TI Comprehensive/ NCLEX Review Guide Questions And Accurate Answers| Graded A+| 2024.

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. Stage III pressure ulcer - correct answer Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Stage IV pressure ulcer - correct answer Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material) Glasgow Coma Score - correct answer is calculated by using appropriate stimuli (a painful stimulus may be necessary) and then assessing the clients response in three areas. Eye opening (E) - The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice. 2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur. Verbal (V) - The best verbal response, with responses ranging from 5 to 1 5 = Conversation is coherent and oriented. 4 = Conversation is incoherent and disoriented. 3 = Words are spoken, but inappropriately. 2 = Sounds are made, but no words. 1 = Vocalization does not occur. Motor (M) - The best motor response, with responses ranging from 6 to 1 6 = Commands are followed. 5 = Local reaction to pain occurs. 4 = There is a general withdrawal to pain. 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present. 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present. 1 = Motor response does not occur. Responses within each subscale are added, with the total score quantitatively describing the client's level of consciousness. E + V + M = Total GCS When verifying NG tube placement, the pH of aspirated gastric fluid should - correct answer A good indication of appropriate placement is obtaining gastric contents with a pH between 0 and 4. Sodium - correct answer 136-145 Potassium - correct answer 3.5-5 Total Calcium - correct answer 9.0-10.5 Magnesium - correct answer 1.3-2.1 Phosphorus - correct answer 3.0-4.5