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

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subjective sources of data - SOLUTION What the client tells the nurse Objective sources of data - SOLUTION Data the nurse obtains through observation and examination secondary subjective data - SOLUTION what others tell the nurse; what the client had told them secondary objective sources of data - SOLUTION Data the nurse collects from other sources; family, friends, caregivers, health care professionals, literature review, medical records, etc. Steps of the Nursing Process - SOLUTION assessment/data collection, analysis/data collection, planning, implementation, evaluation; ADPIE Assessment/Data collection - SOLUTION 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: - SOLUTION recognize patterns or trends; compare the data with expected standards or reference ranges, and arrive to conclusions to guide nursing care Planning - SOLUTION 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 - SOLUTION a process of anticipating and planning for client's needs after discharge. To be effective, discharge planning must begin during admission nurse-initiated/independent interventions - SOLUTION 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

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Provider-initiated/dependent interventions - SOLUTION 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 - SOLUTION interventions nurses carry out in collaboration with other health care team professionals (ensuring that a client receives and eats their evening snack) Implementation - SOLUTION 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 - SOLUTION 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 - SOLUTION "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 - SOLUTION an incomplete database, unrealistic client outcomes, nonspecific nursing interventions, and inadequate time for the client to achieve the outcomes 4 steps of Critical Thinking - SOLUTION 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 clients with diabetes mellitus should eat what when their blood glucose is low? - SOLUTION they should eat a snack of 10-15 grams of carbohydrates, such as 120 mL or 4 oz of fruit juice

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infants and toddlers are at risk for injury due to - SOLUTION a tendency to put objects in their mouth and from hazards encountered while exploring their environment preschool and school-aged children often face injury from - SOLUTION limited or underdeveloped motor coordination adolescents's risks for injury can stem from - SOLUTION increased desire to make independent decisions and relying on peers for guidance rather than family preventing aspiration in infants and toddlers - SOLUTION keep all small objects out of reach; check toys and objects for loose or small parts and sharp edges; do not feed the infant hard candy, peanuts, popcorn, or whole or sliced pieces of hot dog; do not place the infant in the supine position while feeding or prop the infant's bottle; a pacifier (if used) should be constructed of one piece and never placed on a string or ribbon around the neck Antiemetics - SOLUTION used in the treatment and/or prevention of nausea and vomiting. common classes of antiemetics - SOLUTION 5-HT3 receptor antagonists (serotonin antagonists); Dopamine antagonists; Antihistamines (H1 histamine receptor antagonists) 5-HT3 receptor antagonists (serotonin antagonists) - SOLUTION Dolasetron (Anzemet) Granisetron (Kytril, Sancuso) Ondansetron (Zofran) Tropisetron (Navoban) It's 'Tron' to the rescue! Dopamine antagonists - SOLUTION Promethazine (Phenergan) Prochlorperazine (Compazine) Metoclopramide (Reglan): different in generic name because it can have extra-pyramidal side effects

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Antihistamines (H1 histamine receptor antagonists) - SOLUTION Diphenhydramine (Benadryl) Dimenhydrinate (Gravol, Dramamine) Meclizine (Bonine, Antivert) Proton Pump Inhibitors (PPIs) - SOLUTION decrease stomach acid by inhibiting those gastric proton pumps that make the acid - they stop the acid at the pump!; 'Zole' is very friendly (well-tolerated by most clients), but can cause vitamin B12 deficiency if he stays around too long (with long-term use). Common PPIs - SOLUTION Omeprazole (brand names: Prilosec, Zegerid, Omepral, Omez) Lansoprazole (brand names: Prevacid, Zoton, Inhibitol) Dexlansoprazole (brand name: Kapidex, Dexilant) Esomeprazole (brand names: Nexium, Esotrex) Pantoprazole (brand names: Protonix, Somac, Pantozol, Zentro) Erectile Dysfunction Agents - SOLUTION act by increasing nitric oxide which opens and relaxes the blood vessels of the penis causing increased blood flow (helping lead to getting and keeping an erection); side effects: flushing, back pain and muscle aches (with Levitra), temporary vision changes, (blue vision with Viagra); men who have heart problems, uncontrolled blood pressure problems, history of stroke, or a health problem that can cause priapism can't hang out with 'Fil.' common Erectile Dysfunction meds - SOLUTION Sildenafil (Viagra) Vardenafil (Levitra) Tadalafil (Cialis) Notice these end in 'fil'. 'Fil' helps the nitric oxide to 'fil' the penis. Antianemics - SOLUTION 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).

