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ATI Medsurg Proctored Final
Exam 2021
Escharotomy
Explanation of Escharotomy
An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation.
Nursing Statement
The appropriate nursing statement to explain the procedure to the client's spouse is: "Large incisions will be made in the eschar to improve circulation."
Endometriosis
Symptoms of Endometriosis
Endometriosis is a condition in which the type of tissue that lines the uterus implants in locations outside the uterus. This typically causes pelvic pain around the time of the menstrual period, but can cause pain at other times in the cycle. The discomfort is often unrelieved by the use of NSAIDs (non- steroidal anti-inflammatory drugs).
Consistent Finding in Client History
The finding in the client's history that is consistent with a diagnosis of endometriosis is dysmenorrhea (painful menstruation) that is unresponsive to NSAIDs.
Spinal Cord Injury and Rehabilitation
Client Withdrawal and Resistance
After a week on the rehabilitation unit, a client with a spinal cord injury resulting in paraplegia is noted to be withdrawn and increasingly resistant to rehabilitative efforts by the staff.
Nurse's Action
The nurse should establish a plan of care with the client that sets attainable goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable.
Acute Pancreatitis
Laboratory Findings
In a client with acute pancreatitis, the nurse should expect to find an elevation of amylase. Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hours and can remain elevated for 2 to 3 days.
Cholecystitis
Urine Appearance
In a client with suspected cholecystitis, the nurse should expect the client's urine to appear dark and foamy, which indicates the kidneys are filtering excess bilirubin from the blood.
Rheumatoid Arthritis
Monitoring Medication Effectiveness
For a client with rheumatoid arthritis (RA) who is taking aspirin 650 mg every 4 hours, the nurse should monitor the erythrocyte sedimentation rate (ESR) to evaluate the effectiveness of this medication. Rheumatoid arthritis is a chronic inflammatory disease, and ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves, the ESR decreases.
Calcium Oxalate Kidney Stones
Dietary Instruction
For a client with a history of recurring calcium oxalate kidney stones, the nurse should instruct the client to drink at least 3 to 4 liters of fluid every day to dilute the urine and reduce the risk for stone formation.
Osteoporosis Risk Factors
Risk Factors to Include in Teaching
When teaching a client about risk factors for osteoporosis, the nurse should include the following: - Sedentary lifestyle - Aging - Caffeine intake - Secondhand smoke
Tuberculosis Diagnosis
Most Reliable Test
For a client with a history of TB exposure and symptoms of night sweats and hemoptysis, the most reliable test to confirm the diagnosis of active pulmonary TB is a sputum culture for acid-fast bacillus. Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis.
Emphysema
Nursing Assessment Findings
In a client with emphysema, the nurse should expect to assess the following findings: - Dyspnea (shortness of breath) - Barrel chest
The client may also exhibit clubbing of the fingers, which results from chronic low arterial oxygen levels.
Burn Injury Assessment and Management
Priority Nursing Action
For a client who has sustained partial-thickness burns to both lower legs, chest, face, and both forearms, the priority action the nurse should take is to inspect the mouth for signs of inhalation injuries. Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury, which is the priority concern at this time.
Neutropenia and Chemotherapy/Radiation
Dietary Restrictions
For a client with neutropenia who is being treated with chemotherapy and radiation for metastatic breast cancer, the nurse should include the restriction of fresh flowers and potted plants in the client's plan of care. This is to prevent the risk of infection from exposure to potential pathogens.
Chronic Cholecystitis and Dietary Instruction
Dietary Instruction
For a client with episodes of biliary colic from chronic cholecystitis, the nurse should instruct the client to avoid foods high in fat. Clients with chronic cholecystitis have an intolerance to fatty foods, which can trigger episodes of biliary colic.
Gastrectomy and Postoperative Complications
Postoperative Instruction
When providing preoperative teaching for a client scheduled for a gastrectomy, the nurse should include information about the use of a sequential compression device to prevent deep-vein thrombosis, a common postoperative complication.
Early Menopause
Manifestation
For a middle adult female client who reports irregular menstrual periods and hot flashes, the nurse should expect the client to have dryness with intercourse as a manifestation associated with early menopause. This is due to the changes in the vagina resulting from the decrease in estrogen production.
Basal Cell Carcinoma
Skin Lesion Characteristics
A 1-cm (0.4-in) lesion on the client's chest that is raised, flesh-colored with pearly white borders is suggestive of basal cell carcinoma, a type of skin cancer.
Sexually Transmitted Infections (STIs)
Counseling Technique
When teaching newly licensed nurses about effective techniques for counseling clients about sexually transmitted infections (STIs), the nurse should include the statement: "Ask about the client's exposure to any past or present STIs." This allows the nurse to assess the client's history and provide appropriate education and treatment.
