ATI PN Comprehensive Predictor

The correct answer is:  Restlessness and increased heart rate.

Explanation:

Diazepam (Valium) is a benzodiazepine used to manage anxiety, muscle spasms, and seizures. It works by enhancing the effects of gamma-aminobutyric acid (GABA), a neurotransmitter that produces a calming effect on the brain and nervous system. It is appropriate to administer diazepam in a preoperative client who is exhibiting anxiety-related symptoms, such as restlessness and increased heart rate. These are classic manifestations of sympathetic nervous system activation due to anxiety. In this case, the client is likely anxious about the upcoming surgery, and diazepam would help reduce physiological symptoms of anxiety and provide sedation.

Why the other options are incorrect:

Agitation and decreased level of consciousness:

This combination is concerning because agitation with a decreased level of consciousness may indicate a serious underlying condition, such as hypoxia, metabolic disturbance, or drug intoxication. Administering diazepam in this scenario without further assessment could further depress the client's level of consciousness and potentially mask serious clinical changes.

Lethargy and decreased respiratory rate:

These symptoms suggest central nervous system and respiratory depression, which are contraindications for benzodiazepine administration. Giving diazepam in this setting could worsen respiratory depression and place the client at risk for hypoventilation or apnea.

Hostility and increased blood pressure:

While increased blood pressure may be related to anxiety, hostility is not necessarily indicative of anxiety alone. Hostile behavior can stem from various causes, including psychiatric or neurological conditions, and would require a more thorough assessment. Benzodiazepines are not the first-line treatment for hostility, especially without confirmation that it stems from anxiety.

Summary:

The appropriate use of diazepam for preoperative anxiety is based on identifying signs of heightened sympathetic activity, such as restlessness and increased heart rate. These are common anxiety symptoms, and diazepam would help reduce the client’s distress and promote relaxation before surgery. Therefore, option C is the most appropriate indication for administering diazepam in this scenario.

Correct Answer: 0.9% sodium chloride

Explanation:

When irrigating an NG tube, it is important to use a solution that maintains the client's fluid and electrolyte balance. 0.9% sodium chloride, also known as normal saline, is isotonic, meaning it has the same concentration of salt as the body’s cells and blood. This helps to maintain fluid and electrolyte balance when used for irrigation of the NG tube.

Why the other options are incorrect:

Tap water:

Tap water is not recommended for irrigating an NG tube because it can be hypotonic, which means it has a lower concentration of solutes than the body’s cells. This can cause fluid shifts and possibly lead to water intoxication, which could affect the client's electrolyte balance.

Sterile water:

Sterile water is also hypotonic, which means it has no electrolytes. While it is safe for some medical procedures, it is not ideal for irrigating an NG tube, as it could cause the same issues as tap water, including fluid imbalances.

0.45% sodium chloride:

0.45% sodium chloride, also known as half-normal saline, is hypotonic. While it is sometimes used for hydration purposes, it is not the best choice for irrigating an NG tube, as it could lead to electrolyte imbalances when used over time.

Summary:

0.9% sodium chloride (normal saline) is the best solution for irrigating an NG tube because it is isotonic and helps maintain proper fluid and electrolyte balance.

Correct Answer: Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days.

Explanation:

A cheiloplasty is a surgical procedure performed to repair a cleft lip, and the care of the surgical site is an essential part of the discharge instructions. The goal of the post-operative care is to promote healing, prevent infection, and avoid trauma to the sutures.

Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days. – Applying a thin layer of antibiotic ointment to the suture line helps prevent infection and promotes healing. It is common practice to use an antibiotic ointment on a surgical wound, especially for the first few days post-op, unless contraindicated by the healthcare provider. The instruction is accurate, and this is standard care following a cheiloplasty.

Why the other options are incorrect:

Clean your baby's sutures daily with a mixture of chlorhexidine and water. – While it is important to clean the suture site, chlorhexidine is not typically recommended for use in cleaning delicate areas such as the mouth or surgical sites in infants due to its potential to cause irritation or sensitivity. The provider may recommend a mild soap and water solution or a different antiseptic. It’s important to follow specific instructions from the provider regarding wound cleaning.

Expect your baby to swallow more than usual over the next few days.– This is not a typical instruction following a cheiloplasty. While some infants might swallow more due to increased oral secretions, swallowing more than usual is not a normal or expected outcome post-operatively. The infant may be more likely to have difficulty with feeding due to pain or discomfort around the sutures, not increased swallowing.

Inspect your baby's tongue for white patches using a tongue depressor every 8 hours.– The instruction to inspect the tongue for white patches is typically related to oral thrush (a fungal infection) and is not specific to post-cheiloplasty care unless there are concerns about a fungal infection. White patches are not a typical concern for a child recovering from a cheiloplasty unless the child is showing signs of thrush, which would be addressed separately from the surgical site.