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drug administration interactions with iron - SOLUTION 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 - SOLUTION GI complications. Avoid vitamin C intake when taking medication. Iron side effects - SOLUTION 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) - SOLUTION 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 - SOLUTION Atorvastatin (Lipitor) Simvastatin (Zocor) Lovastatin (Mevacor) Pravastatin (Pravachol) Rosuvastatin (Crestor) Fluvastatin (Lescol) Statins (HMG-CoA Reductase Inhibitors) side effects - SOLUTION 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.

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Anticoagulants - SOLUTION 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 - SOLUTION heparin, coumadin HEPARIN - SOLUTION 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) - SOLUTION 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). COUMADIN - SOLUTION 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.

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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 - SOLUTION 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 - SOLUTION 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 - SOLUTION Aspirin (Ecotrin) Clopidogrel (Plavix) Pentoxifylline (Trental) Antiplatelet Nursing Interventions - SOLUTION 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. What do clients who are taking antiplatelets need to know? - SOLUTION Observe for signs of weakness, dizziness, and headache and report them if they occur. These may be signs of hemorrhagic stroke. Bleeding time should be assessed carefully. Coffee ground emesis or bloody, tarry stools should be reported. Watch for bruising, petechiae, and bleeding gums. What interactions may occur with antiplatelets? - SOLUTION Avoid concurrent use of medications that enhance bleeding, including NSAIDs, heparin,and warfarin. Corticosteroids should be avoided as they may increase aspirin effects. Concurrent use of aspirin may reduce hypertensive action of beta blockers.

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Thrombolytic Agents - SOLUTION Thrombolytic Agents are CLOT BUSTERS. They work QUICKLY to restore circulation. As such, they increase a client's risk for bleeding. THINK GHOSTBUSTERS WITH THROMBOLYTIC AGENTS WHO YOU GONNA CALL? (Thrombolytics) - SOLUTION Streptokinase (Streptase). Call right away! Must be administered within 4 to 6 hours of onset of symptoms. IF THERE'S SOMETHING STRANGE IN YOUR NEIGHBORHOOD (Thrombolytics) - SOLUTION Thrombolytic agents dissolve clots that have already been formed. These medications convert plasminogen to plasmin, which destroy fibrinogen and other clotting factors. WHAT'S THE GOAL? (Thrombolytics) - SOLUTION Restoration of circulation, as evidenced by relief of chest pain, and reduction of initial ST segment injury pattern as shown on ECG. WHAT'S THE RISK (Thrombolytics) - SOLUTION Increased bleeding. These medications should only be given while the client is closely monitored. Baseline platelet and blood counts (including aPTT, PT, and INR) should be carefully assessed. Venipunctures and SQ and IM injections should be limited. AFTER THE CLOT HAS LEFT THE BUILDING (Thrombolytics) - SOLUTION Administer beta blockers to decrease myocardial oxygen consumption and reduce the incidence and severity of reperfusion arrhythmias. Herb/Botanical Therapy - SOLUTION Herbal supplements are widely used and have much less precise dosages than more regulated medications. Clients may not mention herbal supplements as a part of their medication history, so it is important to ask clients specifically if they are taking any supplements in addition to prescription or over-the-counter medications. Common herbal supplements - SOLUTION echinacea, ginger root, ginkgo biloba, valerian, black cohosh Echinacea - SOLUTION Used to treat the common cold; with chronic use, echinacea can decrease positive effects of medications for TB, HIV, or cancer.

