ATI Comprehensive/ NCLEX Review
Endometiral infection usually occurs - ---correct answer ---with a
prolonged rupture of membranes, not vacuum-assisted births.
Intenstinal gas is a common side effect of - ---correct answer ---clients
following a cesarean birth
Cervical lacerations are common complications from - ---correct answer
---vacuum-assisted birth are rare but can include perineal, vaginal, or cervical
lacerations
When a client is experiencing a wound evisceration... - ---correct 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 - ---correct answer ---hepatic toxicity
continuous passive motion (CPM) machine - ---correct answer ---Turn of
the CPM machine during meals to promote comfort and dietary intake.
-The affected extremity should maintain neutral alignment.
,Heparin - ---correct 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 - ---correct 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 - ---correct 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: - ---correct 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 - ---correct 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 - ---correct 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 - ---correct 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.
Endometiral infection usually occurs - ---correct answer ---with a
prolonged rupture of membranes, not vacuum-assisted births.
Intenstinal gas is a common side effect of - ---correct answer ---clients
following a cesarean birth
Cervical lacerations are common complications from - ---correct answer
---vacuum-assisted birth are rare but can include perineal, vaginal, or cervical
lacerations
When a client is experiencing a wound evisceration... - ---correct 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 - ---correct answer ---hepatic toxicity
continuous passive motion (CPM) machine - ---correct answer ---Turn of
the CPM machine during meals to promote comfort and dietary intake.
-The affected extremity should maintain neutral alignment.
,Heparin - ---correct 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 - ---correct 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 - ---correct 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: - ---correct 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 - ---correct 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 - ---correct 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 - ---correct 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.
