ATI Comprehensive predictor 2 test Questions Challenge with Solutions
2023-2024
1. Do not delegate
Answer: What you can EAT
E-evaluate
Aassess
T-teach
2. Addison's & Cushing’s
Answer: Addison's = down down up down
Cushings = up up down up
hypo/hypernatremia
hypo/hypertension
blood volume
hypo/hyperkalemia
hypo/hyperglycemia
3. Better peripheral perfusion?
Answer: EleVate Veins
Dangle Arteries
4. APGAR
Answer: Appearance (all pink, pink and blue, blue pale)
Pulse (100, 100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
5. Airborne precautions
Answer: MTV or My chicken hez tb measles
chickenpox (varicella)
Herpes zoster/shingles TB
6. Airborne precautions protective equip
Answer: private room
neg pressure with 6-12 air exchanges/hr
mask & respirator N95 for TB
7. Droplet precautions
Answer: spiderman! Sepsis
scarlet fever
streptococcal pharyngitis
parvovirus
pneumonia
pertussis
influenza
diptheria
epiglottitis
rubella
mumps
meningitis
mycoplasma or meningeal pneumonia
adeNovirus (Private room and mask)
8. Contact precaution
Answer: MRS WHISE protect visitors & caregivers when 3 ft of the pt.
Multidrug-resistant organisms
RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies,
Enteric diseases caused by micro-organisms (C diff),
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag without touching the
outside of the bag
9. PMGG
Answer:
Private room/ share same illness
Mask
Gown
Gloves
10. Skin infection
Answer: VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies
11. Air or Pulmonary Embolism
Answer: S/S chest pain
Dyspnea
Tachycardia
pale/cyanotic
sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.)
12. Woman in labor (un-reassuring FHR)
Answer: (late decels, decreased variability, fetal bradycardia, etc)
Turn pt on Left side
give O2
stop Pitocin
Increase IV fluids!
13. Tube feeding with decreased LOC
Answer: Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent
aspiration)
14. After lumbar puncture and oil based myelogram
Answer: pt is flat SUPINE (prevent headache and leaking of CSF)
15. Pt with heat stroke
Answer: flat with legs elevated
16. During Continuous Bladder Irrigation (CBI)
Answer: catheter is taped to the thigh. leg must be kept straight.
17. After Myringotomy
Answer: position on the side of AFFECTED ear, allows drainage.
18. After Cateract surgery
Answer: pt sleep on UNAFFECTED side with a night shield for 1-4 weeks
19. After Thyroidectomy
Answer: low or semi-fowler's position
support head
neck and shoulders
20. Infant with Spina Bifida
Answer: Prone so that sac does not rupture
21. Buck's Traction (skin)
Answer: elevate foot of bed for counter traction
22. After total hip replacement
Answer: don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate
Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows.
23. Prolapsed cord
Answer: Knee to chest or Trendelenburg oxygen 8 to 10 L
24. Cleft Lip
Answer: position on back or in infant seat to prevent trauma to the suture line. while feeding
hold in upright position.
25. To prevent dumping syndrome
Answer: (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals
for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals.
26. AKA (above knee amputation)
Answer: elevate for first 24 hours on pillow. position prone daily to maintain hip extension.
27. BKA (below knee amputation)
Answer: foot of bed elevated for first 24 hours. position prone to provide hip extension.
28. Detached retina
Answer: area of detachment should be in the dependent position
29. Administration of enema
Answer: pt should be left side lying (Sim's) with knee flexed.
30. After supratentorial surgery
Answer: (incision behind hairline on forehead) elevate HOB 30-40 degrees
31. After infratentorial surgery
Answer: (incision at the nape of neck) position pt flat and lateral on either side.
32. During internal radiation
Answer: on bed rest while implant in place
33. Autonomic Dysreflexia/Hyperreflexia
Answer: S/S pounding headache
profuse sweating
nasal congestion
chills
bradycardia
hypertension
Place client in sitting position (elevate HOB) FIRST!
