ATI Remediation Study Guide

aspartate aminotransferase (AST)

0 to 35 units/l. Elevation occurs with hepatitis or cirrhosis.

ammonia

10 to 80 mcg/dl. Elevated in liver disease

albumin

3.5 to 5 g/dl Decrease can indicate hepatic disease.

amylase

30 to 220 units/l. Elevation occurs with pancreatitis.

What are some liver function tests?

Aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), bilirubin, and albumin. ●Other blood tests that provide information on the functioning of the GI system include amylase, lipase, alpha‑fetoprotein, and ammonia.

QuantiFERON‑TB Gold

Blood test that detects release of interferon‑gamma(IFN‑g) in fresh heparinized whole blood from sensitized people ●Diagnostic for infection, whether active or latent. ●Results are available within 24 hr

Colonoscopy Preparation

Bowel prep ●Can include laxatives, such as bisacodyl and polyethylene glycol ●Polyethylene glycol is not recommended for older adult clients because it can cause fluid and electrolyte imbalances. ●Polyethylene glycol can inhibit the absorption of some medications. Review the client's medications and consult with the provider. ●Clear liquid diet (avoid red, purple, orange fluids). NPO after midnight. ●The client must avoid medications indicated by the provider, such as aspirin, anticoagulants, and antiplatelet medication.

What are the occult blood testing considerations?

Instruct the client about proper collection technique. The client might also need to be instructed about medication restrictions (anticoagulants, NSAIDs) for 7 days before the testing starts, and dietary restrictions to follow (vitamin C rich foods, red meat, chicken, fish) prior to obtaining samples

Colonoscopy Postprocedure

Notify the provider of severe pain (possible perforation) or indication of hemorrhage. ●Monitor for rectal bleeding. ●Monitor vital signs and respiratory status. Maintain an open airway until the client is awake. ●Resume normal diet as prescribed. ●Encourage increased fluid intake. ●Instruct the client that there can be increased flatulence due to air instillation during the procedure. ●Instruct the client not to drive or use equipment for 12 to 18 hr after the procedure

What are the Gastrointestinal procedures currently utilized?

Procedures include liver function tests, other blood tests, urine bilinogen, fecal occult blood test (FoBt), stool samples, endoscopy, and gastrointestinal (Gi) series.

What are the medications given for TB as a regimen?

The current four‑medication regimen includes isoniazid, rifampin, pyrazinamide, and ethambutol. However, streptomycin sulfate may also be given.

Miliary TB

The organism invades the bloodstream and can spread to multiple body organs with complications including the following. ●Headaches, neck stiffness, and drowsiness (can be life‑threatening) ●Pericarditis: Dyspnea, swollen neck veins, pleuritic pain, and hypotension due to an accumulation of fluid in pericardial sac that inhibits the heart's ability to pump effectively. NURSING ACTIONS: Treatment is the same as for pulmonary TB

A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? a. "Your urine can turn a dark orange." b. "Watch for a change in the sclera of your eyes." c. "Watch for any changes in vision." d. "Take vitamin B6 daily."

c. CORRECT: The client who is receiving ethambutol will need to watch for visual changes due to optic neuritis, which can result from taking this medication.

A nurse is preparing to administer a new prescription for isoniazid (iNH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? a. "You might notice yellowing of your skin." b. "You might experience pain in your joints." c. "You might notice tingling of your hands." d. "You might experience a loss of appetite."

c. CORRECT: Tingling of the hands is an adverse effect of isoniazid.

A nurse is reviewing the health record of a client who has a suspected tumor of the jejunum. The nurse should anticipate a prescription for which of the following tests? (select all that apply.) a. Serum alpha‑fetoprotein b. Endoscopic retrograde cholangiopancreatography (ercP) c. Gastrointestinal x‑ray with contrast d. Small bowel capsule endoscopy (M2a) e. Colonoscopy

c. CORRECT: a gastrointestinal x‑ray with contrast involves the client drinking barium, which is then traced through the small intestine to the junction with the colon. this would identify a tumor in the jejunum. d. CORRECT: M2a is a procedure in which the client swallows a capsule with a glass of water for a video enteroscopy to visualize the entire small bowel over an 8‑hr period.

A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing three specimens. Which of the following statements by the client indicates understanding of the teaching? a."i will continue taking my warfarin while icomplete these tests." B."i'm glad i don't have to follow any special diet at this time." c."this test determines if i have parasites in my bowel." D."this is an easy way to screen for colon cancer.

d. CORRECT: Fecal occult blood testing is a screening procedure for colon cancer

lipase

lipase 0 to 160 units/l. Elevation occurs with pancreatitis.

Direct (conjugated) bilirubin

0.1 to 0.3 mg/dl Elevations indicate altered liver function, bile duct obstruction, or other hepatobiliary disorder

alpha‑fetoprotein

Less than 40 mcg/l Elevated in liver cancer, cirrhosis, hepatitis.

indirect (unconjugated) bilirubin

0.2 to 0.8 mg/dl Elevations indicate altered liver function, bile duct obstruction, or other hepatobiliary disorder

total bilirubin

0.3 to 1 mg/dl Elevations indicate altered liver function, bile duct obstruction, or other hepatobiliary disorder.

alkaline phosphatase (ALP)

30 to 120 units/l. Elevation indicates liver damage.

alanine aminotransferase (ALT)

4 to 36 units/l. Elevation occurs with hepatitis or cirrhosis.

