ATI Rationales (Archer) for NCLEX Combined Part 1 and Part 2
Archer ATI Rationales
Safety & Infection
Infectious Diseases
Impetigo contagious bacterial infection of the skin
S/S: lesions (on face), erythema (redness of skin), pruritus (itchy skin),
burning, lymph node
Contact precautions
Increased susceptibility to illness increases autoimmune responses
Hep A infection via consumption of raw or undercooked food, fecal-oral,
contaminated water
S/S: N/V, abdominal pain, fever, anorexia, dark urine, scleral icterus
(yellowish pigmentation of sclera), pale stools, jaundice, pruritus
Preventing aspiration
Chin-down position (tilt head forward, with chin down), provide rest periods during
meals, position upright 30-60 minutes after a meal, position upright 90 degrees in a
chair or HOB, oral hygiene after meals to reduce plaque secretions to decrease
pneumonia, minimize distractions – do not talk – do not rush client, alternate liquids
and bites of food, avoid mixing foods of different textures in the same mouthful,
observe for signs of aspiration (coughing, choking, gagging, drooling of food) – if noted
then suction airway
Preventing falls
Ensuring call button is accessible and within easy reach of the client; the call light can be
clipped or secured when the client is in bed
Completing fall risk assessment at admission or within 2 hours of admission
Setting the bed to the lowest position
Avoid administering diuretics and laxatives before clients sleep to reduce urgent
bathroom needs
Restraints
Assess q 2 hours, behavioral status, skin integrity, neurovascular status (pulse, capillary
refill), continued need for restraint, can be placed without physician’s order but has one
hour to inform provider and obtain an order, should be removed via quick release
buckle
CPR
Compress rate of 100-120 bpm
Utilize early defib for vfib
Carotid pulse should not exceed ten seconds
Compression rate of 30 to 2 rescue breaths in kids its 15 to 2 if there are two people
Should be 2 inches on the center breastbone
Miscellaneous
Water temperature maximum of 49 C (120 F)
Pharmacology
Archer ATI Rationales
Fundamentals
Proper hand hygiene wash hands for 20 seconds in warm, soapy water or use hand
sanitizer if hands are not visibly soiled
Variance work not done in the correct way
Incidents & accidents evens that cause harm to client
Sterile surgical aseptic keep sterile field above their waist, sterile gauze into placed
sterile field, holds hands above their elbows during handwashing
Cane ambulation gait belt before getting out of bed, nurse is on the client’s affected
side slightly behind the client, measure the height of the cane from the wrist crease or
greater trochanter, cane held on the unaffected side, elbow flexed 15-30 degrees, cane
advanced first in 6-10 secs, advance affected leg to the cane, advance the stronger leg
just past the cane, rubber tip should be applied not tennis balls
Crutches ambulation up with good, down with bad, tripod position formed when the
crutches are placed 6 inches in front of and 6 inches to side of each food, elbows flex
between 15-30 degrees, crutch tip is entirely on the stair, have client hold handrail for
support with one hand & strong leg should be next to the railing
Peritoneal dialysis essential teaching handwashing to reduce peritonitis (infection of
the lining of your belly or abdomen)
Lyme disease not transmitted human-to-human & standard precautions
HIV does not require isolation precautions
Standard wash hands
Contact wear gloves & gown & disposable equipment
MRS WEE – MRSA
Contact enteric hand hygiene with soap & water
C.diff, norovirus, rotavirus, shigella
Droplet surgical mask
SPIDERMAN – N.
meningitidis Airborne N95
respirator
MTV, SARS, smallpox
Reverse isolation used to protect immune-compromised clients
Priority tx for PE & acute decompensated HF diuresis & vasodilators, VTE prophylaxis
with ACE inhibitors
Contraindication: CCB b/c of its negative inotropic effects (contract heart
with less force), hydrocortisone, albuterol
Device to locate pulse on a darkskin client transillumination device
Infection measure to implement in TB remove fans
Extravasation vesicant drug comes into subcutaneous tissue
Infiltration non-vesicant drug enters subcutaneous tissue
When to hold BUN & Cr vancomycin (for MRSA), furosemide, ketorolac (NSAID) –
these drugs are nephrotoxic & can cause renal insufficiencies
Asterixis involuntary flapping of the hands
Peak levels doesn’t occur before onset but before end of duration
S/S of meningitis severe HA, fever, stiff neck
Incentive spirometer prevents atelectasis (collapse of alveoli post-surgery)
Short acting insulin regular insulin & has “R” in the drug name
NGT can be used to administer contrast dye for clients who cannot swallow or is
nauseated
Digoxin administered once a day; normal dosage is 0.125 mg to 0.5 mg
Physicians order nurse should not accept a telephone order only in case of
emergencies
Post-op neuro status as soon after and at least every hour after
Post-op pulse status every 15 mins for the first hour, every 30 mins for second hour,
hourly for next 4 hours
Vaccines for adults do not need Hep A or Hep B if not at risk; should get TDAP every
10 hours, adults over age 60 should receive herpes zoster, flu shots recommended every
year
OA assistive devices electric can & jar opener, remote with larger keys, shoes with
Velcro or shoes that slip on, changing doorknobs to levers
Interventions for transfusion reactions stop infusion immediately, disconnect blood
tubing & connect NS to maintain an open IV line, obtain urine specimen & send to lab to
presence of Hgb for red blood cell hemolysis, blood bag & tubing need to be sent to the
blood bank & need to be notified
Assessment finding after a fall shortened & externally rotated leg due to muscle
spasms
Restraints should be assessed every 2 hours, should be tied using a quick-release
knot & never be tied to a fixed portion of the bed frame, should be removed every 2
hours to assess for skin breakdown & to allow the client to eat and or drink, educate
client & client’s family before applying restraints & they need to understand why
restraints are being used and for how long, prn order is prohibited, HCP must identify
why restraint is being used & specific time frame
Nursing actions for speaking to an older client who is hearing impaired maintain
normal voice volume, lower voice pitch, turn TV or radio off not down
Position for client who is unconscious who needs oral care side-lying or lateral to
facilitate flow of secretions by gravity to prevent aspiration during procedure & keep
HOB lowered
Nursing action for IV catheter if client’s vein isn’t palpable due to dehydration dry
heat like applying warm pack for 10-20 minutes to promote vasodilation & stroking vein
downward
Facilitates that provide secondary & tertiary care ED’s, urgent care, critical care,
inpatients
Red zone nurse action indicates 50% or below peak flow and signals emergent
situation so the nurse should call HCP
Diagnostic test for evaluating acute onset of seizures electroencephalogram (EEG)
Thrombocytopenia nursing actions takes client with this longer to clot with fewer
platelets so during times where they are bleeding even after a bandage is placed over