NCLEX ATI Comprehensive
fundal height - ANS at 20 weeks, fundus is at umbilicus
incr ht by 1 cm/week after 20 weeks
at 36 weeks, fundus is at xiphoid process
ex: 24 wk? 24 cm + or - 2 cm
clozapine - ANS 2nd gen Antipsychotic med for schizophrenia
adverse effect: agranulocytosis (sore throat, malaise, fever), leukopenia - monitor WBCs and
ANC closely before tx and during, hypotension, GI upset (take with food), dyslipidemia (elevated
trig and cholesterol), hyperglycemia
schizophrenia brain structure - ANS atrophy of lateral and or 3rd ventricles
The nurse plans care for an older client admitted with a fractured hip. Which analgesic
prescribed by the primary health care provider at standard doses and frequencies would the
nurse question? - ANS Ibuprofen, morphine sulfate, tramadol, and meperidine are all
analgesics. Ibuprofen is a nonsteroidal anti-inflammatory medication and is acceptable for use
in the older client. Tramadol hydrochloride is a centrally acting nonopioid analgesic used for
moderate to moderately severe pain and is a suitable option in this situation. Morphine sulfate
and meperidine hydrochloride are both opioid analgesics, and both are effective in treating
acute pain. Because meperidine hydrochloride produces a neurotoxic metabolite, it would be
used only short term and is not recommended for use in older clients
PVC - ANS abnormal ectopic beats originating in the ventricles characterized by an absence of
P waves, the presence of wide and bizarre QRS complexes, and a compensatory pause that
follows the ectopy.
PP factors rx thromboembolic disorders - ANS smoking, varicose veins, obesity, a history of
thrombophlebitis, pregnant clients older than 35 years or who have had more than three
pregnancies, and clients who have had a cesarean birth
the carina - ANS the ET tube should lie 2 cm above the carina - the bifurcation of R and L
bronchi
bowel sounds - ANS normal bowel sounds = high-pitched clicks/ gurgles.
Loud gurgles (borborygmi) = hyperperistalsis
More high-pitched and louder (hyperresonance) when the intestines are under tension, such as
in intestinal obstruction.
swishing/buzzing sound represents turbulent blood flow associated with a bruit (abnormal)
blood transfusion tubing - ANS in-line filter, macrodrip, no tinting or injection ports
,metronidazole - ANS harmless side effect: dark urine, metallic taste, GI upset
avoid alcohol for 3 days after completion
tx trichomoniasis
scopolamine - ANS anticholinergic medication
adverse effect: dry mouth, urinary retention, dilated pupils, decr sweating
Due to an extreme staff shortage, the nurse has been sent to the intensive care unit to assist
registered nurses in the care of clients. The nurse understands that which factor is most
important to consider when treating a client with cardiogenic shock? - ANS 1) Use of diuretics to
decrease circulating volume
2) Use of whole blood to easily restore fluid volume
3) Use of intravenous and oral fluids to restore circulating volume
4) Restriction of volume expanders because of secondary pulmonary edema (correct)
A client in cardiogenic shock may have secondary issues such as pulmonary edema due to the
ineffective pumping mechanism of the heart. Fluid restoration is a key ingredient in treating
shock states although it must be used conservatively in clients with cardiogenic shock.
Therefore, options 2 and 3 are incorrect. Option 1 is incorrect because the problem is with the
pumping action of the heart and not increased blood volume
aplastic anemia diagnosis confirmed with - ANS bone marrow biopsy
brace care - ANS avoid lotions and powders which cake and cause irritation
The nurse provides teaching on how to relieve discomfort to a client in the second trimester of
pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which
statement made by the client indicates an understanding of the teaching? - ANS 1) "When I get
home, I need to lie on my left side with my feet in a dorsiflexed position."
2) "I need to soak in a tub bath of hot water when I get home and then perform pelvic tilt
exercises."
3) "When I get home, I need to lie on my right side with my feet elevated on a pillow and with a
heating pad on my back."
4)"When I get home, I need to lie on the floor with my legs elevated on a couch and turn my hips
and knees at right angles. (CORRECT)
Lying on the floor with the legs elevated on a couch with the hips and knees at right angles will
produce a posture of pelvic tilt while countering gravity, which is the force that leads to edema of
the lower extremities. Lying on the left side with the feet dorsiflexed may help with the reduction
of hemorrhoids. Remember that heat needs to be prescribed by a primary health care provider
(PHCP).
,PICC line home care - ANS The client would be taught that only minor activity restrictions apply
with this type of catheter. The client needs to protect the site during bathing and would carry or
wear a MedicAlert identification. The client needs to have a repair kit in the home for use as
needed because the catheter is for long-term use.
