ATI COMPREHENSIVE/ NCLEX REVIEW QUESTIONS AND ANSWERS

ATI COMPREHENSIVE/ NCLEX
REVIEW QUESTIONS AND
ANSWERS
Endometiralvbinfectionvbusuallyvboccursvb-vbanswer--
withvbavbprolongedvbrupturevbofvbmembranes,vbnotvbvacuum-assistedvbbirths.

Intenstinalvbgasvbisvbavbcommonvbsidevbeffectvbofvb-vbanswer--
clientsvbfollowingvbavbcesareanvbbirth

Cervicalvblacerationsvbarevbcommonvbcomplicationsvbfromvb-vbanswer--vacuum-
assistedvbbirthvbarevbrarevbbutvbcanvbincludevbperineal,vbvaginal,vborvbcervicalvblacer
ations

Whenvbavbclientvbisvbexperiencingvbavbwoundvbevisceration...vb-vbanswer--
thevbnursevbshouldvbinitiallyvbstayvbwithvbthevbclientvbandvbcallvbforvbhelp.vbNext,vbthev
bnursevbshouldvbplacevbsaline-

soakedvbgauzevbonvbthevbexposedvbbowelsvbtovbkeepvbthevbinternalvborgansvbmoist.
vbThevbnursevbshouldvbthenvbplacevbthevbclientvbinvbavbsupinevbpositionvbwithvbhisvbhi

psvbandvbkneesvbbentvbtovbrelievevbpressurevbfromvbthevbopenvbwound.vbLast,vbthevb
nursevbshouldvbtakevbthevbclient'svbvitalvbsignsvbtovbassessvbforvbchangesvbinvbhemo
dynamics.

Valproicvbacidvbcanvbcausevb-vbanswer--hepaticvbtoxicity

continuousvbpassivevbmotionvb(CPM)vbmachinevb-vbanswer--
TurnvbofvbthevbCPMvbmachinevbduringvbmealsvbtovbpromotevbcomfortvbandvbdietaryvb
intake.
-Thevbaffectedvbextremityvbshouldvbmaintainvbneutralvbalignment.

Heparinvb-vbanswer--
isvbanvbanticoagulantvbthatvbinhibitsvbthevbconversationvbofvbprothrombinvbtovbthrom
bin.vbPatientsvbonvbanvbanticoagulantvbdrugvbsuchvbasvbheparinvbarevbatvbanvbincrea
sedvbriskvbofvbbleeding.
-
Signsvbofvbbleeding:vbecchymoses,vbtarryvbstools,vbmucosalvbbleeding,vbandvbpink/
vbred-tingedvburine.



Correctvbmethodvbforvbwalkingvbupstairsvbwithvbcrutchesvb-vbanswer--
1.vbHoldvbtovbrailvbwithvbonevbhandvbandvbcrutchesvbwithvbthevbothervbhand.
2.vbPushvbdownvbonvbthevbstairvbrailvbandvbthevbcrutchesvbandvbstepvbupvbwithvbthevb"
unaffected"vbleg.
3.vbIfvbnotvballowedvbtovbplacevbweightvbonvbthevb"affected"vbleg,vbhopvbupvbwithvbthevb
"unaffected"vbleg.

,4.vbBringvbthevb"affected"vblegvbandvbthevbcrutchesvbupvbbesidevbthevb"unaffected"vbl
eg.
5.Remember,vbthevb"unaffected"vblegvbgoesvbupvbfirstvbandvbthevbcrutchesvbmovevb
withvbthevb"affected"vbleg.

Dropletvbprecautionsvb-vbanswer--DROPLET:vb"SPIDERMAn"


-Sepsis
-ScarletvbFever
-Strep
-Pertussis
-Pneumonia
-Parvovirus
-Influenza
-Diphtheria
-Epiglottitis
-Rubella
-Mumps
-Adenovirus

Management:vbPrivatevbroom/maskvb

-
Avbprivatevbroomvbavbromvbwithvbothervbclientsvbwithvbthevbsamevbinfectiousvbdiseas
e.
-Masksvbforvbprovidersvbandvbvisitors

Airbornevbprecautions:vb-vbanswer--AIRBORNE:vb"MyvbChickenvbHezvbTB"

-Measles
-Chickenvbpox
-Herpesvbzoster
-TB

Management:vbneg.vbpressurevbroom,vbprivatevbroom,vbmask,vbn-95vbforvbTB.

-Avbprivatevbroom
-Masksvborvbrespiratoryvbprotectionvbdevicesvbforvbcaregiversvbandvbvisitors.
-AnvbN95vborvbhigh-
efficiencyvbparticulatevbairvb(HEPA)vbrespiratorvbisvbusedvbifvbthevbclientvbisvbknownvb
orvbsuspectedvbtovbhavevbTB.
-
Negativevbpressurevbairflowvbexchangevbinvbthevbroomvbofvbatvbleastvbsixvbexchang
esvbpervbhour.

Contactvbprecautionsvb-vbanswer--CONTACT:vb"MRSvbWEE"

-MRSA
-RSV

,-
Skinvbinfectionsvb(herpesvbzoster,vbcutaneousvbdiphtheria,vbimpetigo,vbpediculosis
,vbscabies,vbandvbstaph)
-Woundvbinfections
-Entericvbinfectionsvb(C-Diff)
-Eyevbinfectionsvb(conjunctivitis)

Management:vbgown,vbgloves,vbgoggles,vbprivatevbroom

VRSAvb-
vbcontactvbandvbairbornevbprecautionsvb(privatevbroom,vbdoorvbclosed,vbnegativevbp

ressure)

-Avbprivatevbroomvborvbavbroomvbwithvbothervbclientsvbwithvbthevbsamevbinfection.
-Glovesvbandvbgownsvbwornvbbyvbthevbcaregiversvbandvbvisitors.

