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ATI Comprehensive/ NCLEX Review QUESTIONS AND ANSWERS GRADED A+ 2024/2025
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ATI Comprehensive/ NCLEX Review QUESTIONS AND ANSWERS GRADED A+ 2024/2025
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ATI Comprehensive/ NCLEX ReviewEndometiral contamination usually occurs - ANSwith a prolonged rupture of membranes,
now not vacuum-assisted births.
Intenstinal gas is a common side effect of - ANSclients following a cesarean birth
Cervical lacerations are commonplace headaches from - ANSvacuum-assisted start are rare
however can consist of perineal, vaginal, or cervical lacerations
When a patron is experiencing a wound evisceration... - ANSthe nurse should initially live
with the purchaser and call for assist. Next, the nurse should area saline-soaked gauze at
the exposed bowels to preserve the inner organs moist. The nurse need to then region the
patron in a supine role along with his hips and knees bent to relieve strain from the open
wound. Last, the nurse need to take the consumer's important signs to assess for changes in
hemodynamics.
Valproic acid can cause - ANShepatic toxicity
non-stop passive motion (CPM) system - ANSTurn of the CPM gadget for the duration of
meals to promote consolation and dietary intake.
-The affected extremity have to keep neutral alignment.
Heparin - ANSis an anticoagulant that inhibits the conversation of prothrombin to thrombin.
Patients on an anticoagulant drug which includes heparin are at an expanded chance of
bleeding.
-Signs of bleeding: ecchymoses, tarry stools, mucosal bleeding, and crimson/ red-tinged
urine.
Correct approach for walking upstairs with crutches - ANS1. Hold to rail with one hand and
crutches with the opposite hand.
2. Push down at the stair rail and the crutches and step up with the "unaffected" leg.
Three. If now not allowed to region weight on the "affected" leg, hop up with the "unaffected"
leg.
4. Bring the "affected" leg and the crutches up beside the "unaffected" leg.
Five.Remember, the "unaffected" leg goes up first and the crutches circulate with the
"affected" leg.
Droplet precautions - ANSDROPLET: "SPIDERMAn"
-Sepsis
-Scarlet Fever
-Strep
-Pertussis
,-Pneumonia
-Parvovirus
-Influenza
-Diphtheria
-Epiglottitis
-Rubella
-Mumps
-Adenovirus
Management: Private room/mask
-A private room a rom with different clients with the same infectious sickness.
-Masks for providers and site visitors
Airborne precautions: - ANSAIRBORNE: "My Chicken Hez TB"
-Measles
-Chicken pox
-Herpes zoster
-TB
Management: neg. Pressure room, personal room, masks, n-95 for TB.
-A personal room
-Masks or respiratory protection gadgets for caregivers and visitors.
-An N95 or excessive-efficiency particulate air (HEPA) respirator is used if the purchaser is
known or suspected to have TB.
-Negative pressure airflow trade inside the room of at the least six exchanges according to
hour.
Contact precautions - ANSCONTACT: "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: robe, gloves, goggles, private room
VRSA - touch and airborne precautions (personal room, door closed, poor strain)
-A private room or a room with other customers with the equal infection.
-Gloves and gowns worn via the caregivers and traffic.
,Stage I strain ulcer - ANSIntact skin with a place of chronic, nonblanchable redness,
generally over a bony prominence, which could sense warmer or cooler than the adjacent
tissue. The tissue is swollen and has congestion, with possible discomfort at the web page.
With darker pores and skin tones, the ulcer may also appear blue or pink.
Stage II strain ulcer - ANSPartial-thickness pores and skin loss involving the epidermis and
the dermis. The ulcer is visible and superficial and might seem as an abrasion, blister, or
shallow crater. Edema persists, and the ulcer can also grow to be inflamed, probable with
ache and scant drainage.
Stage III stress ulcer - ANSFull-thickness tissue loss with damage to or necrosis of
subcutaneous tissue. The ulcer may additionally make bigger right down to, however not
through, underlying fascia. The ulcer seems as a deep crater without or with undermining of
adjoining tissue and with out uncovered muscle or bone. Drainage and infection are
commonplace.
Stage IV pressure ulcer - ANSFull-thickness tissue loss with destruction, tissue necrosis, or
harm to muscle, bone, or helping systems. There may be sinus tracts, deep pockets of
infection, tunneling, undermining, eschar (black scab-like cloth), or slough (tan, yellow, or
inexperienced scab-like fabric)
Glasgow Coma Score - ANSis calculated with the aid of using appropriate stimuli (a painful
stimulus may be vital) and then assessing the customers reaction in 3 regions.
Eye establishing (E) - The first-rate eye response, with responses starting from 4 to 1
4 = Eye establishing occurs spontaneously.
Three = Eye beginning takes place secondary to voice.
2 = Eye establishing takes place secondary to pain.
1 = Eye establishing does now not arise.
Verbal (V) - The fine verbal response, with responses starting from 5 to at least one
five = Conversation is coherent and oriented.
4 = Conversation is incoherent and disoriented.
Three = Words are spoken, however inappropriately.
2 = Sounds are made, but no phrases.
1 = Vocalization does no longer arise.
Motor (M) - The nice motor response, with responses starting from 6 to at least one
6 = Commands are accompanied.
Five = Local response to pain happens.
Four = There is a preferred withdrawal to ache.
Three = Decorticate posture (adduction of hands, flexion of elbows and wrists) is present.
2 = Decerebrate posture (abduction of hands, extension of elbows and wrists) is gift.
1 = Motor response does now not occur.
Responses within each subscale are added, with the total rating quantitatively describing the
patron's level of consciousness. E + V + M = Total GCS
, When verifying NG tube placement, the pH of aspirated gastric fluid need to - ANSA proper
indication of appropriate placement is obtaining gastric contents with a pH among zero and
4.
Sodium - ANS136-one hundred forty five
Potassium - ANS3.5-five
Total Calcium - ANS9.Zero-10.Five
Magnesium - ANS1.Three-2.1
Phosphorus - ANS3.0-four.5
BUN - ANS10-20
Creatinine men - ANS0.6-1.2
Creatinine females - ANS0.Five-1.1
Glucose - ANS70-105
HcbA1c - ANS<6.5%
WBC - ANS5,000-10000
RBC men - ANS4.7-6.1 million/mm3
RBC women - ANS4.2-5.4 millin/mm3
Hemoglobin men - ANS14-18
Hemoglobin women - ANS12-16
Hematocrit men - ANS42-52
Hematocrit women - ANS37-47
Platelet - ANS150,000-400,000
pH - ANS7.35-7.45
pC02 - ANS35-45
p02 - ANS80-100
HC03 - ANS21-26
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