Prepare for ATI Comprehensive Practice A with these practice questions and answers. This guide covers fundamentals, pharmacology, and all major nursing specialties.
Q: displacement (defense mechanism)
Answer: – The transfer of feelings from one target to another that is considered less threatening or that is neutral.EX: A client is angry at his doctor, does not express it, but becomes verbally abusive with the nurse.
Q: Regression (defense mechanism)
Answer: A person goes back to an earlier or less mature state or behavior
Q: Suppression: Defense Mechanism
Answer: the denial of disturbing feeling or situation
Q: sublimation (defense mechanism)
Answer: channeling socially unacceptable impulses into constructive, even admirable, behavior
Q: SE of alprazolam
Answer: Orthostatic hypotension, dizziness, confusion and lethargyInitiate fall precautions
Q: how to turn a patient onto the right side
Answer: Use draw sheet to move pt to left sidePlace pillow under the pt left armlower draw sheet on left side
Q: Nurse precaution for MRSA
Answer: Contact
Q: Nurse precaution for pneumonia and influenza
Answer: Droplet
Q: Nurse precaution for tuberculosis and measles
Answer: Airborne
Q: sx of multiple sclerosis
Answer: vision issuespainfatigueimpaired coordinationDifficulty swallowingConstipation
Q: How nurse delegate following task? (AP or LVN)A. Collect of a stool specimenB. Preparation of a client’s postop bedC. Prepare teaching plan for pneumoniaD. Insertion of NG tube
Answer: AB-APC-NurseD- LVN
Q: Suction for tracheostomy
Answer: Use surgical asepsis when performing procedureInsert the catheterOnce resistance is met, nurse withdraw the catheter 1-2cm to prevent damage bronchial tissuesNurse apply suction for 5-15s to minimize oxygen lossSuction can initiate the cough reflex as its opens the airway further and allows for more effective removal of mucus
Q: Why clients received TPN if they has an extensive burn injury?
Answer: When nutritional needs are greater than oral or enteral nutrition can provide.
Q: TPN (total parenteral nutrition)
Answer: Pt who receiving TPN is at risk for hyperglycemia
Q: Priority patient with stroke *right sided weakness
Answer: Referral to physical therapist (high risk injury from falls)
Q: Nursing care for a client with deficit with CN II
Answer: clear objects from the client’s walking area
Q: Nursing care for a client with CVIII
Answer: Ask the client to restate directions
Q: Nursing care for a client with deficit with CN IX
Answer: Evaluate swallowing
Q: Stage of pressure injury
Answer: Stage I: superficial ,skinStage II: partial thickness skin loss blister formationStage III: Visiable sub-q tissueStage IV: muscle damage, tendon exposure
Q: If the infusion pump does not work, how does the nurse give pt TPN?
Answer: Use manual drip tubing to infuse dextrose 10% in water solution at the same rate with TPN infusion.Nurse must administer TPN to ensure accurate dosage and taper the infusion rate before discontinuing the solution to prevent hypoglycemia
Q: Triage pt for different tag
Answer: Green tag: injury is nonurgentBlack tag: Pt is not likely to recoveryYellow tag: client has major injury that requires attention within 30min-2hrRed tag: life-threatening injury and requires immediately tx
Q: cause of constipation in pregnancy during 2nd and 3rd trimester
Answer: – Estrogen and progesterone level increase during pregnancy, leading to decrease peristalsis and relaxation of smooth muscles of intestine which result in constipation- The size and weight of the growing uterus cause both displacement and compression of the intestine. These changes cause a decrease in motility, leading to constipation
Q: recommendation for pt with impaired vision
Answer: Marking the edges of stairs with pain or colored tape for contrast used to reduce the risk of fallExtension cords should be remove from high traffic area in the home and placed along the edges of walls.Use of light fixtures at least 75-watt bulbs to optimize the client’s visibilityInstruct pt receive vision testing at least once each year
Q: First action for the negligent actions
Answer: gather additional information and discuss the issues with staff nurse before deciding on the next course of action
Q: Sleep promotion
Answer: rituals that prepare for bed (hearing a story or taking a bath)
Q: Type of catheter used for continuous urinary drainage
Answer: indwelling urinary catheter
Q: Type of catheter used for continuous bladder irritation
Answer: Three-way urinary catheter
Q: Type of catheter used for to obtain a sterile urine specimen
Answer: Specimen catheter
Q: Type of catheter used for a client who has urinary retention
Answer: Straight urinary catheter
Q: Pt’s heal is reddened and tender. It has risk of_________
Answer: Pressure injury
Q: Type of cast has waterproof, water will not affect integrity
Answer: Fiberglass cast
Q: trach care steps
Answer: remove inner cannularemove soiled dressingclean the stoma with sterile saline (also what you lubricate catheter with)change trachestomy collarwhen inserting catheter when patient is inhaling
Q: MDMA
Answer: A compound drug related to both amphetamines and hallucinogens, especially mescaline; commonly called “ecstasy.”