34. Shock
Answer: bedrest with extremities elevated 20 degrees.
knees straight
head slightly elevated (modified Trendelenberg)
35. Head Injury
Answer: elevate HOB 30 degrees to decrease ICP
36. Peritoneal Dialysis (when outflow is inadequate)
Answer: turn pt from side to side BEFORE checking for kinks in tubing
37. Lumbar Puncture
Answer: After the procedure, the pt should be supine for 4-12 hours as prescribed.
38. Myesthenia Gravis
Answer: worsens with exercise and improves with rest
39. Myesthenia Gravis
Answer: a positive reaction to Tensilon-will improve symptoms
40. Cholinergic Crisis
Answer: Caused by excessive medication-stop giving Tensilon ... will make it worse.
41. Liver biopsy (prior)
Answer: must have lab results for prothrombin time
42. Myxedema/ hypothyroidism
Answer: slowed physical and mental function, sensitivity to cold, dry skin and hair
43. Grave's Disease/ hyperthyroidism
Answer: accelerated physical and mental function
Sensitivity to heat
Fine/soft hair.
44. Thyroid storm
Answer: increased temp
pulse and HTN
45. Post-Thyroidectomy
Answer: semi-fowler's
Prevent neck flexion/hyperextension
Trach at bedside
46. Hypo-parathyroid
Answer: CATS-Convulsions
Arrhythmias
Tetany
Spasms
Stridor (decreased calcium) give high calcium
low phosphorus diet
47. Hyper-parathyroid
Answer: fatigue
muscle weakness
renal calculi
back and joint pain (increased calcium) give a low calcium high phosphorous diet
48. Hypovolemia
Answer: increased temp
rapid/weak pulse
increase respiration
hypotension
anxiety
Urine specific gravity 1.030
49. Hypervolemia
Answer: bounding pulse
SOB
Dyspnea
rales/crackles
peripheral edema
HTN
urine specific gravity 1.010.
semi fowler's
50. Diabetes insipidus (decreased ADH)
Answer: excessive urine output and thirst
Dehydration
Weakness
administer Pitressin
51. SIADH (increased ADH)
Answer: change in LOC
decreased deep tendon reflexes
tachycardia
N/V HA administer Declomycin
Diuretics
52. Hypokalemia
Answer: muscle weakness
Dysrhythmias
increase K (rasins bananas apricots)
oranges
beans
potatoes
carrots
celery
53. Hyperkalemia
Answer: MURDER Muscle weakness
Urine (olig, anuria)
Resp depression
decreased cardiac contractility
ECG changes
Reflexes
54. Hyponatremia
Answer: nausea
muscle cramps
increased ICP
muscular twitching
convulsions
give osmotic diuretics (Mannitol) and fluids
55. Hypernatremia
Answer: increased temp
Weakness
Disorientation
Dilusions
Hypotension
Tachycardia
give hypotonic solution.
56. Hypocalcemia
Answer: CATS Convulsions
Arrythmias
Tetany
spasms and stridor
57. Hypercalcemia
Answer: muscle weakness
lack of coordination
abdominal pain
confusion
absent tendon reflexes
shallow respirations
emergency
58. Hypo Mg
Answer: Tremors
Tetany
Seizures
Dysthythmias
Depression
Confusion
dysphagia (dig toxicity)
59. Hyper Mg
Answer: depresses the CNS
Hypotension
facial flushing
muscle weakness
absent deep tendon reflexes
shallow respirations
EMERGENCY
60. Addison's
Answer: Hypo Na
Hyper K
Hypoglycemia
dark pigmentation
decreased resistance to stress fx
alopecia
weight loss
GI stress.
