ATI Comprehensive

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1.

when removing peripheral

I.V. catheter

remove it parallel to the vein

to reduce the risk of trauma

2.

drying linen in a hot dryer

for 20min will help get rid of

pediculosis capitis

3.

in order to reduce pain

overnight, pregnant women
may

wear a supportive bra to

prevent breast tenderness

4.

when patient is connected

to a disposable chest tube
drainage, report drainage
greater than ____mL to the
provider

report drainage greater than

70mL and reposition this
client every 2 hours

5.

inform prepubescent
female clients that they will

gain weight before they get

taller to prepare them for any
body image issues

NG tube/Salem Sump
Tubing

aspirate gastric residual every

4hr
withhold feeding for more
than 200mL
the nurse should change the
enteral feeding bag and
tubing every 24hours
reposition every 2 hours
set suction at 80-120mm Hg

6.

11.

actinic
keratosis

pre-malignant lesion
flat, scaly area with red edges
12.

cherry
angiomas

expected change with aging skin

7.

adverse effects of
corticosteroid therapy
includes

GI bleeding - dark stools

should be reported
immediately
this client should not receive
any live attenuated vaccines

13.

female
indwelling
catheter
insertion

urine is seen in the tubing

advance another 2.5cm to 5cm/ 1in to 2in
inflate the balloon using 10mL of sterile water
release labia and secure with non-dominant hand
place drainage bag below level of bladder

8.

initial treatment of acute

diverticulitis keeps the
patient

NPO. they receive parenteral

nutrition to promote bowel
rest, then a soft low fiber diet
follow by high fiber once fully
recovered

14.

postoperative
mastectomy

9.

babies should be breastfed

because it reduces baby's risk

of infection
12 times in a 24hour period
at 3-4hr intervals during the
night and
solids should be introduced at
6 months

avoid raising elbow above shoulder until drains are

removed
avoid abduction of arm until wound has completely
healed
plan to return to work in 4-6 weeks
may resume driving in 7-10 days

15.

ensure that
the
interpreter is

culturally compatible with the patient

nurse should make contact with the patient

16.

a COPD
patient
experiencing
an
exacerbation
should be
placed on a

venturi mask

17.

during a
newborn
physical
assessment, if
a baby fails
they will be
retested in

3 months
should be done while the newborn is asleep
soft clicking is done to assess hearing
fail does not necessarily mean hearing loss

10.

when applying sterile gloves

apply the

dominant hand glove first

keep cuff on wrist rolled

18.

a patient with rhinorrhea

after exposure to your gloves
may indicate a

latex allergy

19.

priority action for sickle cell

crisis

oxygenation
ABC's

20.

otitis media is not

contagious and children
should be given

acetaminophen for the pain

21.

for patients undergoing

chemotherapy, the nurse
should encourage them to

purchase a wig before

treatment
hair regrowth will begin
about 1 month after final tx

22.

v fib

irregular rate with P waves,

bizarre and variable QRS

23.

a client receiving radiation

therapy for cancer of the
larynx should wear

a loose scarf to protect the

skin from sun exposure
should wash the affected
area with water only

after venous stripping and

ligation

perform ROM for venous

return
elevate feet
ambulate 5-10min every
hour first 24hr
patient's legs should be
wrapped with an elastic
bandage postoperatively

24.

25.

non stress test

4oz OJ prior to the test

26.

before an IVP the child will

need to have an

soapsuds enema to assist in

visualization of the kidneys,
bladder and ureters

27.

a nurse is legally obligated to

report a new case of TB to

the appropriate regulatory

agency

28.

antiembolic stockings
should be applied

before getting the client out

of bed
or elevate both legs 15-30
min before

29.

before a client signs their

informed consent, the nurse
must verify that

they understand the

procedure before signing

30.

nystatin is an

antifungal drug

31.

newborn on antifungal
parent instructions:

give 1 hour after meals

do NOT rinse
mother may need to take
antifungal also

newborn passes first stool

within 24 hours after
delivery, this stool is called

meconium
is dark green and viscous
contains components of
amniotic fluid, cells, intestinal
secretions and occult blood

32.