Q: s/s MDMA intoxication
Answer: Increased tactile sensitivityLower inhibitionMuscle crampingTeeth clenchingMild hallucinogenic effects
Q: Albumin range and indication
Answer: 3.5-5 g/dLIndication of nutritional status
Q: Hgb range
Answer: 12-18
Q: Risk factor of pressure injury
Answer: DiarrheaDecrease Hgb indicates poor delivery O2 to the tissuesDecreased albumin indicates inadequate nutrition, increase risk of impaired skin integrityWeight loss increase the chance for shearing against the bony prominences
Q: Amitriptyline
Answer: Indication: treat depressionS/E: Dry mouth and constipationC/I: MAOI avoid foods that contain tyraminenursing consideration: take at bedtime to promote sleep and minimize drowsiness during the day
Q: Car seat
Answer: Rear-facing until 2, 45 degrees, snug harness, clip at armpit level, dont cross infant neck or abd- no swaddle blanket before securing (Blanket make it difficult to secure the shoulder harnesses tightlt, leading to injury in the event of collision.-secure the retainer clip at tje level of armpits
Q: Visual analog scale
Answer: used for children who are 8 years old or older
Q: Hemoptysis:
Answer: greater than 250ml/24hr indicates hemorrhage (priority)
Q: Snellen charting
Answer: -Nurse should screen the child with glass, then repeating screen w/o glass-Child stands 3m (10 feet) away-In order to pass the line, identify 6 symbols-keep both eyes open during the testing
Q: administer fresh frozen plasma
Answer: as quickly as patient can tolerate (30-60 minutes) to decrease platelets clumpingrecording type of the product, amnt administered, product number, infusion time, client response
Q: Avoid food for pt with uric acid based urinary calculi formation
Answer: LiverChickenRed wine*contain purine
Q: Nursing action for pt with a cataract extraction
Answer: -Avoid aspirin- use of cool compress to ease the discomfort itching-Avoid bend the wrist, bend the knees to pick up an object-avoid lifting more than 4.5kg
Q: How to give ear drops to an adult
Answer: pull pinna up and back
Q: How to give ear drops to a 9 mo old child. (younger than 3 yrs)
Answer: down and back
Q: Nursing care for pt anorexia nervosa
Answer: Supervise the client during and after eating (monitor the client during and after 1hr after meals to prevent the client from hiding foods or purging)
Q: Chlorpromazine
Answer: a drug that reduces the symptoms of schizophrenia by blocking dopamine D2 receptorsS/S: fever, dysrhythmia, decrease LOC, labile BP
Q: Intervention for large wound
Answer: Double bag soiled dressing in plastic bags to prevent spread of micro-organisms
Q: Kawasaki disease
Answer: Acute: high fever that is unresponsive to ATB or antipyreticsSubacute:1. pain in the weight-bearing jointstachycardia2. Peeling of the hands and feet
Q: uncompensated respiratory acidosis
Answer: pH = ↓PaCO2 = ↑HCO3 = ↔
Q: uncompensated respiratory alkalosis
Answer: pH = ↑PaCO2 = ↓HCO3 = ↔
Q: compensated respiratory acidosis
Answer: pH normalPaCO2 > 45HCO3 > 26
Q: compensated respiratory alkalosis
Answer: pH normalPaCO2 < 35HCO3 < 22
Q: compensated metabolic acidosis
Answer: Normal pH, low HCO3
Q: Uncompensated Metabolic Acidosis
Answer: pH = ↓PaCO2 = ↔HCO3 = ↓
Q: uncompensated metabolic alkalosis
Answer: pH = ↑PaCO2 =↔HCO3 = ↑
Q: compensated metabolic alkalosis
Answer: pH normalPaCO2 > 45HCO3 > 26
Q: Normal PaCO2 range
Answer: 35-45 mm Hg
Q: Normal HCO3 range
Answer: 22-26 mEq/L
Q: Hypertension+Obstructive sleep apnea
Answer: Heart failure + cardiac dysrhythmias
Q: Digoxin toxicity
Answer: nausea, vomiting, anorexia, abdominal pain, bradycardia and visual changesMuscle weaknessDiarrhea
Q: Vitals for newborn
