ATI CAPSTONE A B COMBINATION ASSESSMENT

ATI CAPSTONE A & B COMBINATION ASSESSMENT

• what is montelukast (singular) for?
• a leukotriene modifier, and is taken on a regular basis, once a day, and

not prn, and is not used for exercise induced asthma

• what does advance directives contain?
• written instructions regarding end of life care
• what is the greatest risk to a pt receiving hemodialysis?
• disequilibrium syndrome as a result of rapid loss of fluids and decrease

bun

• what is the clinical manifestation of disequilibrium?
• restlessness and decreased level of consciousness
• what are expected findings in hemodialysis?
• elevated temp

weight loss decreased bp

• what should the nurse do when a pt feels lightheaded and begins to fall?
• spread feet apart and extend one leg for the pt to slide down while

lowering the pt to the floor

• what are the characteristics of a pt with dependent personality disorder?
• they have problems making everyday decision without input from others
• a pregnant pt who is bleeding is always?
• priority
• what should a pregnant pt with urgency and frequent urination do?
• should perform kegel exercises
• what should a pregnant pt with odorless vaginal mucus do?
• practice good hygiene, use perineal pads
• a pregnant pt with edema of the ankles do?
• avoid prolonged standing, to wear support hose, and rest through out the day

with legs/hip elevated

• when should a colostomy bag be changed?

when is 1/3 -1/2 full

• how large should the opening of the stoma pouch be?

no larger than 1/4 inch

• what should the pt with a colostomy avoid?

the use of moisturizers, which will decrease the adherence of the pouch to the skin

• what should the pt do with the pouch removing it?
• they should empty the pouch to avoid spilling the effluent on to the skin
• where should drops be instill into?
• into the conjuctival sac
• what is a positive way of dealing with a terminal illness?
• "remembering things they used to do together"

• what are normal findings after a colonoscopy?
• abd cramping

fatigue passage of liquid stools

• what are unexpected finding after a colonoscopy?
• guarding- can indicate bowel perforation
• what do you do if an order is questioned?
• the nurse should record seeking clarification from the provider
• what should pt with gastritis eat?
• a well balanced diet, they should keep a record of foods that cause discomfort,

pts can modify their diet accordingly

• what is the cause autonomic dysreflexia?
• bladder distention
• what are s/s of icp?
• restlessness

change in LOC

• what is late s/s of ICP?
• widening pulse

decerebrate posturing

• when can a child with varicella(chickenpox) return school?
• the child can return to school when the blisters are dry and no longer drained

(scabbed over)

• what is an appropriate behavior of a pt with hx of violence?
• pt will avoid violence provoking situations
• what is a skin cancer prevention?
• pts should use sunscreen that protects against uva and uvb
• what is the first thing you should do with excessive lochial discharge?
• perform a fundal massage
• what is the nurse responsibility of the nurse when witnessing the pts signature on

an informed consent?

• that the pt is fully informed and understands the procedure befor signing the

consent form

• who are at greater risk for std?
• females because of increased vascularity to the vagina
• does trichomonas vaginalis increased the risk for cervical cancer?

49. NO

• Gonorrhea can lead to?
• pelvic inflammatory disease and tubal scarring and can result in infertility
• what should you do with postmortem care?
• always check about religious practices prior to body preparation in order to honor

fam wishes

• what can you not give to a pt with thickened liquids?
• no ice chips

no water no icepops

• what can a pt with thickened liquids have?

• oatmeal
• what should a pt do with incentive spirometer?
• they should elevate the cylinder by inhaling deeply

assume semi fowlers or high fowlers position

• in order to maintain sterile technique what should the nurse do?
• should open all sterile packages prior to donning sterile gloves
• what is psycho-motor learning?
• have the pt demonstrate back the procedure
• what places a newborn at risk for respiratory depression?
• administration of an opioid analgesic

exa: fentanyl (sublimaze)

• what is an effective method of bowel retraining?
• anal stimulation with a gloved finger after the evening meal, it will help stimulate

the gastrocolic reflex

• when inserting an NG tube?
• the nurse should insert the tube into the airway that is patent and has greater

airflow

• what technique should be NG tube insertion?
• clean technique
• if NG tube meets resistance?
• the nurse should rotate the tube without forcing it past the area of resistance
• what kind of lubricant should be used during NG tube insertion?
• water- based lubricant NOT petroleum jelly
• what is pediculosis capitis management?
• store child's clothing in a separate cubicle at school

boil brushes and combs in water for 10 mins dry bed lines and clothing in a hot dryer for at least 20 mins

• what can visual disturbances indicate?
• preeclampsia
• what is expected 24 hrs after surgery?
• hypo active bowel sounds

pain

• what is an abnormal finding 24 hrs after surgery?
• low HGB
• what must be done in bucks traction?
• the pt must be in proper alignment

boots are secured by 3 straps, around pt leg weights must hang freely footplate is resting 15.24 cm (6inches) from the footboard

• what does pts with delirium demonstrate?
• a fluctuating LOC often at night or in am
• pt with dementia demonstrate?
• difficulty finding correct words to use
• pt with anxiety disorders demonstrate?
• obsessive behavior
• how would the nurse determine progression of ascites?

• abdominal girth should be measured daily
• what is a food high in potassium?
• cantaloupe
• what is an indication of peripheral venous disease?
• brown pigmentation around ankles
• what is indication of peripheral arterial disease?
• intermittent, leg muscle pain
• what is some skin care for pts on radiation therapy?
• pat area when drying

use hand to wash do not use sunscreen

• what can hydromorpone cause?
• urinary retention
• what does bethanechol (urecholine) causes?
• it stimulates urinary out put
• how is nystatin best absorb?
• if given 1 hour before or after a feeding
• what is a sign that a newborn has finished eating?
• a slowed suck/swallow pattern is a sign that the newborn is

finished eating

• what not to do when breastfeeding?
• is not necessary for the entire areola be in the mouth

each feeding should start at the opposite breast do not push back of newborns head-toward the nipple

• what should be included in a stool specimen?
• visible blood, pus, or mucus
• what is the first action in an infiltrated IV?
• to d/c the saline lock
• what is the first action when preparing to do a dressing

change?

• to determine the pts level of pain
• what should a with hemonymous hemionopsia with right visual

field, what will help pt eat better?

• the pt should turn head to the right to see all food on tray
• what are some side effect for theophylline (theo-dur)?
• is used to prevent wheezing,sob, chest tightness in asthma

irregular pulse and dysrhythmias seizures anxiety urinary frequency anorexia n/v diarrhea

• what should you do when given enoxaparin (lovenox)?
• it should be injected SUBQ

do not aspirate