33.

newborn who is breastfed

stool

golden yellow and soft

34.

newborn who is bottlefed

stool

light brown and formed

35.

the cane is held on the

stronger side of the body
(the right). when moving
forward the ____ is moved
first

the cane is moved first in front

of the right foot and the weaker
leg is moved next - so that the
body's weight is evenly
distributed

36.

relaxation techniques to
use during labor

massage with light touch

relaxing music
paced breathing

37.

ferrous sulfate elixir

teaching

rinse mouth after

may take during pregnancy
dark stools are expected
increase fiber

38.

the nurse is providing

postmortem care - what is
the first action?

check with the family about

religious practice
(in order to honor the family's
wishes in regards to body
preparation)
the client's head should be
placed on a pillow to prevent
discoloration of the face from
accumulating blood

39.

client's IV pump alarm is

beeping. priority action:

observe the IV site for

infiltration or phlebitis

40.

toddler with a
tracheostomy action

allow the child to rest for 30-60

seconds after each aspiration
apply suction for no more than
FIVE seconds with each pass then hyperventilate with 100%
oxygen

41.

cystic fibrosis diet

high calorie
high protein
high fiber

42.

a client with dependent

personality disorder will
likely have

trouble making everyday

decisions on their own

43.

the client continues to

relate stories about past
intimate relationships

histrionic personality disorder

44.

the LPN can ____ with the

client's care plan

the LPN can assist - it is not

within the scope of practice for
an LPN to independently
develop one

45.

best Glascow coma scale

score

15 - this is the goal

46.

what should be use to

clean up blood?

chlorine bleach solution

47.

mono is spread by

direct contact with droplets of

saliva by an infected person (the
kissing disease)

48.

the inner cannula of

the trach should be
cleaned with

hydrogen peroxide

49.

Dakin's solution is used

to clean

skin and tissue infections resulting

from cuts, scrapes and pressure
ulcers

50.

when delegating an
enema be sure to

use the 5 rights of administration

and
explain the expected outcome
(right direction)

51.

SIDs teaching

'back to bed'
firm mattress
infant should be placed in a sleep
sack
no soft blankets (can impede
breathing)
all pillows and soft objects should
be removed from the crib

52.

flush the tube feeding

with 30mL of water

before and after med

administration

53.

a client who is
experiencing acute
mania is

easily distracted and should be

given step by step instructions for
performing ADLs
should be placed in a low-stimuli
environment &
have calming activities before
bedtime

54.

before ECT

mild sedative given

NPO

55.

after ECT

orient the client frequently

56.

sign of left sided heart

failure includes

dizziness

57.

a tetanus booster is
recommended every

10 years

58.

sign of mild to severe

preeclampsia
progression

blurred vision

59.

gonorrhea can result in

pelvic inflammatory disease, which

can cause tubal scarring and result
in infertility

60.

good food
recommendation for
iron deficiency anemia

dried beans

61.

risks for colorectal cancer

obesity
high
alcohol/cigarette
consumption
increasing age
(<50)
high protein diet
that includes high
intake of red meat
family hx
history of
gastrectomy or IBS

62.

where would you find information

about the client's personal health
insurance

admission sheet

63.

Clients on Captopril should know

that this over the counter med can
reduce antihypertensive effects

Ibuprofen or any
other NSAID

64.

CDC regulations require that _____ be

reported to the department of health

HIV

65.

fidelity is demonstrated by

fulfilling
commitments and
promises made to
the client

66.

practicing non-malificence involves

taking action to ensure that

no harm comes to
the client

67.

principle of autonomy

respecting the
client's rights to
make her own
decisions

68.

digoxin toxicity

visual changes
headache
N/V
anorexia
diarrhea

69.

clinical manifestations of a hip

fracture

external rotation
muscle spasms
affected leg is
shorter

70.

sequential compression devices

promote venous return post-op by
providing

intermittent
periods of
compression on the
legs

71.

sunscreen teaching

use a spf of at least 15

reapply every 2hr during sun
exposure
greatest risk is between 10-4
should be used within 3 years of
purchase

72.

when injecting a purified

protein derivative (PPD)
to a client with TB the
nurse should

73.

74.

75.

76.

77.

78.