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Ginger root - SOLUTION Used to decrease nausea of morning sickness, motion sickness, and nausea induced by surgery; may also decrease the pain and stiffness of rheumatoid arthritis; these medications suppress platelet aggregation; should be used cautiously in pregnancy. Ginkgo biloba - SOLUTION Promotes vasodilation and may be used to increase recall ability and mental processes. Used commonly with dementia and Alzheimer's Disease. May also be used for erectile dysfunction in clients who take SSRIs and experience impotence as a side effect. May interact with medications that lower the seizure threshold, such as antihistamines, antidepressants, and antipsychotics. May interfere with coagulation. valerian - SOLUTION Increases GABA to prevent insomnia. Promotes sleep with increased effect over time; there is a risk of dependence. May cause drowsiness and depression. Should be used cautiously in clients with mental health disorders. Avoid use in pregnancy or while breastfeeding. Black Cohosh - SOLUTION Acts on the female reproductive system as an estrogen substitute. May be used instead of estrogen therapy during menopause. Increases the effects of antihypertensive medications and may increase effect of estrogen medications. Increases hypoglycemia in clients who are taking insulin or other medications for diabetes. Insulins - SOLUTION used to manage diabetes mellitus, a chronic illness that results from an absolute or relative deficiency of insulin. There are various insulins that are available to manage diabetes. Assessment should occur frequently, but especially during the PEAK of insulin action, as this is when hypoglycemia is most likely to occur. Signs and symptoms of abrupt-onset hypoglycemia include 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). - SOLUTION ONSET: Less than 15 minutes. PEAK: 30 minutes to 1 hour. DURATION: 3 to 4 hours. FAST: Short acting insulins: Regular (Humulin R). - SOLUTION ONSET: 30 minutes to 1 hour.

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PEAK: 2 to 3 hours. DURATION: 5 to 7 hours. SLOW: Intermediate-acting insulins: NPH insulin (Humulin N) - SOLUTION ONSET: 1 to 2 hours. PEAK: 4 to 12 hours. DURATION: 18 to 24 hours. SLOWEST: Long-acting insulins: Insulin glargine (Lantus) - SOLUTION ONSET: 1 hour PEAK: None DURATION: 10 to 24 hours Prioritization Tip - SOLUTION 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 as pneumonia, the client should be considered chronic and stable. This client would not be the nurse's first priority. Vancomycin can cause - SOLUTION 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? - SOLUTION 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.

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What teaching should the nurse provide to a client that is taking montelukast? - SOLUTION 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? - SOLUTION 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? - SOLUTION 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? - SOLUTION 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? - SOLUTION asthma; clients with asthma should avoid Beta2 Blockade agents such as propranolol. Bronchoconstriction can occur. Clients with asthma should be administered a beta1selective agent. 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? - SOLUTION 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 solutions 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. - SOLUTION short-acting; NPH

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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? - SOLUTION 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? - SOLUTION 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? - SOLUTION 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? - SOLUTION hepatotoxicity a client has been prescribed lisinopril. What medication interaction should the nurse instruct this client about? - SOLUTION Potassium supplements and potassium-sparing diuretics increase the risk of hyperkalemia in clients taking ACE inhibitors such as lisinopril. Clients should only take potassium supplements if prescribed by the provider. Clients should also avoid salt substitutes that contain potassium. a nurse is preparing to administer bisacodyl suppository to a client. What actions should the nurse take?

• SOLUTION Don clean gloves, lubricate index finger with sterile water-soluble lubricating jelly, position the client on the left lateral side, gently retract the buttocks with the nondominant hand, insert the suppository gently through the anus, past the internal sphincter, and against the rectal wall. Following the administration of the medication, the nurse should apply gentle pressure to hold the buttocks together momentarily if needed to keep medication in place. What should the nurse do if the wrong medication was administered to a client? - SOLUTION the nurse should acknowledge the error and report it to the provider for further orders, monitor the client for

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adverse effects, and complete an incident report per institutional policy after notifying the health care provider