Pavlik Harness - ANS hips in flexion and abduction
captopril - ANS ACE-i (adverse effect: cough - report)
Adequate fluid is important, but 4 quarts (4 liters) of water daily could actually aggravate the
hypertension. avoid standing in one position for long periods, to change positions slowly, and to
avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The
client would be instructed to monitor for signs of orthostatic hypotension, such as dizziness,
light-headedness, weakness, and syncope.
pernicious anemia - ANS signs: weakness, mild diarrhea, wt loss, tachycardia, and a smooth
red tongue that is sore (glossitis). The client also may have nervous system signs and
symptoms such as paresthesias, difficulty with balance, and occasional confusion
give Vitamin B12
position after tube feeding - ANS high fowlers, R side 30-60 min (facilitates gastric emptying,
prevents vomiting & aspiration)
Ca - ANS 9-10.5
hypocalcemia: tetany, Chvostek's, hypotension (bc decr Ca and decr heart contraction) and
ventricular dysrhythmias and prolonged QT and ST interval
RDA for older adult female: 1200 mg
The nurse is performing an admission assessment on a child with a seizure disorder. The nurse
is interviewing the child's parents to determine their adjustment to their child's chronic illness.
Which statement, if made by the parents, would indicate a need for further teaching? - ANS 1)
Our child sleeps in our bedroom at night." (CORRECT)
2) "We worry about injuries when our child has a seizure."
3) "Our child is involved in a swim program with neighbors and friends."
4) "Our babysitter just completed cardiopulmonary resuscitation training."
Parents are especially concerned about seizures that might go undetected during the night. The
nurse needs to decrease parental overprotection and would suggest the use of a baby monitor
at night. Involvement in a swim program and knowing CPR identify parental understanding of
the disorder. Worrying about injuries when a child has a seizure is a common concern. The
parents need to be reminded that as the child grows, they cannot always observe their child, but
their knowledge of seizure activity and care is appropriate to minimize complications.
Divalproex sodium - ANS tx absence seizures
, most frequent side effects: gastrointestinal (GI) disturbances, such as nausea, vomiting, and
indigestion
pregnant integumentary changes - ANS Striae gravidarum, or stretch marks, reflect separation
within the underlying connective tissue of the skin. After birth they usually fade, although they
NEVER DISAPPEAR COMPLETELY
An epulis is a red raised nodule on the gums that bleeds easily. Chloasma, or mask of
pregnancy, is a blotchy, browning hyperpigmentation of the skin over the cheeks, nose, and
forehead and is especially noticed in dark-complexioned pregnant individuals. Chloasma usually
fades after the birth. Telangiectasias, or vascular "spiders," are tiny star-shaped or
branch-shaped, slightly raised, and pulsating end arterioles usually found on the neck, thorax,
face, and arms. They occur as a result of elevated levels of circulating estrogen. The spiders
usually disappear after delivery.
measles (rubeola) precautions - ANS airborne precautions - MASK, GLOVES. Any articles that
are contaminated would be bagged and labeled.
A client undergoing hemodialysis begins to experience muscle cramping. What is the best
action by the hemodialysis nurse in this situation? - ANS Muscle cramps during hemodialysis
result from either too rapid removal of water and sodium or neuromuscular hypersensitivity. The
nurse corrects this situation by either SLOWING DOWN THE ULTRAFILTRATION RATE on the
hemodialyzer or administering hypertonic or isotonic normal saline
The nurse would include which interventions in the plan of care for a client with hypothyroidism?
Select all that apply. - ANS 1) Provide a cool environment for the client.
2) Instruct the client to consume a high-fat diet.
3) Instruct the client about thyroid replacement therapy. (CORRECT)
4) Encourage the client to consume fluids and high-fiber foods in the diet. (CORRECT)
5) Inform the client that iodine preparations will be prescribed to treat the disorder.
6) Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain
occur. (CORRECT)
The clinical manifestations of hypothyroidism are the result of decreased metabolism from low
levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing
measures to support the signs and symptoms related to decreased metabolism. The client often
has cold intolerance and requires a warm environment. The nurse encourages the client to
consume a well-balanced diet that is low in fat for weight reduction and high in fluids and
high-fiber foods to prevent constipation. Iodine preparations may be used to treat
hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce
the production and release of thyroid hormone; they are not used to treat hypothyroidism. The
client is instructed to notify the PHCP if chest pain occurs because it could be an indication of
overreplacement of thyroid hormone.
s/s: dry coarse hair, periorbital edema, bradycardia
fundal height - ANS at 20 weeks, fundus is at umbilicus
incr ht by 1 cm/week after 20 weeks
at 36 weeks, fundus is at xiphoid process
ex: 24 wk? 24 cm + or - 2 cm
clozapine - ANS 2nd gen Antipsychotic med for schizophrenia
adverse effect: agranulocytosis (sore throat, malaise, fever), leukopenia - monitor WBCs and
ANC closely before tx and during, hypotension, GI upset (take with food), dyslipidemia (elevated
trig and cholesterol), hyperglycemia
schizophrenia brain structure - ANS atrophy of lateral and or 3rd ventricles
The nurse plans care for an older client admitted with a fractured hip. Which analgesic
prescribed by the primary health care provider at standard doses and frequencies would the
nurse question? - ANS Ibuprofen, morphine sulfate, tramadol, and meperidine are all
analgesics. Ibuprofen is a nonsteroidal anti-inflammatory medication and is acceptable for use
in the older client. Tramadol hydrochloride is a centrally acting nonopioid analgesic used for
moderate to moderately severe pain and is a suitable option in this situation. Morphine sulfate
and meperidine hydrochloride are both opioid analgesics, and both are effective in treating
acute pain. Because meperidine hydrochloride produces a neurotoxic metabolite, it would be
used only short term and is not recommended for use in older clients
PVC - ANS abnormal ectopic beats originating in the ventricles characterized by an absence of
P waves, the presence of wide and bizarre QRS complexes, and a compensatory pause that
follows the ectopy.
PP factors rx thromboembolic disorders - ANS smoking, varicose veins, obesity, a history of
thrombophlebitis, pregnant clients older than 35 years or who have had more than three
pregnancies, and clients who have had a cesarean birth
the carina - ANS the ET tube should lie 2 cm above the carina - the bifurcation of R and L
bronchi
bowel sounds - ANS normal bowel sounds = high-pitched clicks/ gurgles.
Loud gurgles (borborygmi) = hyperperistalsis
More high-pitched and louder (hyperresonance) when the intestines are under tension, such as
in intestinal obstruction.
swishing/buzzing sound represents turbulent blood flow associated with a bruit (abnormal)
blood transfusion tubing - ANS in-line filter, macrodrip, no tinting or injection ports
,metronidazole - ANS harmless side effect: dark urine, metallic taste, GI upset
avoid alcohol for 3 days after completion
tx trichomoniasis
scopolamine - ANS anticholinergic medication
adverse effect: dry mouth, urinary retention, dilated pupils, decr sweating
Due to an extreme staff shortage, the nurse has been sent to the intensive care unit to assist
registered nurses in the care of clients. The nurse understands that which factor is most
important to consider when treating a client with cardiogenic shock? - ANS 1) Use of diuretics to
decrease circulating volume
2) Use of whole blood to easily restore fluid volume
3) Use of intravenous and oral fluids to restore circulating volume
4) Restriction of volume expanders because of secondary pulmonary edema (correct)
A client in cardiogenic shock may have secondary issues such as pulmonary edema due to the
ineffective pumping mechanism of the heart. Fluid restoration is a key ingredient in treating
shock states although it must be used conservatively in clients with cardiogenic shock.
Therefore, options 2 and 3 are incorrect. Option 1 is incorrect because the problem is with the
pumping action of the heart and not increased blood volume
aplastic anemia diagnosis confirmed with - ANS bone marrow biopsy
brace care - ANS avoid lotions and powders which cake and cause irritation
The nurse provides teaching on how to relieve discomfort to a client in the second trimester of
pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which
statement made by the client indicates an understanding of the teaching? - ANS 1) "When I get
home, I need to lie on my left side with my feet in a dorsiflexed position."
2) "I need to soak in a tub bath of hot water when I get home and then perform pelvic tilt
exercises."
3) "When I get home, I need to lie on my right side with my feet elevated on a pillow and with a
heating pad on my back."
4)"When I get home, I need to lie on the floor with my legs elevated on a couch and turn my hips
and knees at right angles. (CORRECT)
Lying on the floor with the legs elevated on a couch with the hips and knees at right angles will
produce a posture of pelvic tilt while countering gravity, which is the force that leads to edema of
the lower extremities. Lying on the left side with the feet dorsiflexed may help with the reduction
of hemorrhoids. Remember that heat needs to be prescribed by a primary health care provider
(PHCP).
,PICC line home care - ANS The client would be taught that only minor activity restrictions apply
with this type of catheter. The client needs to protect the site during bathing and would carry or
wear a MedicAlert identification. The client needs to have a repair kit in the home for use as
needed because the catheter is for long-term use.
