ATI Capstone NCLEX Question And Answers 2024 100% Pass, Exams of Nursing

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ATI Capstone NCLEX Question And Answers 2024 100% Pass ATI CAPSTONE NCLEX QUESTIONS AND ANSWERS LATEST UPDATED 2024 GRADED 100% PASS subjective sources of data - EXACT ANSWER What the client tells the nurse Objective sources of data - EXACT ANSWER Data the nurse obtains through observation and examination secondary subjective data - EXACT ANSWER what others tell the nurse; what the client had told them secondary objective sources of data - EXACT ANSWER Data the nurse collects from other sources; family, friends, caregivers, health care professionals, literature review, medical records, etc. Steps of the Nursing Process - EXACT ANSWER assessment/data collection, analysis/data collection, planning, implementation, evaluation; ADPIE Assessment/Data collection - EXACT ANSWER the systemic collection of information about clients' present health statuses to identify needs and additional data to collect based on findings Analysis/data collection requires nurses to look at the data and: - EXACT ANSWER recognize patterns or trends; compare the data with expected standards or reference ranges, and arrive to conclusions to guide nursing care Planning - EXACT ANSWER nurses must establish priorities and optimal outcomes of acre they can readily measure and evaluate, which include interventions to promote, maintain, or restore health Discharge planning - EXACT ANSWER a process of anticipating and planning for client's needs after discharge. To be effective, discharge planning must begin during admission ATI Capstone NCLEX Question And Answers 2024 100% Pass nurse-initiated/independent interventions - EXACT ANSWER nurses use evidence and scientific rationale to take autonomous actions to benefit clients; based on identified problems and health care needs, and make sure they are within their scope of practice. An example is repositioning a client at least every 2 hours to prevent skin breakdown Provider-initiated/dependent interventions - EXACT ANSWER interventions nurses initiate as a result of a provider's prescription (written, standing, or verbal) or the facility's protocol (blood administration procedures) collaborative interventions - EXACT ANSWER interventions nurses carry out in collaboration with other health care team professionals (ensuring that a client receives and eats their evening snack) Implementation - EXACT ANSWER nurses base the care they provide based on assessment data, analysis, and the plan of care they developed in the previous steps of the nursing process. In this step they must use problem-solving, clinical judgement, and critical thinking to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain, or restore health. Evaluation - EXACT ANSWER nurses evaluate clients' responses to nursing interventions and form a clinical judgment about the extent to which clients have met the goals and outcomes; nurses determine the effectiveness of the nursing care plan. They collect data based on the outcome criteria then compare what actually happened with the planned outcomes; clients' outcomes in specific, measurable terms are easier to evaluate Evaluate: Questions to Consider - EXACT ANSWER "Did the client meet the planned outcomes?", "were the nursing interventions appropriate and effective?", "should I modify the outcomes or interventions?" Factors that can lead to lack of goal achievement during evaluation - EXACT ANSWER an incomplete database, unrealistic client outcomes, nonspecific nursing interventions, and inadequate time for the client to achieve the outcomes 4 steps of Critical Thinking - EXACT ANSWER 1. identify and analyze the problem; 2. recall info you need to resolve the problem; 3. evaluate each option; 4. select the correct or priority option ATI Capstone NCLEX Question And Answers 2024 100% Pass Antianemics - EXACT ANSWER Instruct clients to take iron on an empty stomach such as 1 hr before meals to maximize absorption. Stomach acid increases absorption. Instruct clients to space doses at approximately equal intervals throughout day to most efficiently increase red blood cell production. Instruct clients to increase water and fiber intake (unless contraindicated), and to maintain an exercise program to counter the constipation effects. Encourage concurrent intake of appropriate quantities of foods high in iron (liver, egg yolks, muscle meats, yeast). drug administration interactions with iron - EXACT ANSWER antacids or tetracycline's reduces absorption of iron. Separate use by at least 2 hr. Vitamin C increases absorption of iron, but also increases incidence of - EXACT ANSWER GI complications. Avoid vitamin C intake when taking medication. Iron side effects - EXACT ANSWER GI distress (nausea, constipation, heartburn). If intolerable, iron can be administered with food to increase compliance with therapy but this does reduce absorption; inform clients to anticipate a harmless dark green or black color of stool; Iron can cause teeth staining (liquid form), teach clients to dilute liquid iron with water or juice, drink with a straw, and rinse mouth after swallowing; iron can cause staining of skin and other tissues with IM injections. If IM route must be used, give IM doses deep IM using Z track technique. Statins (HMG-CoA Reductase Inhibitors) - EXACT