61. Cushings
Answer: Hyper Na
Hypo K
Hyperglycemia
prone to infection
muscle wasting
weakness
edema
HTN
Hirsutism
moonface/buffalo hump
62. Addesonian crisis
Answer: N/V confusion
abdominal pain
extreme weakness
hypoglycemia
dehydration
decreased BP
63. Pheochromocytoma
Answer: hypersecretion of epi/norepi
persistent HTN
increased HR
hyperglycemia
diaphoresis
tremor
pounding HA
avoid stress
frequent bathing and rest breaks
avoid cold and stimulating foods (surgery to remove tumor)
64. Tetrology of Fallot
Answer: DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary
stenosis)
65. Autonomic Dysreflexia
Answer: (potentially life threatening emergency!)
HOB elevate 90 degrees
loosen constrictive clothing
assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause
stroke, MI, seizure)
66. FHR patterns for OB
Answer: Think VEAL CHOP!
V-variable decels; C - cord compression caused
E-early decels; H - head compression caused
A-accels; O-okay, no problem
L-late decels; P - placental insufficiency, can't fill
67. What to check with pregnancy
Answer: Never check the monitor or machine as a first action.
Always assess the patient first.
Ex .. listen to fetal heart tones with stethoscope.
68. Position of the baby by fetal heart sounds
Answer: Posterior - heard at sides
Anterior - midline by unbilicus and side
Breech - high up in the fundus near umbilicus
Vertex - by the symphysis pubis.
69. Ventilatory alarms
Answer: HOLD
High alarm - Obstruction due to secretions, kink, pt cough etc
Low alarm - Disconnection, leak, etc
70. ICP and Shock
Answer: ICP - Increased BP, decreased pulse, decreased resp
Shock - Decreased BP, increased pulse, increased resp
71. Cor pumonae
Answer: Right sided heart failure caused by left ventricular failure (edema, jugular vein
distention)
72. Heroin withdrawal neonate
Answer: irritable, poor sucking
73. Brachial pulse
Answer: pulse area on an infant
74. Lead poisoning
Answer: test at 12 months of age
75. Before starting IV antibiotics
Answer: obtain cultures!
76. Pt with leukemia may have
Answer: epistaxis due to low platelets
77. When a pt comes in and is in active labor
Answer: first action of nurse is to listen to fetal heart tones/rate
78. For phobias
Answer: use systematic desensitization
79. NCLEX
Answer: tips: choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose
intervention in an emergency or stress situation.
If the has an absolute, discard it.
Give priority to the that deal with the patient's body, not machines, or equipment.
80. ARDS and DIC
Answer: are always secondary to another disease or trauma
81. In an emergency
Answer: patients with a greater chance to live are treated first
82. Cardinal sign of ARDS
Answer: hypoxemia
83. Edema is located
Answer: in the interstitial space, not the cardiovascular space (outside of the circulatory system)
84. The best indicator of dehydration?
Answer: weight - and skin turgor
85. Heat/cold
Answer: hot for chronic pain; cold for accute pain (sprain etc)
86. When pt is in distress ... medication administration
Answer: is rarely a good choice
87. Pneumonia
Answer: fever and chills are usually present. For the elderly confusion is often present.
88. Before IV antibiotics?
Answer: check allergies (esp. penicillin) make sure cultures and sensitivity has been done before
first dose.
89. COPD and O2
Answer: with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be
low because high O2 concentration takes away the pt's stimulation to breathe.
90. Prednisone toxicity
Answer: Cushings (buffalo hump, moon face, high blood sugar, HTN)
91. Neutropenic pts
Answer: no fresh fruits or flowers
92. Chest tubes are placed
Answer: in the pleural space
93. Preload/Afterload
Answer: Preload affects the amount of blood going into Right ventricle. Afterload is the
systemic resistance after leaving the heart.
94. CABG
Answer: Great Saphenous vein in leg is taken and turned inside out (because of valves inside)
Used for bypass surgery of the heart.
95. Unstable Angina
Answer: not relieved by nitro
96. PVC's
Answer: can turn into V fib.
