 (female): 35-65 (male) -- High Desirable
: >130 mg/dL -- Low Desirable (up to 70% of total cholesterol)
: 40-160 (males); 35-135 (females); 55-220 (older adults) -- Evaluates Atherosclerosis
: 4.2-5.4 (female); 4.7-6.1 (male)
: 12-16 (females); 14-18 (males)
: 37-47 (females); 42-52 (males) (3x Hgb)
: 11-12.5 -- See clotting & vit. K
: 30-40 seconds -- Monitor for Heparin; increased if DIC, liver disease
: 2-3 on warfarin (checked with PT)
Respiratory paralysis (serious)
Depressed or absent reflexes
Depressed cardiac function
Wait 20-30 seconds between puffs
Exhale with pursed lips
Rinse mouth afterwards (to decrease chance of infection)
hold breath for 10 seconds
"feels like a
is pulled over my eye"
Causes constipation (due to decreased metabolism)
Increase nutritional intake with meals. (due to increased metabolism using up protein, lipid, and carbohydrate stores)
: Increased BP
Keep collection chamber below lungs
Weight applied to skin traction
should be 5-10 lbs max to prevent skin injury
"Apply skin barrier" to protect skin from enzyme & bile salts
Non-tunneled percutaneous central venous catheter
Place client in trendelenburg position to provide easier access to vessels & decrease risk of air embolus
Newly diagnosed Heart Failure patient
Try to walk at least 3 times a week for exercise
Need pressure bag around the solution, because pressure form an artery is greater than that of the line
-should be taken with high-fiber foods to prevent constipation
-avoid taking with milk because it interferes with absorption
Propanolol (-lol meds - Beta Blockers)
can cause bronchoconstriction
nausea and vomiting
Expect presence of one or more surgical drains
OK to use 0.9% sodium chloride.
--5% dextrose & Ringer's lactate will cause clots
--0.45% cannot use because it's hypotonic
Adverse reaction: Low back pain. Stop transfusion immediately.
--Resuscitation Phase (first 48 hrs): Fluid balance & maintain Electrolyte balance.
--Acute phase (36-48 hrs): Have adequate nutrition to maintain weight, including increased caloric intake.
--Rehabilitative phase: encourage use of affected extremity to maintain maximal limb function.
Erythrocyte Sedimentation Rate (ESR)
Inflammation marker test.
Another inflammation test is: C-Reactive Protein.
--Increase Erythrocyte Sedimentation Rate (ESR)
--Decreased Serum complement level
--Increased Globulin level
Glucose reading <300 mg/dL is improvement
Above the knee amputation and temporary prosthesis
--Have firm mattress (avoid soft mattress)
--Wear compression bandage at all times
--Keep residual limb in extension
Look for chest asymmetry
Type 1 diabetes & acute disease
Continue to take insulin at regular intervals regardless of meal
--Monitor blood glucose Q4h
--Call provider if glucose >250 mg/dL
--Notify provider if ketones present.
Keep toes and fingers open to check for blood circulation
--Crackles in lungs
--Distended neck veins
Irrigating a granulating wound
Use 30 mL syringe
Apply heat and cold to decrease joint inflammation and pain.
Left-sided heart failure
Sign: Oliguria during the day from decreased blood flow to kidneys
Right-sided heart failure
--Jugular vein distention
discontinue if pt taking Isosorbide Mononitrate.
Can cause severe hypotension
Like many antibiotics are nephrotoxic.
Look at kidney functions tests
Stage II experience: joint pain, cardiac and neurologic complications.
If not treated at this stage becomes chronic and causes arthritis, peripheral neuropathy, vasculitis, and myocarditis.
Effectiveness shows decreased viral load.
Right Hemisphere stroke
Affects visual and spatial awareness and proprioception (sense of our body's position)
--one-sided neglect syndrome
--loss of depth perception
--left hemiplegia or hemiparesis
Left hemisphere stroke
Affects language, mathematic skills, & analytic thinking
--Anxiety concerning the future
--Feelings of guilt
--Agnosia, Alexia (reading difficulty), agraphia (writing difficulty)
--depression, anger, & quickly frustrated
Diabetes Type I and traveling
--Change shoes often to decrease risk of blisters and sores.
