ATI Comprehensive/ NCLEX Questions
Review 2024.
Endometiral infection usually occurs - ANSWER with a prolonged rupture of
membranes, not vacuum-assisted births.
Intenstinal gas is a common side effect of - ANSWER clients following a cesarean birth
Cervical lacerations are common complications from - ANSWER vacuum-assisted birth
are rare but can include perineal, vaginal, or cervical lacerations
When a client is experiencing a wound evisceration... - ANSWER the nurse should
initially stay with the client and call for help. Next, the nurse should place saline-soaked
gauze on the exposed bowels to keep the internal organs moist. The nurse should then
place the client in a supine position with his hips and knees bent to relieve pressure
from the open wound. Last, the nurse should take the client's vital signs to assess for
changes in hemodynamics.
Valproic acid can cause - ANSWER hepatic toxicity
continuous passive motion (CPM) machine - ANSWER Turn of the CPM machine
during meals to promote comfort and dietary intake.
-The affected extremity should maintain neutral alignment.
Heparin - ANSWER is an anticoagulant that inhibits the conversation of prothrombin to
thrombin. Patients on an anticoagulant drug such as heparin are at an increased risk of
bleeding.
-Signs of bleeding: ecchymoses, tarry stools, mucosal bleeding, and pink/ red-tinged
urine.
Correct method for walking upstairs with crutches - ANSWER 1. Hold to rail with one
hand and crutches with the other hand.
2. Push down on the stair rail and the crutches and step up with the "unaffected" leg.
3. If not allowed to place weight on the "affected" leg, hop up with the "unaffected" leg.
4. Bring the "affected" leg and the crutches up beside the "unaffected" leg.
5.Remember, the "unaffected" leg goes up first and the crutches move with the
"affected" leg.
Droplet precautions - ANSWER DROPLET: "SPIDERMAn"
-Sepsis
-Scarlet Fever
-Strep
,-Pertussis
-Pneumonia
-Parvovirus
-Influenza
-Diphtheria
-Epiglottitis
-Rubella
-Mumps
-Adenovirus
Management: Private room/mask
-A private room a rom with other clients with the same infectious disease.
-Masks for providers and visitors
Airborne precautions: - ANSWER AIRBORNE: "My Chicken Hez TB"
-Measles
-Chicken pox
-Herpes zoster
-TB
Management: neg. pressure room, private room, mask, n-95 for TB.
-A private room
-Masks or respiratory protection devices for caregivers and visitors.
-An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known
or suspected to have TB.
-Negative pressure airflow exchange in the room of at least six exchanges per hour.
Contact precautions - ANSWER CONTACT: "MRS WEE"
-MRSA
-RSV
-Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies,
and staph)
-Wound infections
-Enteric infections (C-Diff)
-Eye infections (conjunctivitis)
Management: gown, gloves, goggles, private room
VRSA - contact and airborne precautions (private room, door closed, negative pressure)
-A private room or a room with other clients with the same infection.
-Gloves and gowns worn by the caregivers and visitors.
,Stage I pressure ulcer - ANSWER Intact skin with an area of persistent, nonblanchable
redness, typically over a bony prominence, that may feel warmer or cooler than the
adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at
the site. With darker skin tones, the ulcer may appear blue or purple.
Stage II pressure ulcer - ANSWER Partial-thickness skin loss involving the epidermis
and the dermis. The ulcer is visible and superficial and may appear as an abrasion,
blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly
with pain and scant drainage.
Stage III pressure ulcer - ANSWER Full-thickness tissue loss with damage to or
necrosis of subcutaneous tissue. The ulcer may extend down to, but not through,
underlying fascia. The ulcer appears as a deep crater with or without undermining of
adjacent tissue and without exposed muscle or bone. Drainage and infection are
common.
Stage IV pressure ulcer - ANSWER Full-thickness tissue loss with destruction, tissue
necrosis, or damage to muscle, bone, or supporting structures. There may be sinus
tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like
material), or slough (tan, yellow, or green scab-like material)
Glasgow Coma Score - ANSWER is calculated by using appropriate stimuli (a painful
stimulus may be necessary) and then assessing the clients response in three areas.