Radiation Therapy After Mastectomy
Skin Integrity Instructions
When providing discharge teaching for a client who is postoperative following a simple mastectomy and will be starting outpatient radiation therapy, the nurse should instruct the client to: - Do not apply heat to the area of irradiation. This helps avoid tissue damage, as radiated tissue becomes thinner and may lack receptors that would otherwise alert the client to a potential burn injury. - When outdoors in sunlight, the client should wear protective clothing over the area of irradiation.
CA 125 Test
The CA 125 test is used to monitor a client's progress during treatment of ovarian cancer. It is a useful tool for tracking the effectiveness of cancer treatment.
Seven Warning Signs of Cancer
The seven warning signs of cancer that the nurse should include in the teaching are: - A non-healing sore - Bloating - Change in bowel pattern - Change in moles - Nagging cough
Fluid Resuscitation Monitoring
When monitoring a client receiving IV fluid resuscitation therapy for a severe burn injury, the nurse should identify a decrease in heart rate as an indication of adequate fluid replacement. This is because when the circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure.
Myelosuppression Monitoring
When caring for a client who has myelosuppression after receiving chemotherapy, the nurse should monitor for bleeding from the gums. This is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets.
Arteriovenous Fistula Monitoring
When providing discharge teaching to a client with a new arteriovenous fistula in the right forearm, the nurse should include pallor and numbness distal to the fistula site as possible indications of venous insufficiency that should be immediately reported to the provider.
Basal Cell Carcinoma
When planning an educational program about basal cell carcinoma, the nurse should include the information that basal cell carcinoma has a low incidence of metastasis. It is a localized lesion that seldom spreads to other parts of the body.
Blood Transfusion Timing
When receiving a unit of packed RBCs from the blood bank, the nurse should begin the infusion as soon as the client and administration set are prepared. The blood should be infused within 4 hours of being received from the blood bank.
Hepatitis B Self-Management Instructions
Rest Frequently Throughout the Day
The nurse should recommend that the client with hepatitis B rest frequently throughout the day. This is because limiting activity is usually recommended until the symptoms of hepatitis have subsided. Resting frequently can help reduce the metabolic demands upon the liver and decrease energy demands, which is important for the client's recovery.
HIV Laboratory Values
CD4-T-Cell Count 180 cells/mm
The nurse's priority laboratory value for a client with HIV is the CD4-T-cell count. A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.
Decreasing Nausea from Chemotherapy and
Radiation
Eat Foods Served at Room Temperature or Chilled
The nurse should instruct the client to eat foods served at room temperature or chilled. Foods served hot may contribute to nausea associated with chemotherapy and radiation treatments.
Rehabilitation Goals for Left Hemispheric
Cerebrovascular Accident
Establish the Ability to Communicate Effectively
The nurse should include the goal of establishing the client's ability to communicate effectively in the rehabilitation program. This is because a left hemispheric cerebrovascular accident (CVA) can result in aphasia, and the client will require speech therapy to regain communication abilities.
Osteoporosis Risk Factors
Thyroid Hormones
The nurse should include long-term use of synthetic thyroid hormone, such as levothyroxine, as a risk factor for osteoporosis in the teaching.
Gynecological Examination
Assess the Urethral Orifice by Separating the Labia Minora
The nurse should include in the teaching that the urethral orifice, clitoris, and vaginal orifice are examined for lesions, inflammation, and discharge by separating the labia minora during a gynecological examination.
Hypokalemia EKG Abnormalities
Abnormally Prominent U Wave
The nurse should interpret an abnormally prominent U wave on the client's EKG as a sign of hypokalemia, in addition to monitoring for flattened T waves, prolonged PR interval, or ST depression.
Carpal Tunnel Syndrome Assessment
Hold the Wrist at a 90-Degree Flexion
The nurse should request that the client perform the test of holding the wrist at a 90-degree flexion, as this will usually result in numbness, tingling, or weakness, which can help confirm the diagnosis of carpal tunnel syndrome.
Viral Hepatitis Prevention
Avoid Foods Prepared with Tap Water
The nurse should include in the presentation that clients should prepare foods with purified water to decrease the risk of acquiring viral hepatitis.
Uterine Prolapse Manifestations
Feces Present in the Vagina
The nurse should recognize that the client's statement about feces being present in the vagina indicates a need for further teaching, as this is a manifestation of a genital fistula, not uterine prolapse.
Abdominal Wound Dehiscence Management
Cover the Wound with a Moist, Sterile Gauze Dressing
The nurse's first action should be to cover the dehisced abdominal wound with a moist, sterile, saline-soaked gauze dressing to keep the wound clean and manage the exudate.