--Limit physical activity if blood glucose <65 mg/dL
--carry insulin in insulated tote bag to protect against temperature changes
--Drink water every 2 hrs to reduce risk of dehydration
Increase ICP (signs and symptoms)
--Glasgow Coma Scale <15
--sleepiness or difficulty arousing patient
--Decerebrate and decorticate posturing
Side effect: Constipation
Bilateral pneumonia & PaO2 at 80 mm Hg
Administer oxygen per nasal cannula BEFORE High Fowler's position
removes thick mucus secretions from COPD patients w/ SOB, cough, and fatigue.
COPD patients considerations
If hypoxic, deliver O2 to 90%.
--sit up in orthopneic position, with arms resting over bed table to facilitate breathing.
Suctioning a tracheostomy patient
--Preoxygenate at least 30 seconds
--Suction pass 10-15 seconds
--Set pressure between 80-120 mm Hg
--Suction up to three times.
Transurethral Resection of Prostate (TURP) - 12-hr post procedure
Concentrated red urine with intermittent clots indicates client at greatest risk for hemorrhage.
Hormone Replacement Therapy
--Calf pain = DVT
--Numbness in arms & intense headaches= Cerebrovascular problems
--Don't miss a dose
--Antiacids reduce absorption
--Adverse Effect = N/V
--Check pulse rate before each dose
Exhibits increased muscle weakness and twitching
Postpartum, resume sexual activity
--Use water soluble gel for lubrication to prevent discomfort
--May resume sexual activity 2-4 weeks after
Cocaine use during pregnancy
Risk for Abruptio Placenta
Eat to taste
-Some food better than none
Pregnancy Lab tests
--Group B Strep (GBS) @ 35-37 wks
--3-hr glucose tolerance @ 28 wks
--Rubella Titer @ initial consult
Contraceptives and Hx of Osteoporosis
Contraceptives and Hx Cardio, breast cancer, and poor liver function
Avoid: Combined estrogen-progestin oral contraceptive
Pregnant woman, water breaks
Monitor Fetal HR
Betamethasone & preterm labor
Administered to stimulate fetal lung maturity & prevent respiratory distress
Set water heater <120 F
Vaginal deliver & breastfeeding mom
Needs additional 330 calories/day while breastfeeding
Contraction stress test
Negative: (Normal finding) within 10 min period, three uterine contractions & no decels.
Positive: (Abnormal finding) persistent and consistent decelerations on more than half the contractions. Cord or fetal head compression present.
Newborn expected findings
--Breast nodule <10mm apart
--Posterior fontanel smaller than anterior
--overlapping suture lines
--Lanugo over the shoulders
--No yellow on skin
--Void once within 24 hrs; 6-10 times/day post 4th day.
--Erythromycin in eyes within 1 hr from birth
--Vit K for clotting
--Hep B (birth + 1 mo + 6 mo) (NOT same thigh as Vit K)
Cold stress - leads to hypoxia, acidosis, and hypoglycemia (due to use of energy to establish respirations and maintain body heat)
Tx: Cold: warm slowly across 2-4 hrs; Hypoglycemia: breastfeed or formula feed.
Epigastric pain in pregnancy
Indicator of hepatic involvement and clinical manifestation of severe preeclampsia
Biophysical profile for mother in 3rd trimester
Includes Amniotic fluid index
Neonatal sepsis signs
Gonorrhea during pregnancy
Risk for Premature rupture of membranes
Preeclampsia during pregnancy
Risk for Proteinuria
Late Decelerations during labor at 38 weeks.
Specify order of steps to follow
A. Reposition client on her side
B. Elevate her legs
C. Increase maintenance IV fluids
D. Palpate uterus to assess tachysystole
E. Administer Oxygen via face mask @ 8L/min
Client in labor and reports back pain with right occiput posterior position
Apply sacral counterpressure
Hypoglycemia signs in newborn
Jitteriness, twitching, weak high-pitched cry, irregular respiratory effort, cyanosis, lethargy, eye rolling, seizures, blood glucose level <40
Sudden onset of fever, chills, body aches, and unilateral breast pain with tenderness
Nurse notices urticaria, dyspnea, anxiety, and SOB
Administer Epinephrine to induce vasoconstriction & bronchodilation
Ergotamine sublingual for migraine headaches
Take one table at onset of migraine.