ANSWER treat primary hypercholesterolemia, for prevention of coronary events (primary and secondary), for protection against MI and stroke for clients with diabetes, and to help increase HDL levels in clients with primary hypercholesterolemia; You want your LOW (LDL) LOW and your HIGH (HDL) HIGH. Statins (HMG-CoA Reductase Inhibitors) common meds - EXACT ANSWER Atorvastatin (Lipitor) Simvastatin (Zocor) Lovastatin (Mevacor) Pravastatin (Pravachol) Rosuvastatin (Crestor) Fluvastatin (Lescol) ATI Capstone NCLEX Question And Answers 2024 100% Pass Statins (HMG-CoA Reductase Inhibitors) side effects - EXACT ANSWER When you think 'statins' think that we need to protect the liver and muscles stat: there is a risk of hepatotoxicity. It is important to obtain a baseline liver function and to monitor liver function tests after 12 weeks and then every 6 months and to avoid alcohol. There is also a risk of myopathy and peripheral neuropathy. Clients should be told to report muscle weakness and/or aches, pain, tingling, and tenderness. CK levels will be monitored periodically during treatment as well. Anticoagulants - EXACT ANSWER Anticoagulants prevent the formation of blood clots by interfering with the clotting cascade, thereby preventing coagulation. The use of this class of medications is contraindicated with active bleeding, such as with bleeding disorders, ulcers, or hemorrhagic brain injuries. Anticoagulant common meds - EXACT ANSWER heparin, coumadin HEPARIN - EXACT ANSWER HEPARIN H-eparin sodium prevents thrombin from converting fibrinogen to fibrin; it is administered IV or SQ. E-noxaparin (Lovenox) is a low-molecular weight heparin. It has the same action as heparin, but has a longer half-life. It is administered via subcutaneous injection. P-rotamine sulfate is the antidote for heparin. A -dminister heparin when there is the likelihood of clot formation, such as with myocardial infarction or deep-vein thrombosis. R-isk for bleeding is the major side effect that clients should be educated about. Clients should be educated to monitor for bleeding, including bleeding gums, bruises, hematuria, and petechiae. I-nstruct clients to avoid corticosteroid use, salicylates, NSAIDs, green leafy vegetables, and foods high in Vitamin K. N-ormal activated partial thromboplastin time (aPTT) is 20 to 36 seconds, but to maintain a therapeutic level of anticoagulation while on heparin, the aPTT should be 1.5 to 2 times the normal value (60 to 80 seconds). activated partial thromboplastin time (aPTT) - EXACT ANSWER 20-36; to maintain a therapeutic level of anticoagulation while on heparin, the aPTT should be 1.5 to 2 times the normal value (60 to 80 seconds). ATI Capstone NCLEX Question And Answers 2024 100% Pass COUMADIN - EXACT ANSWER C-oumadin (generic name Warfarin sodium) interferes with coagulation factors by antagonizing vitamin K. O-ral administration is typically used. Clients may need continued heparin infusion via IV until therapeutic effect of Coumadin is experienced (may take 3-5 days). U-se is contraindicated in clients with low platelet counts or uncontrolled bleeding. M-ephyton (trade name vitamin K) is the antidote for Coumadin. A-dvise clients to avoid foods that are high in vitamin K, and avoid the use of acetaminophen, glucocorticoids, and aspirin. Clients should wear a medical alert bracelet indicating warfarin use. D-oses are typically taken once daily. I-NR and PT are monitored for clients who are taking Coumadin. Depending on intent of therapy, PT should be 1.5 to 2 times control and INR should be 2-3. Target INR is 3 to 4.5 for clients with a mechanical heart valve. N-o Coumadin for pregnant women! Oral anticoagulants fall into Pregnancy Risk Category X. Heparin may be safely used in pregnancy. INR and PT with Coumadin - EXACT ANSWER INR and PT are monitored for clients who are taking Coumadin. Depending on intent of therapy, PT should be 1.5 to 2 times control and INR should be 2-3. Target INR is 3 to 4.5 for clients with a mechanical heart valve. Antiplatelets - EXACT ANSWER Antiplatelets prevent platelets from clumping together by inhibiting enzymes and factors that normally cause arterial clotting; used to prevent myocardial infarction and stroke. Low dose therapy (81 mg) is effective for prevention of strokes and MI. Common antiplatelets - EXACT ANSWER Aspirin (Ecotrin) Clopidogrel (Plavix) Pentoxifylline (Trental) Antiplatelet Nursing Interventions - EXACT ANSWER WATCH FOR BLEEDING. These medications should be taken with food; these medications should be used cautiously in clients with peptic ulcer disease and in clients with severe renal/hepatic disorders. ATI Capstone NCLEX Question And Answers 2024 100% Pass tachycardia, palpations, diaphoresis, and shakiness. Gradual onset hypoglycemia may manifest with headache, tremors, or weakness. We'll CLIMB TO THE PEAK...starting FAST and ending SLOW. FASTEST: Rapid acting insulins:Lispro (Humalog). - EXACT ANSWER ONSET: Less than 15 minutes. PEAK: 30 minutes to 1 hour. DURATION: 3 to 4 hours. FAST: Short acting insulins: Regular (Humulin R). - EXACT ANSWER ONSET: 30 minutes to 1 hour. PEAK: 2 to 3 hours. DURATION: 5 to 7 hours. SLOW: Intermediate-acting insulins: NPH insulin (Humulin N) - EXACT ANSWER ONSET: 1 to 2 hours. PEAK: 4 to 12 hours. DURATION: 18 to 24 hours. SLOWEST: Long-acting insulins: Insulin glargine (Lantus) - EXACT