Wound Drainage Documentation
Serosanguineous
The nurse should document the watery red drainage observed on the client's wound dressing as serosanguineous.
Colonoscopy Procedure Instructions
Before the Examination, Your Provider Will Give You a
Sedative That Will Make You Sleepy
The nurse's appropriate response addresses the client's concerns about feeling pain during the colonoscopy procedure by informing him that he will be given a sedative that will make him sleepy.
Osteoporosis Prevention Teaching
Reduce Intake of Vitamin K-Rich Foods
The nurse should instruct the client to increase, not reduce, her intake of vitamin K-rich foods, such as green, leafy vegetables, to promote bone health and prevent osteoporosis.
Chest Tube Drainage System Assessment
Verify That the Suction Regulator Is On and Check the
Tubing for Leaks
If the nurse notes no bubbling in the suction control chamber of the client's three-chamber chest tube drainage system, the appropriate action is to verify that the suction regulator is on and check the tubing for any leaks.
Preoperative Teaching for Lower Extremity
Amputation
Your Pain Will Gradually Become Less Severe
The nurse should plan preoperative teaching based on the possibility of phantom leg pain, which usually diminishes over time and is often intermittent in response to a trigger.
BRCA1 Gene Mutation and Breast Cancer
Risk
Developing Breast Cancer
The nurse should recognize that a female middle adult client who tests positive for a mutant BRCA1 gene is at an increased risk for developing breast cancer.
Hysterosalpingography Teaching
The Client Might Experience Shoulder Pain Following the
Procedure
The nurse should include in the teaching plan that the client might experience shoulder pain following the hysterosalpingography procedure, due to phrenic nerve irritation caused by the contrast media.
Menopausal Hormone Therapy (HT)
History of Breast Cancer
Women with a history of breast cancer should be counseled against using menopausal hormone therapy (HT). This is due to the findings in the client's medical history, as HT is not recommended for individuals with a history of breast cancer.
Immunosuppression Following Chemotherapy
Limiting Health Care Worker Exposure
When caring for a client who has immunosuppression following chemotherapy, the nurse should include the intervention of limiting the number of health care workers entering the room. This helps prevent possible overexposure to microorganisms that can lead to an infection in the immunocompromised client.
Discharge Instructions for Clients with AIDS
Preventing Infection Spread
When preparing a client with AIDS for discharge, the nurse should include the following statement in the discharge instructions: "Prevent the spread of infection with good household cleaning practices." The client should follow standard precautions and use a 1:10 solution of bleach to disinfect areas that come into contact with blood and body fluids.
Fluid Volume Deficit Risk
Gastroenteritis and Fever
When caring for four hospitalized clients, the nurse should identify the client with gastroenteritis and fever as being at risk for fluid volume deficit, or dehydration. Gastroenteritis can lead to significant fluid loss through diarrhea and possibly vomiting, while the fever can also contribute to fluid loss through diaphoresis and increased metabolic rate, putting the client at a greater risk for dehydration.
Tracheostomy Care
Partner Readiness for Discharge
When caring for a client with a tracheostomy, the nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the suctioning procedure independently. This indicates the partner's readiness to provide the necessary care at home.
Chemotherapy-Induced Fatigue
Checking Complete Blood Count (CBC)
When a client receiving cisplatin for bladder cancer reports fatigue after several treatments, the nurse should check the results of the client's most recent CBC. The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy, which may require
Pacemakers and Imaging
Contraindications for MRI with Pacemakers
Clients with a permanent pacemaker should not undergo MRI of the chest, as the magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction.
Systemic Lupus Erythematosus (SLE)
Assessing Renal Function in SLE
When caring for a client with SLE, the nurse should monitor the serum creatinine level, as it is a specific and sensitive indicator of renal function.
Osteoarthritis Risk Factors
Risk Factors for Osteoarthritis
The nurse should include the following risk factors for osteoarthritis in the teaching: - Aging - Obesity - Smoking
Acute Pancreatitis Management
Medications for Acute Pancreatitis
The nurse should anticipate a provider's prescription for a proton pump inhibitor, such as pantoprazole, to decrease gastric acid production and ultimately decrease pancreatic secretions.
Transurethral Resection of the Prostate
(TURP) Complications
Assessing for TURP Complications
The nurse should monitor for burgundy-colored urine, which may indicate venous bleeding, a potential complication following a TURP procedure.
Chronic Kidney Disease and Acid-Base
Balance
Arterial Blood Gas Findings in Chronic Kidney Disease
Clients with chronic kidney disease are expected to have metabolic acidosis, characterized by a low pH, low bicarbonate (HCO3-), and low or normal partial pressure of carbon dioxide (PaCO2).