Answer: -Acrocyanosis or slightly blue feet and hands-RR: 30-60-Temp: 36.5-37.5-Pulse: 80-100, up to 180 crying
Q: BRAT diet
Answer: B = BananasR = RiceA = ApplesauceT = Toast*This may be suggested if the child is having a hard time keeping things down from vomiting or GI upset. This is high in carbs but has little nutritional value*C/I for children with acute diarrhea
Q: Infectious Gastroenteritis (Diarrhea) rehydration
Answer: – Should initiate oral rehydration therapy that should contain sodium, potassium, chloride, citrate or bicarb and glucose.
Q: Therapeutic relationship phases
Answer: pre-orientation: setting the stage and timing (getting report on Pt.)orientation: what the encounter will be focused OR what will hopefully be achieved*Establish the termination date of therapyworking: set goals, explore issues, assist client, develop insite and develop skills and progress*Encourage the client’s problem-solving abilities*Discuss the client’s previous experience with loss*promote client’s self esteemtermination: summarize and highlight progress, process loss, bridge to next provider
Q: Propranolol
Answer: beta blocker (Decrease BP)
Q: Phenytoin
Answer: Antiepileptic: prevent seizure
Q: Lorazepam
Answer: short acting sedative to manage discomfort and agitation
Q: Nursing care for hip arthroplasty
Answer: Raised toilet seat to minimize hip flexion and prevent hip dislocationMain the hip at an angle less than 90Use a walkerPt should not place pillow under knee, it impede circulation
Q: Nursing care for colostomy care using two pieces pouching system
Answer: Activate the adhesive in the skin barrier by holding it in place over the stoma for 30 minclean the skin at the stoma use washcloth and warm water to reduce the risk of skin irritationDry the skin around stoma use patting motion before applying the skin barrierCut the skin barrier opening no more than 0.3cm larger than the stoma to reduce the risk of skin irritation
Q: Administer enteral feeding via NG tube
Answer: Inject 10-30 ml air into the NG tube before checking for residual to clear the tube for any feedingFlush the 20ml tap waterKeep HOB to 30-45 for 1-2hr to reduce the risk of aspiration
Q: Nursing actions for gastric lavage for a client who has GI bleeding and NG tube
Answer: Instill the lavage solution at the same temp to reduce the risk of injuryAfter instilling the lavage solution, the nurse should manually withdraw the solution and blood from the client’s NG tube.The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client’s NG tube.The nurse should instill the solution in volumes of 200 to 300 mL at a time to reduce the risk of injury to the client.
Q: s/e of methadone
Answer: SedationDrowsinessRespiratory depression
Q: priority for a boggy uterus with heavy lochia
Answer: massage the uterusexpel clots and increase uterine firmness resulting in decrease bleeding
Q: Nursing intervention for mechanical restraints
Answer: continuously with a client who is in restraintsDocument the client’s status every 15-30 minNot restraint pt until it is calm
Q: during pregancy, use acupressure bands on both wrists
Answer: used to alleviate N&V
Q: For newborns, what indicate effective breastfeeding
Answer: 6-8 wet diapers per dayweight gain 0.04-0.06 per dayNew born has yellow, soft, and seedy by the end of first week of life
Q: clang associations
Answer: associations based on double meanings or on the way words sound
Q: Echolalia
Answer: alteration in speech in which the client repeats back what someone else is saying.
Q: Neologisms
Answer: made-up words that have no meaning to others but do have meaning to the client.
Q: word salad
Answer: alteration in speech in which the client jumbles words because of an extreme level of mental disorganization.
