ATI Comprehensive NCLEX-PN Review 10-16-2024 + + +
Study online at https://quizlet.com/_ftb92c
1. A nurse is admit- Instructor: "I would like to point out with BP! When the blood pressure is below
ting a client who 100 systolic you want to think in the back of your mind -this client could be in shock.
sustained a C3 The majority of client are 100 or grater. There are some elderly who can have less
spinal cord injury. than 100 that is their normal.
Which of the fol-
lowing findings
should the nurse
recognize as the
priority of care?
1. Heart rate
52/min.
2. Respiratory
10/min (COR-
RECT)
3. Temperature
36 C (98.8 F)
4. Blood pressure
88/54 mm Hg
2. What is concep- Conceptual learning encourages students to build upon current knowledge and
tual learning in familiar experiences, relate these experiences to learning new material, and inte-
nursing? (ati) grate new learning into clinical practice.
3. A nurse is as- Verify the information on the packed RBCs with another nurse
sisting in devel- The nurse should verify the information on the label of the packed RBCs with an-
oping the plan other nurse. She should also verify the information on the label with the provider's
of care for an order, the blood administration form from the blood bank, and with the client
older adult client armband and blood bracelet.
who is to receive Infuse the packed RBCs over 4 hr The nurse should administer packed RBCs slowly
a unit of packed to allow the older adult client's body time to adjust to the increased fluid volume.
red blood cells The blood should be infused over 4 hr .Allow the packed RBCs to warm at room
(RBCs). Which temperature for 1 hr before starting the transfusion.
, ATI Comprehensive NCLEX-PN Review 10-16-2024 + + +
Study online at https://quizlet.com/_ftb92c
of the following The nurse should start the blood within 30 min after arriving on the unit, to
actions should decrease the risk of bacterial growth.
the nurse recom-
mend?
4. A nurse is con- Initiate weekly injections of vitamin B12.
tributing to the The nurse should recommend that weekly injections of vitamin B12 be initiated
plan of care for for a client who has pernicious anemia, and then decrease to monthly. Pernicious
a client who has anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from
pernicious ane- the gastrointestinal tract.
mia. Which of the
following inter-
ventions should
the nurse recom-
mend?
5. No metformin If mom was on metformin, she will be off of metformin because metformin does
while pregnant! not go into baby. Baby would come out super high!
So she she starts on insulin sliding scale before meals and bedtime. But her baby
is going to have some issues. First off, she goes hypo and hyperglycemic. Baby
has more anomalies, meaning might have limb problem, might have an organ
problem, more miscarriages, more fetal death.
Ex: macrosomia. A 120 - pound mom delivers an 11-pound baby. That is not
atypical for diabetic, cause that baby had a lot richer source of sugar going on.
6. Cardiac Disease Women who have cardiac issues can still have a baby. The baby is IUGR (intrauter-
in Pregnancy ine growth restriction). It's a tiny baby. Mod doesn't circulate well, so why would we
think baby would circulate well? He may come out at 4 pounds and be full-term.
Mother has to take medicines, but they'll be modified. Propranolol will not hurt
the baby. Heparin will not hurt the baby (No Warfarin!) . And Digoxin will not hurt
the baby. These are things that'll help mom maintain her cardiac problems. She
might even take prophylactic penicillin to make sure she doesn't have difficulties.
, ATI Comprehensive NCLEX-PN Review 10-16-2024 + + +
Study online at https://quizlet.com/_ftb92c
She is high-risk automatically if she lives with cardiac diseases. Remember, this is
one of those acute-over-chronic things. During the delivery, the acutes thing is the
delivery. She lives with the chronicity of having a heart problem.
In the second stage of labor, please know that's the pushing stage. So she has
to have her head up. She can't breathe. Think of what lithotomy position is - the
woman down with the legs and hip up, ready fo the baby to be caught by the
doctor. Well, guess what? This might be when the lady gets to sit up like this, and
the doctor's on a little chair down there, or the midwife, because she can't breathe
if you put her in lithotomy. HOB is head of bed - up !
7. A nurse arrives at 1. A client who has a closed fracture reporting "a pain level of 3",
a work site explo- 2. A client who has fixed pupils and agonal respirations.
sion. Which of the 3. A client who has burns to face with respiratory stridor.
following clients 4. A client who has type 2 diabetes mellitus who is disoriented
should be triaged Rationale : In an explosion you see hot vapor that is breathed in: there are burns
first? on inside of throat
Use-SURVIVAL POTENTIAL: Possible to have respiratory burns as well
#2 has who has fixed pupils and agonal respirations (2gasps /min).=brain injury,
will have black tag #4 will be yellow tag, they will be next to help (30min-2hour);
#1 will be green tag (will help to evacuate).
8.
9. A client who is Blood pressure 166/110 mm Hg and proteinuria 4+
at 37 weeks of Rationale: The persistent headache and visual changes are consistent with severe
gestation reports preeclampsia. With severe preeclampsia the blood pressure is going to be higher
severe headache and we know that it should be on two separate occasions 6 hours apart when the
with blurry vision diagnosis for preeclampsia is being made. Proteinuria will also be present and this
and seeing spots! one you'll notice we've got a four plus with severe preeclampsia (3 and higher)
That develops after 20 weeks gestation.