97. 1 tsp
Answer: 5 mL
98. 1 oz
Answer: 30 mL
99. 1 cup
Answer: 8 oz
100. 1 quart
Answer: 2 pints
101. 1 pint
Answer: 2 cups
102. 1 g (gram)
Answer: 1000 mg
103. 1 kg
Answer: 2.2 lbs
104. I lb
Answer: 16 oz
105. Centigrade to Fahrenheit conversion
Answer: F = C + 40 multiply 5/9 and subtract 40
C = F + 40 multiply 9/5 and subtract 40
106. Angiotenson II
Answer: In the lungs ... potent vasodialator
aldosterone attracts sodium.
107. Iron toxicity reversal
Answer: deferoxamine
108. S3 sound
Answer: normal in CHF. Not normal in MI
109. After endoscopy
Answer: check gag reflex
110. TPN given in
Answer: subclavian line
111. Pain with diverticulitis
Answer: located in LLQ
112. Appendicitis pain
Answer: located in RLQ
113. Trousseau and Chvostek's signs observed in
Answer: Hypocalcemia
114. Never give K+ in
Answer: IV push
115. DKA is rare
Answer: in DM II (there is enough insulin to prevent fat breakdown)
116. Glaucoma patients lose
Answer: peripheral vision.
117. Autonomic dysreflexia
Answer: patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7
or above)
118. Spinal shock occurs
Answer: immediately after injury
119. Multiple sclerosis
Answer: myelin sheath destruction. disruptions in nerve impulse conduction
120. Myasthenia gravis
Answer: decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes
mastication and pharyngeal musles. watch for aspiration.
121. Gullian -Barre syndrome
Answer: ascending paralysis. watch for respiratory problems.
122. TIA
Answer: transient ischemic attack ... mini stroke, no dead tissue.
123. CVA
Answer: cerebriovascular accident. brain tissue dies.
124. Hodgkin's disease
Answer: cancer of the lymph. very curable in early stages
125. Burns rule of Nines
Answer: head and neck 9%
each upper ext 9%
each lower ext 9%
front trunk 18%
back trunk 18%
genitalia 1%
126. Birth weight
Answer: doubles by 6 months triples by 1 year
127. If HR is 100 (children)
Answer: Hold Dig
128. Early sign of cystic fibrosis
Answer: meconium in ileus at birth
129. Meningitis check for
Answer: Kernig's/ brudinski's signs
130. Wilm's tumor
Answer: encapsulated above kidneys ... causes flank pain
131. Hemophilia is x linked
Answer: passed from mother to son
132. When phenylaline increases
Answer: brain problems occur
133. Buck's traction
Answer: knee immobility
134. Russell traction
Answer: femur or lower leg
135. Dunlap traction
Answer: skeletal or skin
136. Bryant's traction
Answer: children 3 y 35 lbs with femur fx
137. Eclampsia is
Answer: a seizure
138. Perform amniocentesis
Answer: before 20 weeks to check for cardiac and pulmonary abnormalities
139. Rh mothers receive Rhogam
Answer: to protect next baby
140. Anterior fontanelle closes by ... posterior by..
Answer: 18 months, 6-8 weeks
141. Caput succedaneum
Answer: diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3
days
142. Physiological jaundice occurs
Answer: before 24 hours (lasts 7 days) after 24 hours
143. Placental abrution
Answer: there is no pain, but there is bleeding there is pain, but no bleeding (board like abd)
144. Bethamethasone (celestone)
Answer: surfactant. premature babies
145. Milieu therapy
Answer: taking care of pt and environmental therapy
146. Cognitive therapy
Answer: counselling
147. Five interventions for psych patients
Answer: safety setting limits
establish trusting relationship meds least restrictive methods/environment
148. SSRI's
Answer: take about 3 weeks to work
patients with hallucinations
149. Patients with delusions
Answer: redirect them distract them
150. Thorazine and Haldol
Answer: can cause EPS
151. Alzheimer's
Answer: 60% of all dementias, chronic, progressive degenerative cognitive disorder.