Up to 3 tablets/day
--Monitor signs of infection such as fever
Reversal agent for Benzodiazepine Toxicity
Narcan & Naloxone
Reversal agent for Opioid toxicity
Reversal agent for inhibitor overdose
Reversal agent for neuromuscular blocker overdose
Interferes with oral contraceptives
Narcan & Naloxone
--> Inhibitor overdose
--> Magnesium sulfate toxicity
--> acetaminophen toxicity
--> Digoxin toxicity (prevent absorption)
--> High levels of K in body
Indication of ototoxicity.
Forms a protective barrier over ulcers
Atorvastatin (statins medications)
Monitor CK (due to muscle breakdown)
Emphysema patient receiving mechanical ventilation, who appears anxious and restless, and high-pressure alarm is sounding
Anxiety and restless indicate "fighting the ventilator". Instruct the patient to allow the machine to breathe for him.
In the event of ventilator failure, disconnect the machine and manually bag.
Steps for gastric hemorrhage patient going into shock
1. administer O2
2. Initiate IV therapy
3.insert NG tube to assess bleeding and prevent gastric dilation
4. administer Ranitidine once bleeding stops to prevent stress ulcer.
Irritable Bowel Syndrome with constipation
consume at least 30 g of fiber daily
How to check for placement of NG tube
Check pH of aspirated fluid
Postoperative following an amputation of toes
priority assessment is to check the color of the extremity
In hepatic encephalopathy
therapeutic goal to decrease ammonia via stool. However, patient at risk of dehydration if stools too frequent.
Patient who has dehydration, what is priority assessment?
muscle strength to assess fall risk
Endometrial biopsy location
come from inside the uterus
Stress incontinence considerations
+diet to lose weight and decrease abdominal pressure.
+For postmenopausal women, estrogen may improve the tone of the periurethral muscles
+follow a daily voiding schedule
+do not limit fluid intake
For Stage III pressure ulcer wound dressing
Use Hydrocolloid dressing
Nephrostomy tube findings
Report back pain to provider
(may indicate that tube is dislodged or clogged)
For acute kidney failure
Calcium Carbonate (tums, rolaids) is safe
Naproxen is not.
Magnesium hydroxide is not.
Gentamicin is not.
For auscultating heart sounds
Sitting, leaning forward
Turned toward left side (best for auscultating extra heart sounds)
Manifestations of hypokalemia
ECG: PVC's, flattening T-waves, ST depression
Enalapril adverse effect
Decreased perfusion to the lower extremities; therefore palpate femoral pulse first
For sealed radiation implant for cervical cancer
Keep lead-lined container in client's room in case of accidental dislodgment of the implant
Treatment for PVCs and ventricular dysrhythmias
Fibrocystic breast condition
Take diuretic & limit sodium to decrease great engorgement.
Take Oral contraceptives to decrease estrogen overstimulation
For Biliary colic
Administer hydromorphone for pain
Report to provider weight gain
Hypothermia can cause
vasoconstriction which leads to HTN
ileostomy care expectations
-Stoma will remain red and moist
-Feces will become thicker and more paste-like over time
-Minimal or sweet odor of feces
-Stoma should remain free of irritation and excoriation
a layer of black, gray, or brown nonviable, denatured collagen
-a full-thickness pressure ulcer is often covered by this
Healing Stage 2 pressure ulcer signs
Moist, bright red surface in wound bed
Lab results in pancreatitis
Increased pancreatic enzymes
All the -ases remain high
Serum calcium and magnesium decrease due to fat necrosis
Post lumbar puncture
maintain in supine (dorsal recumbent) position
IV Urography priority finding
Swollen lips - indicates anaphylactic reaction to contrast media
cannot be mixed with any other insulins due to the low pH of the diluent
Experience anorexia & severe diarrhea.
Have diet high in protein and calories, and low-fat, low-fiber (low-residue) diet.
Flooding (Behavioral Therapy technique)
exposure to extensive amounts of stimulus so that the patient learns that he can deal with the situation that he fears, facilitating a decrease in anxiety.
Antihistamines produce anticholinergic effects
No sight (blurred vision)
No spit (dry mouth, decreased saliva)
No sh*t (constipation)
drowsiness, sedation, confusion, delirium, memory impairment
Causes osmotic diuresis
Excessive levels of cortisol causing a round face "moon face"
A Tricyclic antidepressant has anticholinergic effects
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