Eye opening (E) - The best eye response, with responses ranging from 4 to 1
4 = Eye opening occurs spontaneously.
3 = Eye opening occurs secondary to voice.
2 = Eye opening occurs secondary to pain.
1 = Eye opening does not occur.
Verbal (V) - The best verbal response, with responses ranging from 5 to 1
5 = Conversation is coherent and oriented.
4 = Conversation is incoherent and disoriented.
3 = Words are spoken, but inappropriately.
2 = Sounds are made, but no words.
1 = Vocalization does not occur.
Motor (M) - The best motor response, with responses ranging from 6 to 1
6 = Commands are followed.
5 = Local reaction to pain occurs.
4 = There is a general withdrawal to pain.
3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present.
2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present.
1 = Motor response does not occur.
, Responses within each subscale are added, with the total score quantitatively
describing the client's level of consciousness. E + V + M = Total GCS
When verifying NG tube placement, the pH of aspirated gastric fluid should - ANSWER
A good indication of appropriate placement is obtaining gastric contents with a pH
between 0 and 4.
Sodium - ANSWER 136-145
Potassium - ANSWER 3.5-5
Total Calcium - ANSWER 9.0-10.5
Magnesium - ANSWER 1.3-2.1
Phosphorus - ANSWER 3.0-4.5
BUN - ANSWER 10-20
Creatinine males - ANSWER 0.6-1.2
Creatinine females - ANSWER 0.5-1.1
Glucose - ANSWER 70-105
HcbA1c - ANSWER <6.5%
WBC - ANSWER 5,000-10000
RBC men - ANSWER 4.7-6.1 million/mm3
RBC women - ANSWER 4.2-5.4 millin/mm3
Hemoglobin men - ANSWER 14-18
Hemoglobin women - ANSWER 12-16
Hematocrit men - ANSWER 42-52
Hematocrit women - ANSWER 37-47
Platelet - ANSWER 150,000-400,000
pH - ANSWER 7.35-7.45
pC02 - ANSWER 35-45
Review 2024.
Endometiral infection usually occurs - ANSWER with a prolonged rupture of
membranes, not vacuum-assisted births.
Intenstinal gas is a common side effect of - ANSWER clients following a cesarean birth
Cervical lacerations are common complications from - ANSWER vacuum-assisted birth
are rare but can include perineal, vaginal, or cervical lacerations
When a client is experiencing a wound evisceration... - ANSWER the nurse should
initially stay with the client and call for help. Next, the nurse should place saline-soaked
gauze on the exposed bowels to keep the internal organs moist. The nurse should then
place the client in a supine position with his hips and knees bent to relieve pressure
from the open wound. Last, the nurse should take the client's vital signs to assess for
changes in hemodynamics.
Valproic acid can cause - ANSWER hepatic toxicity
continuous passive motion (CPM) machine - ANSWER Turn of the CPM machine
during meals to promote comfort and dietary intake.
-The affected extremity should maintain neutral alignment.
Heparin - ANSWER is an anticoagulant that inhibits the conversation of prothrombin to
thrombin. Patients on an anticoagulant drug such as heparin are at an increased risk of
bleeding.
-Signs of bleeding: ecchymoses, tarry stools, mucosal bleeding, and pink/ red-tinged
urine.
Correct method for walking upstairs with crutches - ANSWER 1. Hold to rail with one
hand and crutches with the other hand.
2. Push down on the stair rail and the crutches and step up with the "unaffected" leg.
3. If not allowed to place weight on the "affected" leg, hop up with the "unaffected" leg.
4. Bring the "affected" leg and the crutches up beside the "unaffected" leg.
5.Remember, the "unaffected" leg goes up first and the crutches move with the
"affected" leg.
Droplet precautions - ANSWER DROPLET: "SPIDERMAn"
-Sepsis
-Scarlet Fever
-Strep
,-Pertussis
-Pneumonia
-Parvovirus
-Influenza
-Diphtheria
-Epiglottitis
-Rubella
-Mumps
-Adenovirus
Management: Private room/mask
-A private room a rom with other clients with the same infectious disease.