Q: sx of autonomic dysreflexia
Answer: Facial flushingNasal congestionHAblurred vision
Q: NI for pt receiving hemodialysis via an establish AV fistula in right arm
Answer: Auscultate the AV fistula every 4 hr to ensure bruit is present, indicate patencyencourage pt perform ROM
Q: sx of delirium
Answer: Rapid speech
Q: Nursing intervention for insertion of a tunneled central venous catheter
Answer: Keep the catheter clamped to prevent blood flow backFlush catheter daily with heparinChange dressing every 5-7 days
Q: contact precautions
Answer: HSV
Q: Droplet precautions
Answer: PertussisRubellaStreptococcal pharyngitis
Q: airbrone precaution
Answer: VaricellaRubeolaTB
Q: How to assess infant’s rooting reflex
Answer: Stroke the infant’s cheek
Q: How to assess infant’s extrusion reflex
Answer: Depress the infant’s tongue cause thinfant to stick out the tongue
Q: How to assess infant’s tonic neck reflex
Answer: Turn the infant’s head to one side
Q: How to assess infant’s glabellar reflex
Answer: Tap on the bridge of the infant’s nose cause the infant close her eyes tightly
Q: Lithium toxicity symptoms
Answer: Confusion, coarse hand tremors, incoordination, ECG changes, sedation
Q: macular degeneration (MD)
Answer: breakdown of the tissues in the macula, resulting in loss of central vision
Q: sx of glaucoma
Answer: Increase in intrasocular pressure
Q: S/S of retinal detachment
Answer: floating dark spots
Q: S/S of cataract
Answer: Double vision
Q: fluid volume deficit
Answer: orthostatic hypotensionIncrease BUN level
Q: fluid overload s/s
Answer: Enlarged neck veins. Increased Blood pressure. Dyspnea.Decrease BUN levelsVisual disturbance: blurred vision
Q: Rationalization (defense mechanism)
Answer: – Attempting to make excuses or formulate logical reasons to justifying unacceptable feelings or behaviors.EX: John tells the rehab nurse, “I drink because its the only way I can deal with my bad marriage and awful job.”
Q: Hypokalemia S/S
Answer: Hypoactive bowel soundsMuscle weakness , decrease DTR
Q: Hypernatremia causes
Answer: Dry and sticky mucous membranes
Q: Hypocalcemia
Answer: Numbness and tingling of extremities and around mouth
Q: antisocial personality disorder s/s
Answer: Lack of remorse
Q: narcissistic personality disorder S/S
Answer: Sensitivity to rejection
Q: bipolar disorder s/s
Answer: Extreme mood swing
Q: borderline personality disorder
Answer: self-mutilating behavior
Q: S/S of vaso-occlusive crisis
Answer: Painful swelling of hands and feetHematuria (sickle cell crisis resulting from ischemia of kidney)Visual disturbances
Q: Injection site of enoxaparin
Answer: Sub-q tissue
Q: NI of DVT
Answer: AmbulateDrink 2-3L fluidWarm compression to reduce swelling and promote comfortElevate the affected leg
Q: Safety measure for children
Answer: No skateboard for children younger than 5Avoid sun exposure b/t 10-2pmCut hot dog for child to avoid chockingAvoid to place children on a raised place
Q: When the varicella is not contagious
Answer: Crusts formed on every lesion
Q: Indicate true labor
Answer: cervix transitions to an anterior position and begins to dilate in preparation for birthContraction in lower abdomen and backContraction intensity increase with ambulationCervix progressively shortens and thins
Q: Audible stridor post-op
Answer: High pitched sound heard in the client’s airway indicates edema, laryngeal spasm secretions, or airway obstruction
Q: Finding for acute glomerulonephritis
Answer: Proteinuria
Q: Sx of hemolytic transfusion reaction
Answer: Low back painTachycardiaHypotension
Q: SE of estradiol
Answer: HypotensionHASwelling and tenderness of extremity or fluid retention
Q: How to relieve the discomfort of engorgement?