Study online at https://quizlet.com/_ftb92c
1. A nurse is admit- Instructor: "I would like to point out with BP! When the blood pressure is below
ting a client who 100 systolic you want to think in the back of your mind -this client could be in shock.
sustained a C3 The majority of client are 100 or grater. There are some elderly who can have less
spinal cord injury. than 100 that is their normal.
Which of the fol-
lowing findings
should the nurse
recognize as the
priority of care?
1. Heart rate
52/min.
2. Respiratory
10/min (COR-
RECT)
3. Temperature
36 C (98.8 F)
4. Blood pressure
88/54 mm Hg
2. What is concep- Conceptual learning encourages students to build upon current knowledge and
tual learning in familiar experiences, relate these experiences to learning new material, and inte-
nursing? (ati) grate new learning into clinical practice.
3. A nurse is as- Verify the information on the packed RBCs with another nurse
sisting in devel- The nurse should verify the information on the label of the packed RBCs with an-
oping the plan other nurse. She should also verify the information on the label with the provider's
of care for an order, the blood administration form from the blood bank, and with the client
older adult client armband and blood bracelet.
who is to receive Infuse the packed RBCs over 4 hr The nurse should administer packed RBCs slowly
a unit of packed to allow the older adult client's body time to adjust to the increased fluid volume.
red blood cells The blood should be infused over 4 hr .Allow the packed RBCs to warm at room
(RBCs). Which temperature for 1 hr before starting the transfusion.
, ATI Comprehensive NCLEX-PN Review 10-16-2024 + + +
Study online at https://quizlet.com/_ftb92c
of the following The nurse should start the blood within 30 min after arriving on the unit, to
actions should decrease the risk of bacterial growth.
the nurse recom-
mend?
4. A nurse is con- Initiate weekly injections of vitamin B12.
tributing to the The nurse should recommend that weekly injections of vitamin B12 be initiated
plan of care for for a client who has pernicious anemia, and then decrease to monthly. Pernicious
a client who has anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from
pernicious ane- the gastrointestinal tract.
mia. Which of the
following inter-
ventions should
the nurse recom-
mend?
5. No metformin If mom was on metformin, she will be off of metformin because metformin does
while pregnant! not go into baby. Baby would come out super high!
So she she starts on insulin sliding scale before meals and bedtime. But her baby
is going to have some issues. First off, she goes hypo and hyperglycemic. Baby
has more anomalies, meaning might have limb problem, might have an organ
problem, more miscarriages, more fetal death.
Ex: macrosomia. A 120 - pound mom delivers an 11-pound baby. That is not
atypical for diabetic, cause that baby had a lot richer source of sugar going on.
6. Cardiac Disease Women who have cardiac issues can still have a baby. The baby is IUGR (intrauter-
in Pregnancy ine growth restriction). It's a tiny baby. Mod doesn't circulate well, so why would we
think baby would circulate well? He may come out at 4 pounds and be full-term.
Mother has to take medicines, but they'll be modified. Propranolol will not hurt
the baby. Heparin will not hurt the baby (No Warfarin!) . And Digoxin will not hurt
the baby. These are things that'll help mom maintain her cardiac problems. She
might even take prophylactic penicillin to make sure she doesn't have difficulties.
, ATI Comprehensive NCLEX-PN Review 10-16-2024 + + +
Study online at https://quizlet.com/_ftb92c
She is high-risk automatically if she lives with cardiac diseases. Remember, this is
one of those acute-over-chronic things. During the delivery, the acutes thing is the
delivery. She lives with the chronicity of having a heart problem.
In the second stage of labor, please know that's the pushing stage. So she has
to have her head up. She can't breathe. Think of what lithotomy position is - the
woman down with the legs and hip up, ready fo the baby to be caught by the
doctor. Well, guess what? This might be when the lady gets to sit up like this, and
the doctor's on a little chair down there, or the midwife, because she can't breathe
if you put her in lithotomy. HOB is head of bed - up !
7. A nurse arrives at 1. A client who has a closed fracture reporting "a pain level of 3",
a work site explo- 2. A client who has fixed pupils and agonal respirations.
sion. Which of the 3. A client who has burns to face with respiratory stridor.
following clients 4. A client who has type 2 diabetes mellitus who is disoriented
should be triaged Rationale : In an explosion you see hot vapor that is breathed in: there are burns
first? on inside of throat
Use-SURVIVAL POTENTIAL: Possible to have respiratory burns as well
#2 has who has fixed pupils and agonal respirations (2gasps /min).=brain injury,
will have black tag #4 will be yellow tag, they will be next to help (30min-2hour);
#1 will be green tag (will help to evacuate).
8.
9. A client who is Blood pressure 166/110 mm Hg and proteinuria 4+
at 37 weeks of Rationale: The persistent headache and visual changes are consistent with severe
gestation reports preeclampsia. With severe preeclampsia the blood pressure is going to be higher
severe headache and we know that it should be on two separate occasions 6 hours apart when the
with blurry vision diagnosis for preeclampsia is being made. Proteinuria will also be present and this
and seeing spots! one you'll notice we've got a four plus with severe preeclampsia (3 and higher)
That develops after 20 weeks gestation.
