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ATI Adult Medical Surgical Retake 1 (2022/2023) (Verified
Answers by Expert)
Seizures and Epilepsy: Seizure precautions (62) - ✅✅During a seizure: Position client on the floor and provide a patent airway, turn client to side and loosen restrictive clothing Cancer treatment options: Protective Isolation (999) - ✅✅If WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions.
- Have client remain in his room unless be needs to leave for a diagnostic procedure, in case of transport place a mask on him
- Protect from possible sources of infection (plants, change water in equipment daily)
- Have client, staff and visitors perform frequent hand hygiene, restrict ill visitors
- Avoid invasive procedures (rectal temps, injections)
- Administer (neupogen, neulasta) to stimulate WBC production Infection control: Appropriate room assignment - ✅✅Standard Precautions:
- applies to all patients
- Hand washing a. alcohol based preferred unless hands visually soiled
- Gloves - when touching anything that has the potential to contaminate.
- Masks, eye protection & face shields when care may cause splashing or spraying of body fluids Droplet:
- private room or with someone with same illness
- masks Airborne:
- private room
- masks or respiratory protection devices a. use an N95 respirator for tuberculosis
- Negative pressure airflow
- full face protection if splashing or spraying is possible Contact:
- private room or room with same illness
- gloves & gowns
- disposal of infections dressing materials into a single, nonporous bag without touching the outside of the bag TB: Priority action for a client in the emergency department (249) - ✅✅-Wear an N95 or HEPA respirator -Place client in negative airflow room and implement airborne precautions -use barrier protection when the risk of hand or clothing contamination exists Immunizations: Recommended vaccinations for older adult clients (943) - ✅✅Adults age 50 or older: -Pneumococcal Vaccine (PPSV)
- Influenza vaccine
- Herpes Zoster Vaccine -Hepatitis A
- Hepatitis B
- Meningococcal Vaccine Pulmonary Embolism: Risk factors for DVT (258) - ✅✅-Long term immobility
- Oral contraceptives
- Pregnancy
Pain Management: use of non pharmacological methods of pain relief - ✅✅- Cutaneous (skin) stimulation- TENS, heat, cold, therapeutic touch and massage
- Distraction (deep breathing, ambulation, visitors, TV and music)
- Relaxation (meditation, yoga and progressive muscle relaxation -Imagery (focus on pleasant thoughts)
- Elevation of extremities to promote venous return Acute Kidney injury and chronic kidney disease: Evaluating teaching about nutrition - ✅✅- Restrict dietary intake of potassium, phosphate and magnesium during oliguric phase -K and Na is regulated according to stage of kidney injury
- high protein diet to replace the high rate of protein breakdown due to the stress from the illness. Possible TPN Heart failure and pulmonary edema: Dietary teaching about sodium restriction - ✅✅Maintain fluid and sodium restriction Increase dietary intake of potassium Pulmonary Embolism: Planning care for a client who is receiving enoxaparin - ✅✅-Assess for contraindications (active bleeding, peptic ulcer disease, history of stroke, recent trauma) -Monitor bleeding times (PT, aPTT and INR) -Monitor for side effects such as thrombocytopenia, anemia and hemmorhage Rheumatoid Arthritis: Reviewing Laboratory Values - ✅✅-Positive Anti- cyclic citrullinated peptide -RF Antibody (Diagnostic level for RA is 1:40-1:60) expected reference range 1:
- Elevated ESR 20-40 mild inflammation 40-70 moderate
70-150 severe
- Positive C-reactive protein
- Positive ANA titier
- Elevated WBC's Medications affecting coagulation: Heparin Contraindications - ✅✅Avoid NSAIDS while on heparin Antibiotics affecting protein synthesis: Adverse effects of gentamicin - ✅✅-Ototoxicity: cochlear damage (hearing loss) and vestibular damage (loss of balance). -Nephrotoxicity (proteinuria, elevated BUN, creatinine levels). -Hypersensitivity ( rash, pruritis, parathesia of hands and feet, and urticaria). Electrolyte imbalance: manifestations of hypokalemia - ✅✅Weak, irregular pulse, hypotension, respiratory distress Premature ventricular contractions, bradycardia, inverted T waves, ST depression Decreased GI motility, abdominal distension, constipation, n/v, anorexia, polyuria Decreased K (<3.5) ABG: Metabolic alkalosis (pH > 7.45) Electrolyte imbalance: Priority assessment for hypokalemia - ✅✅Assessing for a patent and open airway Blood and blood product transfusions: Administering Fresh Frozen Plasma - ✅✅Initiate a large bore IV access: 20 gauge needle Complete transfusion withing 2-4 hours time frame
Angina and MI: Client teaching about nitroglycerin - ✅✅Nitrogylcerin prevents coronary artery vasospasm and reduces preload and afterload. Used to treat angina and help with BP.
