ATI Rationales (Archer) for NCLEX Combined Part 1 and Part 2<\/p>\n\n\n\n
Archer ATI Rationales
Safety & Infection
Infectious Diseases
\uf0b7 Impetigo \uf092 contagious bacterial infection of the skin
\uf0aa S\/S: lesions (on face), erythema (redness of skin), pruritus (itchy skin),
burning, lymph node
\uf0aa Contact precautions
\uf0b7 Increased susceptibility to illness \uf092 increases autoimmune responses
\uf0b7 Hep A \uf092 infection via consumption of raw or undercooked food, fecal-oral,
contaminated water
\uf0aa S\/S: N\/V, abdominal pain, fever, anorexia, dark urine, scleral icterus
(yellowish pigmentation of sclera), pale stools, jaundice, pruritus
Preventing aspiration
\uf0b7 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 \u2013 do not talk \u2013 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) \u2013 if noted
then suction airway
Preventing falls
\uf0b7 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
\uf0b7 Completing fall risk assessment at admission or within 2 hours of admission
\uf0b7 Setting the bed to the lowest position
\uf0b7 Avoid administering diuretics and laxatives before clients sleep to reduce urgent
bathroom needs
Restraints
\uf0b7 Assess q 2 hours, behavioral status, skin integrity, neurovascular status (pulse, capillary
refill), continued need for restraint, can be placed without physician\u2019s order but has one
hour to inform provider and obtain an order, should be removed via quick release
buckle
CPR
\uf0b7 Compress rate of 100-120 bpm
\uf0b7 Utilize early defib for vfib
\uf0b7 Carotid pulse should not exceed ten seconds
\uf0b7 Compression rate of 30 to 2 rescue breaths in kids its 15 to 2 if there are two people
\uf0b7 Should be 2 inches on the center breastbone
Miscellaneous
\uf0b7 Water temperature \uf092 maximum of 49 C (120 F)
Pharmacology
<\/p>\n\n\n\n
Archer ATI Rationales
Fundamentals
\uf0b7 Proper hand hygiene \uf092 wash hands for 20 seconds in warm, soapy water or use hand
sanitizer if hands are not visibly soiled
\uf0b7 Variance \uf092 work not done in the correct way
\uf0b7 Incidents & accidents \uf092 evens that cause harm to client
\uf0b7 Sterile surgical aseptic \uf092 keep sterile field above their waist, sterile gauze into placed
sterile field, holds hands above their elbows during handwashing
\uf0b7 Cane ambulation \uf092 gait belt before getting out of bed, nurse is on the client\u2019s 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
\uf0b7 Crutches ambulation \uf092 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
\uf0b7 Peritoneal dialysis essential teaching \uf092 handwashing to reduce peritonitis (infection of
the lining of your belly or abdomen)
\uf0b7 Lyme disease \uf092 not transmitted human-to-human & standard precautions
\uf0b7 HIV \uf092 does not require isolation precautions
\uf0b7 Standard \uf092 wash hands
\uf0b7 Contact \uf092 wear gloves & gown & disposable equipment
\uf0aa MRS WEE – MRSA
\uf0b7 Contact enteric \uf092 hand hygiene with soap & water
\uf0aa C.diff, norovirus, rotavirus, shigella
\uf0b7 Droplet \uf092 surgical mask
\uf0aa SPIDERMAN \u2013 N.
meningitidis \uf0b7 Airborne \uf092 N95
respirator
\uf0aa MTV, SARS, smallpox
\uf0b7 Reverse isolation \uf092 used to protect immune-compromised clients
\uf0b7 Priority tx for PE & acute decompensated HF \uf092 diuresis & vasodilators, VTE prophylaxis
with ACE inhibitors
\uf0aa Contraindication: CCB b\/c of its negative inotropic effects (contract heart
with less force), hydrocortisone, albuterol
\uf0b7 Device to locate pulse on a darkskin client \uf092 transillumination device
\uf0b7 Infection measure to implement in TB \uf092 remove fans
\uf0b7 Extravasation \uf092 vesicant drug comes into subcutaneous tissue
\uf0b7 Infiltration \uf092 non-vesicant drug enters subcutaneous tissue
\uf0b7 When to hold BUN & Cr \uf092 vancomycin (for MRSA), furosemide, ketorolac (NSAID) \u2013
these drugs are nephrotoxic & can cause renal insufficiencies
\uf0b7 Asterixis \uf092 involuntary flapping of the hands
\uf0b7 Peak levels \uf092 doesn\u2019t occur before onset but before end of duration
\uf0b7 S\/S of meningitis \uf092 severe HA, fever, stiff neck<\/p>\n\n\n\n
\uf0b7 Incentive spirometer \uf092 prevents atelectasis (collapse of alveoli post-surgery)
\uf0b7 Short acting insulin \uf092 regular insulin & has \u201cR\u201d in the drug name
\uf0b7 NGT \uf092 can be used to administer contrast dye for clients who cannot swallow or is
nauseated
\uf0b7 Digoxin \uf092 administered once a day; normal dosage is 0.125 mg to 0.5 mg
\uf0b7 Physicians order \uf092 nurse should not accept a telephone order only in case of
emergencies
\uf0b7 Post-op neuro status \uf092 as soon after and at least every hour after
\uf0b7 Post-op pulse status \uf092 every 15 mins for the first hour, every 30 mins for second hour,
hourly for next 4 hours
\uf0b7 Vaccines for adults \uf092 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
\uf0b7 OA assistive devices \uf092 electric can & jar opener, remote with larger keys, shoes with
Velcro or shoes that slip on, changing doorknobs to levers
\uf0b7 Interventions for transfusion reactions \uf092 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
\uf0b7 Assessment finding after a fall \uf092 shortened & externally rotated leg due to muscle
spasms
\uf0b7 Restraints \uf092 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\u2019s 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
\uf0b7 Nursing actions for speaking to an older client who is hearing impaired \uf092 maintain
normal voice volume, lower voice pitch, turn TV or radio off not down
\uf0b7 Position for client who is unconscious who needs oral care \uf092 side-lying or lateral to
facilitate flow of secretions by gravity to prevent aspiration during procedure & keep
HOB lowered
\uf0b7 Nursing action for IV catheter if client\u2019s vein isn\u2019t palpable due to dehydration \uf092 dry
heat like applying warm pack for 10-20 minutes to promote vasodilation & stroking vein
downward
\uf0b7 Facilitates that provide secondary & tertiary care \uf092 ED\u2019s, urgent care, critical care,
inpatients
\uf0b7 Red zone nurse action \uf092 indicates 50% or below peak flow and signals emergent
situation so the nurse should call HCP
\uf0b7 Diagnostic test for evaluating acute onset of seizures \uf092 electroencephalogram (EEG)
\uf0b7 Thrombocytopenia nursing actions \uf092 takes client with this longer to clot with fewer
platelets so during times where they are bleeding even after a bandage is placed over
<\/p>\n","protected":false},"excerpt":{"rendered":"
ATI Rationales (Archer) for NCLEX Combined Part 1 and Part 2 Archer ATI RationalesSafety & InfectionInfectious Diseases\uf0b7 Impetigo \uf092 contagious bacterial infection of the skin\uf0aa S\/S: lesions (on face), erythema (redness of skin), pruritus (itchy skin),burning, lymph node\uf0aa Contact precautions\uf0b7 Increased susceptibility to illness \uf092 increases autoimmune responses\uf0b7 Hep A \uf092 infection via consumption of […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-114723","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/114723","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=114723"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/114723\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=114723"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=114723"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=114723"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}