-Masks for providers and visitors
Airborne precautions: - ANSWER AIRBORNE: "My Chicken Hez TB"
-Measles
-Chicken pox
-Herpes zoster
-TB
Management: neg. pressure room, private room, mask, n-95 for TB.
-A private room
-Masks or respiratory protection devices for caregivers and visitors.
-An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known
or suspected to have TB.
-Negative pressure airflow exchange in the room of at least six exchanges per hour.
Contact precautions - ANSWER CONTACT: "MRS WEE"
-MRSA
-RSV
-Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies,
and staph)
-Wound infections
-Enteric infections (C-Diff)
-Eye infections (conjunctivitis)
Management: gown, gloves, goggles, private room
VRSA - contact and airborne precautions (private room, door closed, negative pressure)
-A private room or a room with other clients with the same infection.
-Gloves and gowns worn by the caregivers and visitors.
,Stage I pressure ulcer - ANSWER Intact skin with an area of persistent, nonblanchable
redness, typically over a bony prominence, that may feel warmer or cooler than the
adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at
the site. With darker skin tones, the ulcer may appear blue or purple.
Stage II pressure ulcer - ANSWER Partial-thickness skin loss involving the epidermis
and the dermis. The ulcer is visible and superficial and may appear as an abrasion,
blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly
with pain and scant drainage.
Stage III pressure ulcer - ANSWER Full-thickness tissue loss with damage to or
necrosis of subcutaneous tissue. The ulcer may extend down to, but not through,
underlying fascia. The ulcer appears as a deep crater with or without undermining of
adjacent tissue and without exposed muscle or bone. Drainage and infection are
common.
Stage IV pressure ulcer - ANSWER Full-thickness tissue loss with destruction, tissue
necrosis, or damage to muscle, bone, or supporting structures. There may be sinus
tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like
material), or slough (tan, yellow, or green scab-like material)
Glasgow Coma Score - ANSWER is calculated by using appropriate stimuli (a painful
stimulus may be necessary) and then assessing the clients response in three areas.
Eye opening (E) - The best eye response, with responses ranging from 4 to 1
4 = Eye opening occurs spontaneously.
3 = Eye opening occurs secondary to voice.
2 = Eye opening occurs secondary to pain.
1 = Eye opening does not occur.
Verbal (V) - The best verbal response, with responses ranging from 5 to 1
5 = Conversation is coherent and oriented.
4 = Conversation is incoherent and disoriented.
3 = Words are spoken, but inappropriately.
2 = Sounds are made, but no words.
1 = Vocalization does not occur.
Motor (M) - The best motor response, with responses ranging from 6 to 1
6 = Commands are followed.
5 = Local reaction to pain occurs.
4 = There is a general withdrawal to pain.
3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present.
2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present.
1 = Motor response does not occur.
, Responses within each subscale are added, with the total score quantitatively
describing the client's level of consciousness. E + V + M = Total GCS
When verifying NG tube placement, the pH of aspirated gastric fluid should - ANSWER
A good indication of appropriate placement is obtaining gastric contents with a pH
between 0 and 4.
Sodium - ANSWER 136-145
Potassium - ANSWER 3.5-5
Total Calcium - ANSWER 9.0-10.5
Magnesium - ANSWER 1.3-2.1
Phosphorus - ANSWER 3.0-4.5
BUN - ANSWER 10-20
Creatinine males - ANSWER 0.6-1.2
Creatinine females - ANSWER 0.5-1.1
Glucose - ANSWER 70-105
HcbA1c - ANSWER <6.5%
WBC - ANSWER 5,000-10000
RBC men - ANSWER 4.7-6.1 million/mm3
RBC women - ANSWER 4.2-5.4 millin/mm3
Hemoglobin men - ANSWER 14-18
Hemoglobin women - ANSWER 12-16
Hematocrit men - ANSWER 42-52
Hematocrit women - ANSWER 37-47
Platelet - ANSWER 150,000-400,000
pH - ANSWER 7.35-7.45
pC02 - ANSWER 35-45