- Place nitro under tongue to dissolve
- Take up to two more doses of nitro at 5-min intervals
- Stop activity and rest Headache is a common side effect Orthostatic hypotension Osteoporosis: Teaching about self administration of Alendronate - ✅✅Take with 8oz water in the early morning before eating Remain upright for 30 minutes after taking medication Diabetes Mellitus Management: teaching about self administration of insulin - ✅✅- Rotate injection sites
- Inject at a 90 degree angle. Aspiration is not necessary
- Advise client to eat at regular intervals, avoid alcohol intake and adjust insulin to exercise and diet to avoid hypoglycemia
- When mixing insulin's, draw up the shorter acting insulin into the syringe first and then the longer acting insulin. IV therapy: Performing Venipuncture on an older adult client - ✅✅a 22-24 gauge catheter is best to use on older adults Tie the tourniquet sparingly and try to avoid veins in the hand Dosage calculations: Calculating IV infusion rate - ✅✅Ex: nurse is preparing to administer dextrose 5% in water 500 mL IV to infuse over 4 hours. The nurse should set the IV infusion pump to deliver how many mL/hr> -Volume (mL)/Time (hr) = X -500 mL/5hr = 125 mL/hr
IV therapy: Medication administration - ✅✅Know -Right Patient -Right drug -Right Dose -Right Time -Right Route Arthoplasty: Pain control - ✅✅Analgesics - opiods (epidural, PCA, IV, Oral) NSAIDS Continuous peripheral nerve block Ice or cold therapy to reduce swelling Head of bed slightly elevated and the affected leg in a neutral position. place a pillow or abduction device between the legs when turning to the unaffectedNe side Pain management: PCA - ✅✅Small frequent dosing ensure consistent plasma levels Morphine and Dilaudid Let nurse know if the pump doesn't control the pain Client is the only person to push the button Pain management: Interventions to promote postoperative recovery - ✅✅Managing acute severe pain with short term around the clock administration of opiods parental route is best for immediate short term relief GI therapeutic procedures: D/C TPN therapy - ✅✅Never abruptly stop TPN, gradually decrease (10%) to allow body adjustment. Monitor vital signs q 4-8 hours
Respiratory acidosis, metabolic alkalosis compensation Hematologic Diagnostic Procedures: Laboratory findings to report - ✅✅RBC: 4.2-5.4 and 4.7-6. WBC: 5-10, Platelets: 150-400, Hgb: 12-16 and 14- Hct: 37-47% and 42-52% PT: 11-12.5 sec aPPT: 1.5-2 times normal range of 30- INR: 2-3 on warfarin Acid base imbalance: Interpreting ABG results - ✅✅1) Look at pH <7.35 acidosis
7.45 Alkalosis
- PaCo2 and HCO <35 or >45 PaCO2 is respiratory <22 or >26 is metabolic Diabetes Mellitus Management: Evaluating Glycemic Control - ✅✅Monitor with HbA1c expected reference range is 4-6% acceptable target for clients with diabetes 6.5-8% indicator of average blood glucose for the past 120 days Electrolyte Imabalances: Increasing the risk for digoxin toxicity - ✅✅Hypokalemia and client receiving digoxin increases the risk for digoxin toxicity
Respiratory Diagnostic Procedures: Client positioning for thoracentesis - ✅✅Position the client sitting upright with his arms and shoulders raised and supported on pillows and/or on an overbed table and with his feet and legs well supported Hepatitis and Cirrhosis: Client positioning following a biopsy - ✅✅Assist the client into a supine position with the upper right quadrant of the abdomen exposed Cushing Disease/ Syndrome: Priority Actions - ✅✅Daily weights Monitor I&O assess for hypervolemia monitor for skin breakdown Fractures and Immobilization devices: Assessing for complications (795) - ✅✅Fat embolism: Dyspnea, chest pain and decreased oxygen saturation Decreased mental acuity Respiratory distress Tachycardia Tachypnea Fever Osteomyelitis: Constant bone pain Edema Fever Possible elevated sedimentation rate Gastrointestinal Therapeutic Procedures: Ostomy complications - ✅✅Necrosis:
Peripheral Vascular Diseases: Arterial Revascularization - ✅✅used for severe claudication and or limb pain at rest
- maintain adequate circulation
- check pedal and dorsalis pulse -Note color, temperature, sensation and cap refill Diagnostic and therapeutic procedures for female reproductive disorders: Discharge teaching for abdominal hysterectomy - ✅✅well balanced diet (high in protein) Hormonal therapy restrict activity for as long as 6 weeks avoid use of tampons look for foul smelling drainage and temp > 100F Arthroplasty: Preventing complications following hip arthoplasty - ✅✅Follow position restrictions to avoid dislocation