152. Draw up regular and NHP?
Answer: Air into NHP, air into Regular. Draw regular, then NHP
153. Cranial nerves
Answer: S = sensory
M = motor
B = both
Oh (Olfactory I) Some
Oh (Optic II) Say
Oh (Oculomotor III) Marry
To (trochlear IV) Money
Touch (trigeminal V) But
And (Abducens VI) My
Feel (facial VII) Brother
A (auditory VIII) Says
Girl's (glossopharyngeal IX) Big
Vagina (vagus X) Bras
And (accessory XI) Matter
Hymen (Hypoglossal XII) More
154. Hypernatremia
Answer: S (Skin flushed)
A (agitation)
L (low grade fever)
T (thirst)
155. Developmental
Answer: 2-3 months: turns head side to side
4-5 months: grasps, switch and roll
6-7 months: sit at 6 and waves bye
8-9 months: stands straight at 8
10-11 months: belly to butt
12-13 months: 12 and up, drink from a cup
156. Hepatitis A
Answer: Ends in a vowel, comes from the bowel
157. Hepatitis b
Answer: B = blood and body fluids (hep c is the same)
158. Apgar measures
Answer: HR RR Muscle tone, reflexes, skin color.
Each 0-2 points. 8-10 ok, 0-3 resuscitate
159. Glasgow coma scale
Answer: eyes, verbal, motor
Max - 15 pts, below 8 = coma
160. Cushing's syndrome:
Answer: "add" hormone have extra "cushion" of hormone
161. Dumping syndrome
Answer: increase fat and protein, small frequent meals, lie down after meal to decrease
peristalsis. Wait 1 hr after meals to drink
162. Disseminated herpes zoster localized herpes zoster
Answer: Disseminated herpes = airborne precautions
Localized herpes = contact precautions. A nurse with localized may take care of patients as long
as pts are not immunosuppressed and the lesions must be covered!
163. Isoniazid
Answer: causes peripheral neuritis
164. Weighted NI (naso intestinal tubes)
Answer: Must float from stomach to intestine. Don't tape right away after placement. May leave
coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris
165. Cushings ulcers
Answer: r/t brain injury
166. Cushing's triad
Answer: r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure)
167. Thyroid storm
Answer: HOT (hyperthermia)
168. Myxedema coma
Answer: COLD (hypothermia)
169. Glaucoma
Answer: No atropine
170. Non Dairy calcium
Answer: Rhubarb sardines collard greens
171. Koplick's spots
Answer: prodomal stage of measles. Red spots with blue center, in the mouth think kopLICK in
the mouth
172. INH can cause peripheral neuritis
Answer: Take vitamin B6 to prevent.
173. Hepatotoxic pancreatitis pts
Answer: put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are
probably going to get
TPN/Lipids
174. Murphy's sign
Answer: Pain with palplation of gall bladder (seen with cholecystitis)
175. Cullen's sign
Answer: ecchymosis in umbilical area, seen with pancreatitis
176. Turner's sign
Answer: Flank greyish blue. (turn around to see your flanks) Seen with pancreatitis
177. McBurney's point
Answer: Pain in RLQ with appendicitis
178. LLQ
Answer: Diverticulitis
179. RLQ
Answer: appendicitis watch for peritonitis
180. Guthrie test
Answer: Tests for PKU. Baby should have eaten protein first
181. Shilling test
Answer: Test for pernicious anemia
182. Peritoneal dialysis
Answer: Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath
(tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok
183. Absent reflexes
Answer: upper motor neuron issue (your reflexes are over the top)
Lower motor neuron issue
184. Latex allergies
Answer: assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados,
chestnuts, tomatoes and peaches
185. Tensilon
Answer: used in myesthenia gravis to confirm diagnosis
186. ALS
Answer: (amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower
motor neuron systems
187. Transesophageal fistula
Answer: esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn:
choking, coughing, cyanosis)
188. MMR
Answer: is given SQ not IM
189. Codes for pt care
Answer: Red - unstable, ie.. occluded airway, actively bleeding ... see first
Yellow - stable, can wait up to an hour for treatment
Green - stable can wait even longer to be seen walking wounded
Black - unstable, probably will not make it, need comfort care
DOA - dead on arrival
190. Contraindication for Hep B vaccine
Answer: anaphylactic reaction to baker's yeast
191. What to ask before flu shot
Answer: allergy to eggs
192. What to ask before MMR
Answer: allergy to eggs or neomycin
193. When on nitroprusside monitor
Answer: cyanide. normal value should be 1.
