ATI Comprehensive/ NCLEX Review
Study online at https://quizlet.com/_h17szi
1. Endometiral in- with a prolonged rupture of membranes, not vacuum-assisted births.
fection usually
occurs
2. Intenstinal gas is clients following a cesarean birth
a common side ef-
fect of
3. Cervical lacera- vacuum-assisted birth are rare but can include perineal, vaginal, or cervical lacer-
tions are com- ations
mon complica-
tions from
4. When a client the nurse should initially stay with the client and call for help. Next, the nurse
is experiencing a should place saline-soaked gauze on the exposed bowels to keep the internal
wound eviscera- organs moist. The nurse should then place the client in a supine position with his
tion... 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.
5. Valproic acid can hepatic toxicity
cause
6. continuous pas- Turn of the CPM machine during meals to promote comfort and dietary intake.
sive motion -The affected extremity should maintain neutral alignment.
(CPM) machine
7. Heparin 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.
8.
, ATI Comprehensive/ NCLEX Review
Study online at https://quizlet.com/_h17szi
Correct method 1. Hold to rail with one hand and crutches with the other hand.
for walking 2. Push down on the stair rail and the crutches and step up with the "unaffected"
upstairs with leg.
crutches 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.
9. Droplet precau- DROPLET: "SPIDERMAn"
tions
-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
10. Airborne precau- AIRBORNE: "My Chicken Hez TB"
tions:
-Measles
, ATI Comprehensive/ NCLEX Review
Study online at https://quizlet.com/_h17szi
-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.
11. Contact precau- CONTACT: "MRS WEE"
tions
-MRSA
-RSV
-Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, sca-
bies, 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.
12. Stage I pressure Intact skin with an area of persistent, nonblanchable redness, typically over a bony
ulcer prominence, that may feel warmer or cooler than the adjacent tissue. The tissue
, ATI Comprehensive/ NCLEX Review
Study online at https://quizlet.com/_h17szi
is swollen and has congestion, with possible discomfort at the site. With darker
skin tones, the ulcer may appear blue or purple.
13. Stage II pressure Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is
ulcer 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.
14. Stage III pres- Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The
sure ulcer 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.
15. Stage IV pressure Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle,
ulcer 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)
16. Glasgow Coma is calculated by using appropriate stimuli (a painful stimulus may be necessary)
Score 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.
Study online at https://quizlet.com/_h17szi
1. Endometiral in- with a prolonged rupture of membranes, not vacuum-assisted births.
fection usually
occurs
2. Intenstinal gas is clients following a cesarean birth
a common side ef-
fect of
3. Cervical lacera- vacuum-assisted birth are rare but can include perineal, vaginal, or cervical lacer-
tions are com- ations
mon complica-
tions from
4. When a client the nurse should initially stay with the client and call for help. Next, the nurse
is experiencing a should place saline-soaked gauze on the exposed bowels to keep the internal
wound eviscera- organs moist. The nurse should then place the client in a supine position with his
tion... 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.
5. Valproic acid can hepatic toxicity
cause
6. continuous pas- Turn of the CPM machine during meals to promote comfort and dietary intake.
sive motion -The affected extremity should maintain neutral alignment.
(CPM) machine
7. Heparin 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.
8.
, ATI Comprehensive/ NCLEX Review
Study online at https://quizlet.com/_h17szi
Correct method 1. Hold to rail with one hand and crutches with the other hand.
for walking 2. Push down on the stair rail and the crutches and step up with the "unaffected"
upstairs with leg.
crutches 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.
9. Droplet precau- DROPLET: "SPIDERMAn"
tions
-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
10. Airborne precau- AIRBORNE: "My Chicken Hez TB"
tions:
-Measles
, ATI Comprehensive/ NCLEX Review
Study online at https://quizlet.com/_h17szi
-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.
11. Contact precau- CONTACT: "MRS WEE"
tions
-MRSA
-RSV
-Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, sca-
bies, 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.
12. Stage I pressure Intact skin with an area of persistent, nonblanchable redness, typically over a bony
ulcer prominence, that may feel warmer or cooler than the adjacent tissue. The tissue
, ATI Comprehensive/ NCLEX Review
Study online at https://quizlet.com/_h17szi
is swollen and has congestion, with possible discomfort at the site. With darker
skin tones, the ulcer may appear blue or purple.
13. Stage II pressure Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is
ulcer 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.
14. Stage III pres- Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The
sure ulcer 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.
15. Stage IV pressure Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle,
ulcer 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)
16. Glasgow Coma is calculated by using appropriate stimuli (a painful stimulus may be necessary)
Score 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.