ANSWER ONSET: 1 hour PEAK: None DURATION: 10 to 24 hours Prioritization Tip - EXACT ANSWER To avoid some common pitfalls when answering priority questions, be aware of the following: Never perform ABC checks blindly without considering whether airway, breathing or circulation issues are acute versus chronic or stable versus unstable. For example, a client who is quadriplegic and on a ventilator has chronic airway/breathing problems. However, if there is not an acute consideration such ATI Capstone NCLEX Question And Answers 2024 100% Pass as pneumonia, the client should be considered chronic and stable. This client would not be the nurse's first priority. Vancomycin can cause - EXACT ANSWER infusion reactions; red man syndrome is an infusion reaction that results in rashes, flushing, tachycardia, and hypotension. For this reason, vancomycin should be administered over a 60 minute period What instructions should the nurse provide to a client that is taking their first dose of doxazosin mesylate? - EXACT ANSWER First-dose orthostatic hypotension can occur with doxazosin. The nurse should instruct clients to change positions slowly and to lie down if feeling dizzy, lightheaded or faint; the nurse should instruct clients to avoid activities requiring mental alertness for the first 12 to 24 hours. What teaching should the nurse provide to a client that is taking montelukast? - EXACT ANSWER advise client to take the medication once daily at bedtime; leukotriene modifiers are used for long-term therapy of asthma in adults and children, and to prevent exercise-induced bronchospasm a 45-year-old client is taking methylprednisolone. What pharmacological action should the nurse expect with this therapy? - EXACT ANSWER corticosteroids, such as methylprednisolone, will suppress airway mucus production; therapy should promote responsiveness of beta2 receptors. Adverse effects of this medication include bone loss and formation of candidiasis What are contraindications to salicylate acid therapy? - EXACT ANSWER Salicylate acid is a category D agent and should not be administered to pregnant clients. Salicylate acid is contraindicated in clients with bleeding disorders and thrombocytopenia. Salicylate acid should not be given to children or adolescents with fever or recent chickenpox due to the risk of Reye syndrome. Salicylate acid therapy is used in what type of clients? - EXACT ANSWER Salicylate acid inhibits platelet aggregation and is often used in the treatment and prevention of thrombosis. Salicylate acid is commonly prescribed to clients with coronary artery disease to prevent thrombus formation. a client is prescribed propranolol. What client history findings would require the nurse to clarify this prescription? - EXACT ANSWER asthma; clients with asthma should avoid Beta2 Blockade agents such as propranolol. Bronchoconstriction can occur. Clients with asthma should be administered a beta1selective agent. ATI Capstone NCLEX Question And Answers 2024 100% Pass a nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. What is the correct order the nurse should follow? - EXACT ANSWER inspect the vials for contaminants, roll NPH vial between palms of hands, inject air into NPH insulin vial, inject air onto regular Insulin vial, withdraw short-acting insulin into syringe add intermediate insulin to syringe; when the prescription requires the administration of two types of insulin, it is preferable to mix the exact answers into one syringe if they are compatible to prevent the client from receiving two injections. The mixture is stable for 28 days. When two insulins are to be mixed, withdraw the ___ insulin first to avoid contaminating the stock vial with ___ insulin. - EXACT ANSWER short-acting; NPH a 52-year-old client with a Hx of angina has been prescribed transdermal nitroglycerin. Which of the following adverse effects is not seen with this therapy? - EXACT ANSWER productive cough; nitroglycerin therapy does not directly have an effect lung function. Physiologically, vasodilation should effect capillary perfusion and decrease lung secretions. before administering blood products, which action should be taken? - EXACT ANSWER assess the client's temperature; assess the client's vital signs, obtain consent for the procedure and ensure compatibility. Prime the IV tubing with 0.9% sodium chloride. The nurse would not document client response or administer epinephrine prior to starting the transfusion. a nurse is caring for a client with prescribed digoxin. What should alert the nurse to possible digitalis toxicity? - EXACT ANSWER Anorexia, fatigue and weakness are signs of potential digitalis toxicity. GI effects of digitalis toxicity include anorexia, nausea, vomiting and abdominal pain. CNS effects include fatigue, weakness, vision changes (diplopia, blurred vision, yellow-green or white halos around objects). Bradycardia is also commonly noted in digitalis toxicity. A client is taking disulfiram daily for abstinence maintenance. What is an adverse effect of disulfiram? - EXACT ANSWER hepatotoxicity a client has been prescribed lisinopril. What medication interaction should the nurse instruct this client about? - EXACT ANSWER Potassium supplements and potassium-sparing diuretics increase the risk of hyperkalemia in clients taking ACE inhibitors such as lisinopril. Clients should only take potassium