194. William's position
Answer: semi Fowler's with knees flexed to reduce low back pain
195. S/S of hip fx
Answer: External rotation, shortening adduction
196. Fat embolism
Answer: blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis.
Hypocalcemia, increased serum lipids.
197. Complications of mechanical ventilation
Answer: pneumothorax, ulcers
198. Paget's disease
Answer: tinnitus, bone pain, elnargement of bone, thick bones
199. With allopurinol
Answer: no vitamin C or warfarin!
200. IVP requires
Answer: bowel prep so bladder can be visualized
201. Acid ash diet
Answer: cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
202. Alk ash diet
Answer: milk, veggies, rhubarb, salmon
203. Orange tag in psych
Answer: is emergent psych
204. Thyroid med side effects
Answer: insomnia. body metabolism increases
205. Tidal volume is
Answer: 7-10 ml/kg
206. COPD patients and O2
Answer: 2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less
207. Kidney glucose threshold
Answer: 180
208. Stranger anxiety is greatest at what age?
Answer: 7-9 months … separation anxiety peaks in toddlerhood
209. When drawing an ABG
Answer: put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt
was on O2
210. Munchausen syndrome vs munchausen by proxy
Answer: Munchausen will self-inflict injury or illness to fabricate symptoms of physical or
mental illness to receive medical care or hospitalization. by proxy mother or other care taker
fabricates illness in child
211. Multiple sclerosis
Answer: motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling,
tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia
212. Hungtington's
Answer: 50% genetic autosomal dominan at disorder.. s/s uncontrolled muscle movements of
face, limbs and body.
213. WBC left shift
Answer: pt with pyelo. neutrophils kick in to fight infections
214. Pancreatic enzymes are taken
Answer: with each meal!
215. Infants IM site
Answer: Vastus lateralis
216. Toddler 18 months + IM site
Answer: Ventrogluteal
217. IM site for children
Answer: deltoid and gluteus maximus
218. Thoracentesis:
Answer: position pt on side or over bed table. no more than 1000 cc removed at a time. Listen
for bilateral breath sounds, V.S, check leakage, sterile dressing
219. Cardiac cath
Answer: NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to
cough with injection of dye. Post: V.S. keep leg straight. bedrest for 6-8 hr
220. Cerebral angio prep
Answer: well hydrated, lie flat, site shaved, pulses marked. Post keep flat for 12-14 hr. check
site, pulses, force fluids.
221. Lumbar puncture
Answer: fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral
analgesics for headache.
222. ECG
Answer: no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours
before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for
seizures after the procedure.
223. Myelogram
Answer: NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld
48 hours prior. Table moved to various positions during test. Post neuro assessment q2-4 hours,
water soluble HOB UP. oil soluble HOB down. oral analgesics for HA. No po fluids. assess for
distended bladder. Inspect site
224. Liver biopsy
Answer: administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect
to be asked to hold breath for 5-10 sec. stupide position, lateral with upper arms elevated. Postposition on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk.