Summary:

The most appropriate instruction is to apply a thin layer of antibiotic ointment to the suture line to prevent infection and promote healing. The other instructions are either irrelevant or not recommended for the immediate post-operative care of a child following a cheiloplasty. Therefore, the correct answer is D. Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days.

The correct answer is : A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill.

Explanation:

An ethical dilemma occurs when there is a situation involving a conflict between two or more ethical principles or values, where making a decision may benefit one principle but harm another. In this case, the family’s conflicting feelings about whether to initiate enteral tube feedings for their terminally ill father creates a moral conflict. They may be torn between respecting the patient's autonomy (if the patient had expressed wishes regarding such a decision) and the principle of beneficence (the healthcare provider’s desire to help sustain life through feeding). This situation presents a challenge in balancing these values, making it an ethical dilemma.

Why the other options are incorrect:

A nurse on a med surge unit demonstrates signs of chemical impairment:

This is a professional issue, not an ethical dilemma. While it is serious and requires intervention for the safety of the nurse and patients, it is more related to the nurse’s competence and ability to provide safe care, rather than conflicting ethical principles.

A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed she will restrain him:

This is an ethical violation rather than a dilemma. The nurse’s threat to restrain the client without a medical indication violates the principle of autonomy and could be considered abuse. It is a clear breach of professional and ethical conduct, not a dilemma where two values are in conflict.

A client who is terminally ill hesitates to name her spouse on her durable power of attorney form:

This is a personal decision regarding the client’s end-of-life planning and does not present a conflict of ethical principles. The client may have personal reasons for hesitating to name someone on the form, but it does not create an ethical dilemma where conflicting principles must be balanced.

Summary:

The situation where the family is conflicted about whether to initiate enteral tube feedings for a terminally ill family member creates an ethical dilemma, as it involves conflicting values such as autonomy, beneficence, and possibly the patient’s wishes for end-of-life care.

Correct answer: Semi-Fowler's position.

Explanation:

This position promotes easier breathing and helps prevent aspiration, which is crucial during recovery from anesthesia and after the procedure. The semi-Fowler's position involves elevating the head of the bed to a 30-45 degree angle, which facilitates respiratory function, enhances lung expansion, and reduces the risk of aspiration. It also supports proper drainage of secretions and overall respiratory comfort, making it the most appropriate position for recovery.

Why the other options are incorrect:

Prone, with the head turned to the side: While the prone position may be appropriate in some cases for specific conditions like respiratory distress, it is not ideal after a bronchoscopy, as it could increase the risk of aspiration or compromise respiratory function.

With the head of the bed elevated 45° and the neck extended: While this position might support lung expansion, excessive neck extension can lead to discomfort and may interfere with the patient's airway. The semi-Fowler's position is a more comfortable and safer choice.

Supine, with the head in the midline position: The supine position can increase the risk of aspiration, particularly after a procedure like bronchoscopy. It does not facilitate optimal lung expansion and can be less comfortable for the patient post-procedure.

Summary:

The semi-Fowler's position is the most appropriate for an 8-year-old patient post-bronchoscopy as it promotes breathing, helps prevent aspiration, and supports recovery following anesthesia and the procedure.

The correct answer is: Suggest fluid intake of at least 2 L per day.

Explanation:

Constipation after colostomy surgery can occur due to changes in bowel function and dietary adjustments following the procedure. Adequate fluid intake is crucial for preventing constipation because it helps soften the stool and facilitates bowel movements. A minimum of 2 liters of fluid per day is recommended to ensure proper hydration and support healthy digestion. Fluids, especially water, help in maintaining the proper consistency of stool and assist in promoting regular bowel movements.

Why the other options are wrong:

Instruct the patient to keep a record of food intake.

While keeping track of food intake can be beneficial for monitoring dietary habits and identifying specific triggers for constipation, it is not the primary intervention for relieving constipation. Fluid intake and dietary adjustments (e.g., increasing fiber) are more directly relevant to addressing the patient's constipation.

Instruct the patient to avoid prune or apple juice.

This suggestion is incorrect because prune and apple juice are both natural remedies for constipation. Prune juice, in particular, is known for its ability to help relieve constipation due to its high fiber content and sorbitol, which has a laxative effect. Avoiding these juices would not be appropriate unless specifically contraindicated by a healthcare provider, as they can aid in bowel regularity.

Assist the patient regarding the correct diet or to minimize food intake.

While it's important to assist the patient with dietary choices, suggesting that the patient minimize food intake is not advisable for constipation. Rather, a diet rich in fiber, including fruits, vegetables, and whole grains, is more beneficial. Inadequate food intake could lead to further complications such as malnutrition or insufficient fiber, which could worsen constipation.

Summary:

For a patient experiencing constipation after colostomy surgery, the most effective intervention is to suggest a fluid intake of at least 2 liters per day to maintain hydration and promote bowel regularity. While tracking food intake can be helpful for monitoring diet, it's not as directly relevant to managing constipation. Prune and apple juices can actually aid in relieving constipation, and minimizing food intake is not an appropriate approach for this issue.