81.

perform a fundal massage - this

stimulates uterine muscle contractions
to prevent further excess bleeding

use a 10 degree angle

0.1 mL intradermally

16hours post
delivery, client is
experiencing
excessive lochia
drainage. the nurse's
first action should
be to

82.

venipuncture of a
client

client at high risk for

suicide - nurse's highest
priority

search client's personal

belongings

select a vein in the antecubital fossa

for blood draws
position the extremity in a dependent
position

83.

reddish brown urine

umbilical cord teaching

sponge bath the baby until the

cord falls off
remove cord clamp in 24hr when
dry

expected adverse
effect of
metronidazole
(Flagyl)

84.

manifestations of
PTSD

hyper-vigilance, irritability, insomnia

and difficulty concentrating and
recurrent recollections of precipitating
trauma

85.

adverse effect of
atorvastatin
(Lipitor)

muscle injury/tenderness that can

lead to rhabdomylosis

86.

when removing twopiece ostomy system

hold skin taut while removing the

barrier

87.

safe use of crutches

hold both crutches on the side

opposite injured leg when sitting
wear snug-fitting rubber soled shoes

88.

the nurse should

complete an
incident report for
any situation that

places the client or others at risk for

harm

89.

pleural effusion

post ORIF distal pulse is

weak and affected
extremity is cool,
priority action

notify nursing supervisor

before hemodialysis

take weight (ensures

effectiveness of treatment)

plan of care for client at

risk for developing
pressure ulcers

30 degree lateral position

limit time spent in chair to 2hr a
day

penrose drain (looks like

open pen)

safety pin should be placed at

distal end of drain to prevent it
from slipping back into the
wound
79.

ambulating a client with

impaired vision the nurse
should walk

just ahead of the client and offer

their arm for guidance

80.

newborn hypoglycemia
manifestation

jitteriness
lethargy
blood glucose less than 40mg/dL

90.

thoracentesis

after a
circumcision,
the yellow
drainage should
be

left alone as it contributes to the healing

process
instruct mother not to wipe off

dependent
personality
disorder

reinforce assertive behavior, allowing the

client to become more independent

when taking
nitroglycerin
you may
experience a

headache, but with time it will go away

after a lumbar
puncture

increase fluids to replace those lost

95.

ketorolac is an

NSAID

96.

bethancehol is a

muscarinic agonist and is given to treat

post op urinary retention

tomatos are high

in

vitamin C

referring a client
to package
inserts for
information is

appropriate

sublimation is a

positive coping mechanism substituting

an acceptable activity with one that is
restricted

91.

92.

93.

94.

97.

98.

99.

a slow
suck/swallow
pattern in a
newborn is an
indication

they are done with feeding

101.

take lithium

with food & increase fluids

102.

neonatal
security

hospital inservice on policies

neonatal safety device to each newborn
ID bracelets to newborns and parents
distinct ID badges for personnel in
nursery

100.

103.

FLACC pain scale

facial expression
leg movement
activity
cry
consolability

104.

what should the nurse

instruct the client to expect
in the first trimester

leukorrhea - abundant
mucus production

105.

regular consumption red

meats such as lamb or beef
increases the

risk of cancer

106.

passive behavior

lack of active participation

107.

antisocial behavior

violates the rights of others

108.

histrionic behavior is

very dramatic and brings

attention to the client

109.

newborn RR

30-60

110.

a CBI with normal saline helps

prevent bladder spasms

with may lead to
postoperative bleeding

111.

shortness of breath is an early

indication of

poor oxygenation in a
client who experienced an
MI

112.

a history of preterm labor is

the most important risk

factor for subsequent
preterm L&D

113.

to verify the identity of a

client

check the MAR against the

client's ID bracelet

114.

what is the purpose of the

apgar score at birth?

to determine if the
newborn needs
resuscitation

115.

suspicious injuries on a child's

body must be reported to

child protective services

116.

restraints must be released

every

2 hours

117.

IBS retraining program

will be instructed to take

bulk forming laxatives

118.

manifestations of digoxin
toxicity

visual disturbances:
yellow vision or halos
double vision
blurred vision

119.

how to suction baby's mouth

suction the mouth first,

then the nose

120.

7 months and up IM injection

site

ventrogluteal

121.

primary cause of PUD

infection with gram

negative H. pylori

122.

ECG changes in hypokalemia

peaked P waves
flat T waves
a depressed ST segment
prominent U waves

123.

potassium chloride administered IV must always be

diluted in IV fluid (normal saline)

124.

for a client with receptive aphasia encourage

nonverbal communication, including pictures and gestures

125.

when caring for a client in labor it is safe to administer Demorol

during

the active phase of the first stage of labor

126.

to correctly double bag contaminated items one person needs

to be inside the isolation room and the other

needs to be outside of the room - double bagging is performed

by the assistant standing outside of the room

127.

during the working phase the nurse and client

mutually plan the client's care and then activate the care plan