225. Paracentesis
Answer: semi fowler's or upright on edge of bed. Empty bladder. post VS report elevated temp.
watch for hypovolemia
226. Laparoscopy
Answer: CO2 used to enhance visual. general anaesthesia. foley. Post ambulate to decrease CO2
buildup
227. PTB
Answer: low grade afternoon fever
228. Pneumonia
Answer: rusty sputum
229. Asthma
Answer: wheezing on expiration
230. Emphysema
Answer: barrel chest
231. Kawasaki syndrome
Answer: strawberry tongue
232. Pernicious anemia
Answer: red beefy tongue
233. Downs syndrome
Answer: protruding tongue
234. Cholera
Answer: rice watery stool
235. Malaria
Answer: stepladder like fever with chills
236. Typhoid
Answer: rose spots on the abdomen
237. Diptheria
Answer: pseudo membrane formation
238. Measles
Answer: koplick's spots
239. Sle (systemic lupus)
Answer: butterfly rash
240. Pyloric stenosis
Answer: olive like mass
241. Addison's
Answer: bronze like skin pigmentation
242. Cushing's
Answer: moon face, buffalo hump
243. Hyperthyroidism/ grave's disease
Answer: exophthalmos
244. Myasthenia gravis
Answer: descending musle weakness
245. Gullian-barre syndrome
Answer: ascending muscle weakness
246. Angina
Answer: crushing, stabbing chest pain relieved by nitro
247. MI
Answer: crushing stabbing chest pain unrelieved by nitro
248. Cystic fibrosis
Answer: salty skin
249. DM
Answer: Polyuria
Polydipsia
Polyphagia
250. DKA
Answer: kussmal's breathing (deep rapid)
251. Bladder CA
Answer: painless hematuria
252. BPH
Answer: reduced size and force of urine
253. Retinal detachment
Answer: floaters and flashes of light.
254. Glaucoma
Answer: painful vision loss. tunnel vision. Halo
255. Retino blastoma
Answer: cat's eye reflex
256. Increased ICP
Answer: hypertension, bradypnea,, bradycarday (cushing's triad)
257. Shock
Answer: Hypotension
Tachypnea
tachycardia
258. Lymes disease
Answer: bullseye rash
259. Intraosseous infusion
Answer: often used in peds when venous access can't be obtained. hand drilled through tibia
where cryatalloids, colloids, blood products and meds are administered into the marrow. one med
that CANNOT be administered IO is isoproterenol, a beta agonist.
260. Sickle cell crisis
Answer: two interventions to prioritize: fluids and pain relief.
261. Glomuloneprhitis
Answer: the most important assessment is blood pressure
262. Children 5 and up
Answer: should have an explanation of what will happen a week before surgery
263. Kawasaki disease
Answer: (inflammation of blood vessels, hence the strawberry tongue) causes coronary artery
aneurysms.
264. Ventriculoperitoneal shunt
Answer: watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability
and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed
bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the
HOB 15-30 degrees
265. 3-4 cups of milk a day for a child?
Answer: NO too much milk can reduce the intake of other nutrients especially iron. Watch for
ANEMIA
266. MMR and varicella immunizations
Answer: after 15 months!
267. Cryptorchidism
Answer: undescended testicles! risk factor for testicular cancer later in life. Teach self-exam for
boys around age 12-most cases occur in adolescence
268. CSF meningitis
Answer: HIGH protein LOW glucose
269. Head injury or skull fx
Answer: no nasotracheal suctioning
270. Otitis media
Answer: feed upright to avoid otitis media!
271. Positioning for pneumonia
Answer: lay on affected side, this will splint and reduce pain. However, if you are trying to
reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that
side up, it clears!)