Answer: Avoid nipple stimulationAvoid expressing milkPlace ice packs to reduce swellingWear tight-fitting, supportive bra to decrease discomfort
Q: Priority for the pt refuse to ambulate
Answer: Ask the client to rate pain level(Administer analgesic, wait 30-45min, encourage to ambulate)
Q: Spinal Manipulative Therapy
Answer: adjusting and aligning the spine, help with back pain, asthma and allergies
Q: acupuncture
Answer: Improve immune, neurologic, cardiac, and endocrineRelieve pain, and assist with substance withdrawal
Q: guided imagery
Answer: Helping clients imagine themselves as strong and capable and in settings that are positive and therapeutic can assist clients who have PTSD by relieving anxiety and pain.
Q: Nursing action to prevent clogging of the percutaneous gastrostomy tube
Answer: Flush the tube with at least 30 ml of water before and after medsChange feeding tube every 24-48 hr to prevent clogging and to reduce the risk of infectionCrush each med separatly, don’t mix
Q: SX of Raynaud’s disease
Answer: Blanching of the fingers and toes in response to exposure to cold or emotional stress.Pallor develop first, then cyanosis, followed by redness or heat as the vessels reperfuse before the skin returns
Q: Thrombocytopenia has the risk of
Answer: Bleeding
Q: Neutropenia has the risk of
Answer: InfectionRestrict visitors to family membersProhibit fresh flowers in the client’s room
Q: Techniques used to maintain surgical aseptic techniques
Answer: Place the catheter tray on a work surface at or above waist levelOpen the top outer flap away from the body to prevent contamination of sterile fieldDon sterile gloves before touching any items
Q: NI for umbilical cord prolapses
Answer: Knee chest position
Q: NI for early deceleration during 2nd stage
Answer: Continue observing the fetal HR.
Q: S/E of misoprostol
Answer: diarrheaUterine contraction (serum pregnancy test!)reduce gastric acid secretion
Q: Hep A is spread by
Answer: fecal-oral routeNI: clean the surfaces
Q: S/S of cyclophosphamide (used for neuroblastoma)
Answer: Hemorrhagic cystitisOffer fluids to maintain hydration to prevent Hemorrhagic cystitis
Q: Nursing priority of femur fracture
Answer: Sx of fat embolism syndromeUpper chest petechiaeDyspneaHypoxiaHALethargyconfusion
Q: Sx of pt with cystic fibrosis develop Oxygen toxicity
Answer: CracklesSubsternal pain
Q: Sx of pulsus paradoxus
Answer: Systolic BP is 10mm Hg or greater on expiration than inspiration
Q: Sx of cardiac tamponade
Answer: Beck triad (hypoTn, distended neck veins, distant heart sounds)Pulsus paradoxus
Q: S/S of multiple sclerosis
Answer: scanning speech, intention tremor, nystagmus, paresthesias, weakness
Q: S/S of Cushing’s Syndrome?
Answer: Think of the Cush Man… Moon face, buffalo hump, thin legs and bones, striae (stretch marks), male breasts, hirstusism etc,
Q: s/s of myasthenia gravis
Answer: descending muscle weakness, ptosis (drooping of eyelids)
Q: Sx of abruptio placenta
Answer: persistent uterine contrations,board-like abdomendark red vaginal bleeding
Q: fundal height
Answer: not palpable until 12 weeks, 2nd and 3rd trimesters week gestation 20-22 in cm so at the navel is 20 weeks
Q: Lab elevated indicate MI
Answer: Troponin T
Q: Lab elevated indicate ischemic heart disease, CVD, PVD
Answer: Homocysterine
Q: antidote to morphine
Answer: Naloxone
Q: antidote to lorazepam
Answer: Flumazenil
Q: Antidote to acetaminophen
Answer: acetylcysteine
Q: antidote of neostigmine
Answer: Atropine
Q: Clozapine
Answer: cause agranulocytosisLife threateningWBC less than 3000 is contraindicated to receive clozapine
Q: grandiose delusions
Answer: clients who are in the manic phase of BPD exhibit behaviors that appears to be euphoric.Clients have abrupt mood changes, unlimited energy, poor impulse control, grandiose delusion
Q: sx of schizoid personality disorder
Answer: Reclusive behaviorsocial withdrawal
Q: Sx of avoidant personality disorder
Answer: Hypersensitivity to criticism
Q: Sx in borderline PD
Answer: Fears of abandonment