StagevbIvbpressurevbulcervb-vbanswer--
Intactvbskinvbwithvbanvbareavbofvbpersistent,vbnonblanchablevbredness,vbtypicallyvbo
vervbavbbonyvbprominence,vbthatvbmayvbfeelvbwarmervborvbcoolervbthanvbthevbadjace
ntvbtissue.vbThevbtissuevbisvbswollenvbandvbhasvbcongestion,vbwithvbpossiblevbdisco
mfortvbatvbthevbsite.vbWithvbdarkervbskinvbtones,vbthevbulcervbmayvbappearvbbluevborvb
purple.

StagevbIIvbpressurevbulcervb-vbanswer--Partial-
thicknessvbskinvblossvbinvolvingvbthevbepidermisvbandvbthevbdermis.vbThevbulcervbisv
bvisiblevbandvbsuperficialvbandvbmayvbappearvbasvbanvbabrasion,vbblister,vborvbshallo

wvbcrater.vbEdemavbpersists,vbandvbthevbulcervbmayvbbecomevbinfected,vbpossiblyvb
withvbpainvbandvbscantvbdrainage.

StagevbIIIvbpressurevbulcervb-vbanswer--Full-
thicknessvbtissuevblossvbwithvbdamagevbtovborvbnecrosisvbofvbsubcutaneousvbtissue
.vbThevbulcervbmayvbextendvbdownvbto,vbbutvbnotvbthrough,vbunderlyingvbfascia.vbThe
vbulcervbappearsvbasvbavbdeepvbcratervbwithvborvbwithoutvbunderminingvbofvbadjacent

vbtissuevbandvbwithoutvbexposedvbmusclevborvbbone.vbDrainagevbandvbinfectionvbare

vbcommon.



StagevbIVvbpressurevbulcervb-vbanswer--Full-
thicknessvbtissuevblossvbwithvbdestruction,vbtissuevbnecrosis,vborvbdamagevbtovbmu
scle,vbbone,vborvbsupportingvbstructures.vbTherevbmayvbbevbsinusvbtracts,vbdeepvbp
ocketsvbofvbinfection,vbtunneling,vbundermining,vbescharvb(blackvbscab-
likevbmaterial),vborvbsloughvb(tan,vbyellow,vborvbgreenvbscab-likevbmaterial)

GlasgowvbComavbScorevb-vbanswer--
isvbcalculatedvbbyvbusingvbappropriatevbstimulivb(avbpainfulvbstimulusvbmayvbbevbnec
essary)vbandvbthenvbassessingvbthevbclientsvbresponsevbinvbthreevbareas.

Eyevbopeningvb(E)vb-
vbThevbbestvbeyevbresponse,vbwithvbresponsesvbrangingvbfromvb4vbtovb1

vb4vb=vbEyevbopeningvboccursvbspontaneously.

vb3vb=vbEyevbopeningvboccursvbsecondaryvbtovbvoice.

, vb2vb=vbEyevbopeningvboccursvbsecondaryvbtovbpain.
vb1vb=vbEyevbopeningvbdoesvbnotvboccur.
vb

Verbalvb(V)vb-
vbThevbbestvbverbalvbresponse,vbwithvbresponsesvbrangingvbfromvb5vbtovb1

vb5vb=vbConversationvbisvbcoherentvbandvboriented.

vb4vb=vbConversationvbisvbincoherentvbandvbdisoriented.

vb3vb=vbWordsvbarevbspoken,vbbutvbinappropriately.

vb2vb=vbSoundsvbarevbmade,vbbutvbnovbwords.

vb1vb=vbVocalizationvbdoesvbnotvboccur.
vb

Motorvb(M)vb-
vbThevbbestvbmotorvbresponse,vbwithvbresponsesvbrangingvbfromvb6vbtovb1

vb6vb=vbCommandsvbarevbfollowed.

vb5vb=vbLocalvbreactionvbtovbpainvboccurs.

vb4vb=vbTherevbisvbavbgeneralvbwithdrawalvbtovbpain.

vb3vb=vbDecorticatevbposturevb(adductionvbofvbarms,vbflexionvbofvbelbowsvbandvbwrist

s)vbisvbpresent.
vb2vb=vbDecerebratevbposturevb(abductionvbofvbarms,vbextensionvbofvbelbowsvbandvb

wrists)vbisvbpresent.
vb1vb=vbMotorvbresponsevbdoesvbnotvboccur.
vb

Responsesvbwithinvbeachvbsubscalevbarevbadded,vbwithvbthevbtotalvbscorevbquantita
tivelyvbdescribingvbthevbclient'svblevelvbofvbconsciousness.vbEvb+vbVvb+vbMvb=vbTotalvb
GCS

WhenvbverifyingvbNGvbtubevbplacement,vbthevbpHvbofvbaspiratedvbgastricvbfluidvbsho
uldvb-vbanswer--
Avbgoodvbindicationvbofvbappropriatevbplacementvbisvbobtainingvbgastricvbcontentsvb
withvbavbpHvbbetweenvb0vbandvb4.

Sodiumvb-vbanswer--136-145

Potassiumvb-vbanswer--3.5-5

TotalvbCalciumvb-vbanswer--9.0-10.5

Magnesiumvb-vbanswer--1.3-2.1

Phosphorusvb-vbanswer--3.0-4.5

BUNvb-vbanswer--10-20

Creatininevbmalesvb-vbanswer--0.6-1.2

Creatininevbfemalesvb-vbanswer--0.5-1.1

Glucosevb-vbanswer--70-105

HcbA1cvb-vbanswer--<6.5%

WBCvb-vbanswer--5,000-10000