Esophageal Varices Management
Care for Clients with Sengstaken-Blakemore Tube
Clients with a Sengstaken-Blakemore tube in place are unable to swallow, so the nurse should provide frequent oral and nasal care, such as encouraging the client to spit saliva into a tissue or basin, or gently suctioning the oral cavity and nares to remove secretions.
Postoperative Care after Coronary Artery
Bypass Graft (CABG)
Importance of Deep Breathing after CABG
For clients receiving opioid medications after CABG surgery, the nurse should identify that the most important desired effect of the medications, aside from pain management, is to facilitate the client's deep breathing, which is crucial for their recovery.
HIV Infection Symptoms
Initial Symptoms of HIV Infection
The nurse should explain that the initial symptoms of HIV infection may include flu-like symptoms and night sweats.
Nursing Interventions for Clients with Various
Medical Conditions
Pneumonia in a Client with AIDS
The nurse should obtain a sputum culture to determine the specific organism causing the recurring pneumonia in the client with AIDS. This will help identify the appropriate antibiotic needed to treat the infection.
Chest Pain Assessment for Myocardial Infarction
When a client reports a new onset of severe chest pain, the nurse should perform a 12-lead electrocardiogram (ECG) to determine if the client is experiencing a myocardial infarction (heart attack).
Hospice Care for Advanced Lung Cancer
The client's statement indicating a correct understanding of hospice care is "I should expect the hospice team to help me manage my dyspnea." The primary purpose of hospice care is to provide relief of
Diagnostic Tests for Myocardial Infarction
The laboratory tests used to diagnose a myocardial infarction are troponin I and troponin T. These cardiac enzymes are released into the bloodstream when the heart muscle is damaged.
Chest Tube Transport Precautions
When transporting a client with a chest tube connected to a closed drainage system, the nurse should keep the drainage system below the level of the client's chest at all times. This prevents air and drainage fluid from re-entering the thoracic cavity.
Monitoring a Three-Chamber Chest Tube System
If the nurse notices a rise in the water seal chamber with client inspiration, the appropriate action is to continue to monitor the client. This rise and fall of the fluid in the water seal chamber, known as tidaling, is a normal finding and indicates that the lung is expanding and contracting properly.
Wound Drainage Documentation
The nurse should document the watery red drainage observed in the client's wound dressing as serosanguineous, which refers to a drainage that is a mixture of serum and blood.
Appropriate Snack Choices for a Low-Fat, Low-Sodium,
Low-Cholesterol Diet
The food choice that indicates the need for further teaching is a slice of cheese, as cheese is high in fat and sodium and should be limited on this type of diet.
Findings in Hypercalcemia
With a serum calcium level of 12.3 mg/dL, which is above the normal range, the nurse should expect to find lethargy, generalized weakness, and confusion in the client during the initial assessment.
Vital Sign Monitoring During Blood Transfusion
When initiating a transfusion of packed red blood cells for a client with anemia, the nurse should check the client's vital signs every 15 minutes at the start of the transfusion, then every 1 hour, to monitor for any transfusion reactions.
Foods to Avoid on a Low-Potassium Diet
The foods the nurse should instruct the client to avoid on a low- potassium diet are yogurt and orange juice, as they are high in potassium.
Infection Indicator in a Client with a Pressure Ulcer
An elevation in the client's white blood cell (WBC) count would indicate the development of an infection in the pressure ulcer.
Medication Administration During Cardiopulmonary Arrest
If the client's restored rhythm is symptomatic bradycardia, the emergency response team would administer atropine to the client during cardiopulmonary resuscitation (CPR).
Interventions to Prevent Postoperative Pulmonary
Complications
The nurse should include encouraging the use of an incentive spirometer in the plan of care to help prevent pulmonary complications in the postoperative client.
Precautions for Immunocompromised Clients Receiving
Chemotherapy and Radiation
The nurse should include the restriction of fresh flowers and potted plants in the client's room in the plan of care, as immunocompromised clients are more susceptible to infection from these sources.
Adverse Effects to Monitor for with Furosemide
The nurse should monitor the client for the adverse effect of hypokalemia, as furosemide is a diuretic that can cause potassium depletion.
Electrolyte Imbalance with Postoperative Ileus and
Nasogastric Suctioning
The nurse should monitor the client for a decreased potassium level (hypokalemia) due to the prolonged nasogastric suctioning associated with the postoperative ileus.
Interventions for Epistaxis in a Client with Hypertension
The appropriate actions the nurse should take are: Apply pressure to the nares to help stop the bleeding. Place ice to the bridge of the client's nose to promote vasoconstriction and decrease bleeding.