- use elevated seating
- straight chairs with arms
- abduction pillow or a pillow between client legs
- externally rotate toes Cancer disorders: client teaching following partial glossectomy - ✅✅-Client need for alternate communication following surgery -head of bed elevated to reduce edema -report leakage of fluid from the suture line or swallowing difficulty -thicken liquids -frequent oral hygiene
Meningitis: Planning interventions for care (53) - ✅✅-Isolate client as soon as meningitis is expected -Implement fever reduction measures -report to public health department -Bed rest with HOB 30 degrees -Provide quiet environment and minimize exposure to bright light -Avoid coughing and sneezing which increased ICP -Maintain safety and seizure precautions Chest tube insertion and monitoring: Maintaining drainage system - ✅✅First Chamber: Drainage collection Second Chamber: Water seal Third Chamber: Suction control Position client in semi-fowlers to high-fowlers position to promote optimal lung expansion
- Tidaling with movement is expected in the water seal chamber
- Cessation of tidaling in the water seal chamber signals lung reexpansion
- Continuous bubbling in the water seal chamber (air leak finding) Diabetes Mellitus Management: Sick Day Management - ✅✅Monitor blood glucose every 3- hours Continue to take insulin or oral hypoglycemia agents consume 4oz sugar free liquid every 30 minutes meet carb needs with soft foods Test urine for ketones Head Injury: indications of increased intracranial pressure - ✅✅-Severe headache
Encourage foods high in K Fluid imbalances: Assessment findings - ✅✅Hypo: Increased Hct Increased urine specific gravity increased serum sodium Hyper: Decreased Hct Normal sodium decreased electrolytes, BUN and creatinine Respiratory alkalosis Fluid Imbalances: Clinical manifestations of hypervolemia - ✅✅Tachycardia bounding pulse hypertension muscle weakness headache ascites orthopnea crackeles distended neck veins Fluid Imbalances: Clinical manifestations of Dehydration - ✅✅Hyperthermia tachycardia thready pulse hypotension
decreased CVP tachypneic hypoxia dizziness syncope confusion thirst decreased cap refill Hyperthyroidism: Caring for a client following a thyroidectomy - ✅✅Client in high fowlers position, support head and neck with pillow and avoid neck extension check surgical site for excessive bleeding have trach supplies immediately available Hypocalcemia can occur Anemias: Manifestations of anemia - ✅✅Pallor Fatigue irritability dypnea sensitivity to cold tachycardia bright red tongue (vit b12 deficiency) Hemodialysis and Peritoneal Dialysis: Manifestations of Peritonitis - ✅✅Severe abdominal pain which worsens with movement Anemias: Administering Epoetin Alfa - ✅✅Monitor for an increase in blood pressure
Dry Macular Degeneration: Smokers HTN Female Short body stature Family History Diet lacking carotene and Vitamin A
- Lack of depth perception
- Distorted objects
- Blurred vision
- Loss of central vision
- Blindness Disorders of the eye: Indications of Glaucoma - ✅✅Open Angle
- Headache
- Mild eye pain
- loss of peripheral vision
- decreased acommodation
- Elevated IOP (>21) Angle- Closure
- Rapid onset of elevated IOP
- Decreased or blurred vision
- Halos around lights
- non reactive pupils
- severe pain and nausea
- photophobia Posterior Pituitary Disorders: Medications to treat diabetes insipidus - ✅✅Desmopressin acetate (DDAVP)
- Notify weight gain >2 lbs in 24 hours Cabamazepine (Tegretol) -Notify sore throat, fever or bleeding Vasopressin (Pitressin)
- Notify headache or confusion Head injury: Identification of altered respiratory patterns - ✅✅Cheyne stokes respirations central neurogenic hyperventilation apnea Emergency Nursing principles and management: Priority action for abdominal trauma (9) - ✅✅ABCDE (Airway, breathing, circulation, disability and exposure) Hemodynamic Shock: Priority intervention for hypovolemic shock - ✅✅Continuously monitor airway and vital signs Administer fluids (0.9% NaCl or Lactated Ringers) Have resuscitation equipment available Hypertension: Action for hypertensive crisis - ✅✅Administer IV anti-hypertensives therapies, such as nitroprusside, nicardipine and labetaolol Monitor BP every 5-15 minutes Assess neurological status Monitor Cardiac status