The correct answer is : Latex.

Explanation:

When preparing to administer IV therapy, the nurse should prioritize any allergies that may directly affect the materials involved in the procedure. In this case, latex is the most critical allergy to communicate to the healthcare team. Many IV supplies, such as gloves, tubing, and IV catheters, can contain latex. A latex allergy can cause severe reactions, including anaphylaxis, so it is essential to ensure that non-latex alternatives are used to prevent an allergic response.

Why the other options are wrong:

Penicillin.

While penicillin is a significant allergy to note for any treatment involving antibiotics, it is less directly related to IV therapy unless the patient is prescribed penicillin during the procedure. The primary concern in this case is ensuring latex-free materials for the IV process.

Shellfish.

A shellfish allergy is typically related to reactions to iodine or certain contrast agents used in imaging studies, not the materials used for IV therapy. While it is important to note, it does not pose an immediate risk for the administration of IV fluids or medications unless contrast agents are being used.

Pollen.

Pollen allergies primarily affect the respiratory system and are not likely to have an immediate impact on IV therapy. While it is important to be aware of any allergies, pollen is not a direct concern during the administration of IV therapy.

Summary:

The nurse should prioritize communicating a latex allergy to the healthcare team when preparing for IV therapy, as latex is commonly used in medical supplies, and a latex allergy could lead to severe reactions. Other allergies, such as penicillin, shellfish, or pollen, are also important to note but are less likely to interfere directly with the IV procedure itself.

The correct answer is:  peripheral edema and anorexia.

Explanation:

Cor pulmonale refers to right-sided heart failure caused by chronic pulmonary disease, most commonly chronic obstructive pulmonary disease (COPD). In cor pulmonale, the right ventricle must pump harder to move blood through the damaged lungs, eventually leading to failure of the right side of the heart.

Peripheral edema occurs due to the backup of blood into the systemic circulation when the right side of the heart fails. Anorexia (loss of appetite) results from congestion of the gastrointestinal tract, a common symptom of right-sided heart failure.

Why the other options are incorrect:

increasing respiratory difficulty seen with exertion

This symptom is more commonly associated with left-sided heart failure or primary lung disease. While clients with cor pulmonale may experience dyspnea, peripheral edema and anorexia are more direct indicators of right-sided failure.

cough productive of a large amount of thick, yellow mucus

This is more indicative of an infectious process like bronchitis or pneumonia, not specifically cor pulmonale. Cor pulmonale itself does not directly cause a productive cough with yellow mucus.

twitching of extremities

This is not characteristic of cor pulmonale. Muscle twitching might suggest electrolyte imbalances, neurological issues, or side effects of medications, but it is not a hallmark of right-sided heart failure.

Summary:

The hallmark signs of cor pulmonale (right-sided heart failure) are related to systemic venous congestion, including peripheral edema and anorexia. Therefore, the correct answer is C.

Correct Answer:  a school-age child who has sickle cell anemia and reports decreased vision in the left eye

Explanation:

When prioritizing patients in a healthcare setting, the nurse must assess which child presents with the most immediate concern or potential for a life-threatening complication. Here's the rationale for each option:

A. a school-age child who has sickle cell anemia and reports decreased vision in the left eye – Decreased vision in a child with sickle cell anemia is a serious concern. Sickle cell anemia can cause retinopathy or vascular occlusion in the eye, leading to visual impairment or even permanent blindness if not treated promptly. This child requires immediate evaluation to determine if there is any acute complication of sickle cell disease, such as a stroke or retinal detachment, which can be life-threatening.

Why the other options are incorrect:

 a school-age child who has cystic fibrosis and a frequent nonproductive cough – A nonproductive cough in a child with cystic fibrosis is common due to the thick mucus that accumulates in the lungs. While this child may require treatment, a nonproductive cough alone is generally not an immediate emergency and does not require priority over other issues.

a preschooler who has asthma and a peak flow meter reading in the green zone – The green zone on a peak flow meter indicates that the child’s asthma is well-controlled, with no signs of an asthma attack. This child is stable, and there is no indication of any urgent issues, so they do not require immediate attention.

an adolescent who has meningitis and reports a sensitivity to light and noise – Sensitivity to light (photophobia) and noise (phonophobia) are common symptoms of meningitis and suggest that the adolescent's condition is still within the expected course of the illness. However, unless the child is showing signs of deterioration (e.g., changes in consciousness, seizures, or respiratory distress), this is not as urgent as the child with sickle cell anemia and visual changes.

Summary:

The child with sickle cell anemia and decreased vision requires the nurse's attention first because it could indicate a serious and potentially life-threatening complication related to the vascular issues associated with sickle cell disease. Therefore, the correct answer is A. a school-age child who has sickle cell anemia and reports decreased vision in the left eye.