ATI Med/ Surg
What is an expected finding when someone is hypovolemic?
Tachycardia. W/ loss of blood volume, the heart rate increases to try and maintain bp.
What pt education will you provide to pt w/ DM regarding foot care?
- Trim nails straight across (emery board to smooth) - Wear cotton socks to reduce risk of tissue damage - DON'T soak feet in water - DON'T treat callous. Seek provider's help.
Sodium (Normal Electrolyte Value)
136-145 mEq/L
Pt has traumatic brain injury. What is an indication of increased intracranial pressure?
Dilated or fixed pupils
Pt w/ HIV discharge teaching
-Take temp. daily -Maintain hydration (drink min. 3 L / day) -Avoid exposure to anyone who is ill -Bathe daily using antimicrobial soap (if not possible, clean pits, groin, peri 2x/day)
Findings for increased intracranial pressure
-distended jugular veins -sleepiness -widening pulse pressure (increase systolic w/ concurrent decrease diastolic) -decerebrate/decoriate posture
Nurse is caring for a pt with a fistula for hemodialysis. What is an appropriate nursing action?
- The nurse should take the client's weight before and after each dialysis treatment to evaluate the amount of fluid removed during the treatment. - Inform dialysis tx lasts about 4 hrs DO NOT: - admin meds before (admin after dialysis bc meds are dialyzable) - The nurse should not perform routine venipunctures using the AV fistula or use the extremity in which the AV fistula is located to reduce the risk for clot formation.
Caring for a pt post upper GI radiographic series w/ barium. What action should the nurse plan to take?
- Administer laxative to promote evacuation of the thick, chalky, white _______ ingested during the procedure. -Check for clay colored stools first 24/72 hrs -Encourage pt to increase oral fluid intake
What to do when you're about to administer packed RBCs?
- Check pt's name and ID # in comparison w/ RBC label -Verify blood compatibility w/ pt's blood type in MAR -Dbl check w/ another RN/ LPN against MAR
Nurse is teaching a pt with polycystic kidney disease about self management. What should nurse say?
- Increase fiber in your diet (prevents chronic constipation r/t pressure on colon from enlarged kidneys) - Increase fluids to 2-3 L/ day to prevent constipation - Avoid NSAIDs (they decrease blood flow to kidneys) - Weigh yourself daily
Pt experiencing tonic clonic seizure. What should nurse do?
- Loosen restricting clothing. Loosen tie around neck so airway is not obstructed. - Place pt on their side to allow secretions to drain and prevent aspiration - DON'T restrain pt - DON'T insert tongue blade
Empty your ostomy pouch when it is _______ to ______ of the way full.
1/3 to 1/2 bc a heavy bag can pull and break the seal on the skin
Diverticular disease manifestations
Abdominal distention. A client who has __________ can have abdominal distention due to the herniation, inflammation, or perforation of the diverticulum, causing protrusion of the abdomen.
Planning care for pt with low cardiac output from heart failure. What med should nurse administer?
According to evidence-based practice, the nurse should FIRST plan to administer enalapril, which is an ACE inhibitor. Enalapril causes dilation of the arteries, improves stroke volume, and decreases afterload. The result is to increase cardiac output.
Why would you administer haloperidol?
Administer to a pt who has acute amphetamine toxicity. ___________ will decrease CNS hyperactivity, which includes irritability, insomnia, and agitation.
Why would you administer activated charcoal?
Administer to a pt who has acute aspirin toxicity. ________________ adsorbs the ingested aspirin and eliminates it in the stool, preventing absorption of the medication in the client's circulatory system
Pt receiving TPN through PICC line. What do you do if TPN is temporarily unavailable?
Infuse 10% dextrose in water at the same rate if the TPN solution runs out and the next isn't available yet. This reduces the risk of hypoglycemia.
Hypernatremia expected finding
Muscle twitching due to the rapid movement of sodium across cell membranes during depolarization, which causes the tissue to become excitable.
Hypokalemia expected finding
Paralytic ileus due to a decrease in the gastrointestinal smooth muscle contraction of the intestines.
Why would you administer flumazenil?
Pt oversedated from a benzodiazepine meds. ___________ is a benzodiazepine receptor antagonist that can reverse sedation but might not reverse a slow respiratory rate.
Pt 2 days post op following gastrectomy. Pt coughs and reports feeling something pop under my dressing. What should nurse do?
The nurse should cover the client's surgical wound with a sterile moistened dressing to keep the wound and intestinal organs intact and to reduce the risk of infection.
Patient just had a vertebral compression fracture (VCF) and is postop following a kyphoplasty. What intervention should nurse do?
The nurse should position the client supine with the head of the bed flat for 1 to 2 hr following the procedure until the bone cement is set in the vertebral area.
What to do when obtaining blood specimens from PICC line?
To maintain patency of the catheter, the nurse should flush the PICC with 20 mL of 0.9% sodium chloride after obtaining blood.
Pt has afib and is taking warfarin. Which finding should the nurse report to the provider before administering the next dose? a. Platelet 200,000/mm3 b. aPTT 36 seconds c. INR 4.0 d. Fibrinogen 220 mg/dL
c. INR 4.0 (0.9-1.2 normal range)
Pt has hx of coronary artery disease and is experiencing chest pain and nausea. Which finding should nurse report to provider immediately? a. Total cholesterol 260 mg/dL b. RBC count 6.2 million/mm3 c. Troponin T 0.3 ng/mL d. C-reactive protein 1.3 mg/dL
c. Troponin T 0.3 ng/mL. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a troponin T level of 0.3 ng/mL, which is above the expected reference range. This can indicate the client is experiencing myocardial injury or infarction and requires immediate intervention.
Cardiac output is the relationship between ____________ and _____________.
stoke volume & heart rate