272. For neutropenic pts
Answer: no fresh flowers, fresh fruits or veggies and no milk
273. Antiplatelet drug hypersensitivity
Answer: bronchospasm
274. Bowel obstruction
Answer: more important to maintain fluid balance than to establish a normal bowel pattern (they
can’t take in oral fluids)
275. Basophils release histamine
Answer: during an allergic response
276. Iatragenic
Answer: means it was caused by treatment, procedure or medication
277. Tamoxifen
Answer: watch for visual changes indicates toxicity
278. Post spelectomy
Answer: pneumovax 23 is administered to prevent pneumococcal sepsis
279. Alkalosis/ Acidosis and K+
Answer: ALKalosis = al K = low sis. Acidosis (K + high)
280. No phenylalanine
Answer: to a kid with PKU. No meat, dairy or aspartame
281. Never give potassium
Answer: to a pt who has low urine output!
282. Nephrotic syndrome
Answer: characterized by massive proteinuria caused by glomerular damage. corticosteroids are
the mainstay
283. The first sign of ARDS
Answer: increased respirations! followed by dyspnea and tachypnea
284. Normal PCWC (pulmonary capillary wedge pressure)
Answer: is 8-13 readings 18-20 are considered high
285. First sign of PE
Answer: sudden chest pain followed by dyspnea and tachypnea
286. Digitalis
Answer: increases ventricular irritability could convert a rhythm to v-fib following
cardioversion
287. Cold stress and the newborn
Answer: biggest concern resp. distress
288. Parathyroid relies on
Answer: vitamin D to work
289. Glucagon increases the effects of?
Answer: anticoagulants
290. Sucking stab wound
Answer: cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it
could turn into a closed pneumo or tension pneumo!
291. Chest tube pulled out?
Answer: occlusive dressing
292. PE
Answer: Needs O2
293. DKA
Answer: acetone and keytones increase! once treated expect postassium to drop! have K+ ready
294. Hirschprung's
Answer: diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic
ribbon-like/foul smelling stools
295. Intussusception
Answer: Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools.
Enema resolution = bowel movements
296. Laboring mom's water breaks?
Answer: first thing worry about prolapsed cord!
297. Toddlers need to express
Answer: independence!
298. Addison's
Answer: causes sever hypotension!
299. Pancreatitis
Answer: first pain relief, second cough and deep breathe
300. CF chief concern?
Answer: Respiratory problems
301. A nurse makes a mistake?
Answer: take it to him/her first then take up the chain
302. Nitrazine paper
Answer: turns blue with alkaline amniotic fluid. turns pink with other fluids
303. Down stairs with crutches?
Answer: good leg first followed by crutches(good girls go to heaven) crutches with the injured
leg followed by the good leg.
304. Dumping syndrome?
Answer: use low fowler's to avoid. limit fluids
305. TB drugs are
Answer: hepatotoxic!
306. Clozapine, Clozaril
Answer: antipsychotic anticholinergic
307. Clozapine s/e
Answer: weight gain
Hypotension
hyperglycemia
agranulocytosis
308. Dehydration
Answer: hypovolemia
elevated urine specific gravity
309. Flumazenil, Roma icon
Answer: benzo overdose
310. Umbilical cord compression
Answer: reposition side to side or knee-chest
311. Short cord
Answer: discontinue Pitocin
312. TB
Answer: A positive Mantoux test indicates pt developed an immune response to TB.
Acid-fast bacilli smear and culture:(+suggests an active infection) the diagnosis is CONFIRM by
a positive culture for M TB
A chest x-ray may be ordered to detect active lesions in the lungs QuantiFERON-TB Gold:
DIAGNOSTIC for infection, whether it is active or latent
313. Battery
Answer: performing procedure without consent
314. Assault
Answer: Threatening to give pt. medication putting another person in fear of a harmful or an
offensive contact.
315. Imprisonment
Answer: Telling the client you cannot leave the hospital
316. Defamation
Answer: is a false communication or careless disregard for the truth that causes damage to
someone's reputation. in writing(Libel) or Verbally(Slander)
317. Sprain or Strain
Answer: RICE
Rest
Ice
Compress
Elevate