Pavlik Harness - ANS hips in flexion and abduction
captopril - ANS ACE-i (adverse effect: cough - report)
Adequate fluid is important, but 4 quarts (4 liters) of water daily could actually aggravate the
hypertension. avoid standing in one position for long periods, to change positions slowly, and to
avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The
client would be instructed to monitor for signs of orthostatic hypotension, such as dizziness,
light-headedness, weakness, and syncope.
pernicious anemia - ANS signs: weakness, mild diarrhea, wt loss, tachycardia, and a smooth
red tongue that is sore (glossitis). The client also may have nervous system signs and
symptoms such as paresthesias, difficulty with balance, and occasional confusion
give Vitamin B12
position after tube feeding - ANS high fowlers, R side 30-60 min (facilitates gastric emptying,
prevents vomiting & aspiration)
Ca - ANS 9-10.5
hypocalcemia: tetany, Chvostek's, hypotension (bc decr Ca and decr heart contraction) and
ventricular dysrhythmias and prolonged QT and ST interval
RDA for older adult female: 1200 mg
The nurse is performing an admission assessment on a child with a seizure disorder. The nurse
is interviewing the child's parents to determine their adjustment to their child's chronic illness.
Which statement, if made by the parents, would indicate a need for further teaching? - ANS 1)
Our child sleeps in our bedroom at night." (CORRECT)
2) "We worry about injuries when our child has a seizure."
3) "Our child is involved in a swim program with neighbors and friends."
4) "Our babysitter just completed cardiopulmonary resuscitation training."
Parents are especially concerned about seizures that might go undetected during the night. The
nurse needs to decrease parental overprotection and would suggest the use of a baby monitor
at night. Involvement in a swim program and knowing CPR identify parental understanding of
the disorder. Worrying about injuries when a child has a seizure is a common concern. The
parents need to be reminded that as the child grows, they cannot always observe their child, but
their knowledge of seizure activity and care is appropriate to minimize complications.
Divalproex sodium - ANS tx absence seizures
, most frequent side effects: gastrointestinal (GI) disturbances, such as nausea, vomiting, and
indigestion
pregnant integumentary changes - ANS Striae gravidarum, or stretch marks, reflect separation
within the underlying connective tissue of the skin. After birth they usually fade, although they
NEVER DISAPPEAR COMPLETELY
An epulis is a red raised nodule on the gums that bleeds easily. Chloasma, or mask of
pregnancy, is a blotchy, browning hyperpigmentation of the skin over the cheeks, nose, and
forehead and is especially noticed in dark-complexioned pregnant individuals. Chloasma usually
fades after the birth. Telangiectasias, or vascular "spiders," are tiny star-shaped or
branch-shaped, slightly raised, and pulsating end arterioles usually found on the neck, thorax,
face, and arms. They occur as a result of elevated levels of circulating estrogen. The spiders
usually disappear after delivery.
measles (rubeola) precautions - ANS airborne precautions - MASK, GLOVES. Any articles that
are contaminated would be bagged and labeled.
A client undergoing hemodialysis begins to experience muscle cramping. What is the best
action by the hemodialysis nurse in this situation? - ANS Muscle cramps during hemodialysis
result from either too rapid removal of water and sodium or neuromuscular hypersensitivity. The
nurse corrects this situation by either SLOWING DOWN THE ULTRAFILTRATION RATE on the
hemodialyzer or administering hypertonic or isotonic normal saline
The nurse would include which interventions in the plan of care for a client with hypothyroidism?
Select all that apply. - ANS 1) Provide a cool environment for the client.
2) Instruct the client to consume a high-fat diet.
3) Instruct the client about thyroid replacement therapy. (CORRECT)
4) Encourage the client to consume fluids and high-fiber foods in the diet. (CORRECT)
5) Inform the client that iodine preparations will be prescribed to treat the disorder.
6) Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain
occur. (CORRECT)
The clinical manifestations of hypothyroidism are the result of decreased metabolism from low
levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing
measures to support the signs and symptoms related to decreased metabolism. The client often
has cold intolerance and requires a warm environment. The nurse encourages the client to
consume a well-balanced diet that is low in fat for weight reduction and high in fluids and
high-fiber foods to prevent constipation. Iodine preparations may be used to treat
hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce
the production and release of thyroid hormone; they are not used to treat hypothyroidism. The
client is instructed to notify the PHCP if chest pain occurs because it could be an indication of
overreplacement of thyroid hormone.
s/s: dry coarse hair, periorbital edema, bradycardia