M2A Swallow the capsule with a glass of water for a video enteroscopy to visualize the entire small bowel over an 8‑hr period. The capsule is not used to view the colon

ANESTHESIA: None POSITIONING: Return to normal activity during the study PREPARATION ●Fast (water only) for 8 to 10 hr before the test and NPO for first 2 hr of the testing. Normal eating 4 hr after swallowing the capsule. ●The abdomen is marked for the location of the sensor. Eight‑lead sensors are placed and connected to a data recorder, which captures images of the small intestines. POSTPROCEDURE ●After 8 hr, the client returns the recorder for downloading of the images. ●The client will evacuate the capsule in the stool

Sigmoidoscopy Scope is shorter than colonoscope, allowing visualization of the anus, rectum, and sigmoid colon to test for colon cancer, investigate for a GI bleed, diagnose or monitor inflammatory bowel disease

ANESTHESIA: None required POSITIONING: On left side PREPARATION ●Bowel prep, which can include laxatives, such as bisacodyl, cleansing enema or sodium biphosphate enema ●Clear liquid diet at least 24 hr before the procedure ●NPO after midnight ●The client must avoid medications as indicated by the provider. POSTPROCEDURE ●Monitor vital signs and respiratory status. ●Monitor for rectal bleeding. ●Resume normal diet as prescribed. ●Encourage increased fluid intake. ●Instruct the client that there can be increased flatulence due to air instillation during the procedure

Esophagogastroduodenoscopy (EGD) Insertion of endoscope through the mouth into the esophagus, stomach, and duodenum to identify or treat areas of bleeding, dilate an esophageal stricture, and diagnose gastric lesions or celiac disease

ANESTHESIA:Moderate sedation per IV access: Topical anesthetic to depress the gag reflex, atropine to decrease secretions POSITIONING: Left side‑lying with head of bed elevated. PREPARATION: NPO 6 to 8 hr. Remove dentures prior to procedure. POSTPROCEDURE ●Monitor vital signs and respiratory status. Maintain an open airway until the client is awake. ●Notify the provider of bleeding, abdominal or chest pain, and any evidence of infection. ●Withhold fluids until return of gag reflex. ●Discontinue IV fluid therapy when the client tolerates oral fluids without nausea and vomiting. ●Instruct the client not to drive or use equipment for 12 to 18 hr after the procedure. ●Teach the client to use throat lozenges if a sore throat or hoarse voice persists following the procedure

ERCP: Insertion of an endoscope through the mouth into the biliary tree via the duodenum. Allows visualization of the biliary ducts, gall bladder, liver, and pancreas. X‑rays are taken after a contrast medium is injected into the common duct

ANESTHESIA:Moderate sedation per IV access:Topical anesthetic to depress the gag reflex, atropine to decrease secretions. POSITIONING: Initially semi‑prone with repositioning throughout procedure PREPARATION ●NPO 6 to 8 hr. Remove dentures prior to procedure. ●Explain the procedure and the need to change positions during the procedure. POSTPROCEDURE ●Monitor vital signs and respiratory status. Maintain an open airway until the client is awake. ●Notify the provider of bleeding, abdominal or chest pain, and any evidence of infection. ●Withhold fluids until return of gag reflex. ●Discontinue IV fluid therapy when the client tolerates oral fluids without nausea and vomiting. ●Instruct the client not to drive or use equipment for 12 to 18 hr after the procedure. ●Teach the client to use throat lozenges if a sore throat or hoarse voice persists following the procedure

Rifampin (RIF)

Is a bacteriostatic and bactericidal antibiotic that inhibits DNA‑dependent RNA polymerase activity in susceptible cells. NURSING CONSIDERATIONS ●Observe for hepatotoxicity. ●Liver function testing should be completed prior to and at least monthly after starting RIF. CLIENT EDUCATION ●Inform the client that urine and other secretions will be orange. ●Advise the client to immediately report yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise. ●Inform the client this medication can interfere with the efficacy of oral contraceptives

Pyrazinamide (PZA)

Is a bacteriostatic and bactericidal. Its exact mechanism of action is unknown. NURSING CONSIDERATIONS ●Observe for hepatotoxicity. ●Assess for history of gout, as the medication will cause an adverse effect of nongouty polyarthralgias. ●Liver enzymes should be completed baseline and every 2weeks after starting PZA. CLIENT EDUCATION ●Instruct the client to drink a glass of water with each dose and increase fluids during the day to help prevent gout and kidney problems. ●Advise the client to immediately report yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise. ●Advise the client to avoid using alcohol while taking pyrazinamide.

Ethambutol (EMB)

Is a bacteriostatic and works by suppressing RNA synthesis, subsequently inhibiting protein synthesis. NURSING CONSIDERATIONS ●Obtain baseline visual acuity tests, and complete monthly after starting treatment. ●Determine color discrimination ability ●This medication should not be given to children younger than 8 years of age. ●Stop medication immediately if ocular toxicity occurs. CLIENT EDUCATION: Instruct the client to report changes in vision immediately

Streptomycin sulfate

Is an aminoglycoside antibiotic. It potentiates the efficacy of macrophages during phagocytosis. NURSING CONSIDERATIONS ●Due to its high level of toxicity, this medication should be used only in clients who have multidrug‑resistant TB (MDR‑TB). ●Streptomycin can cause ototoxicity, so monitor hearing function and tolerance often. ●Report significant changes in urine output and renal function studies. CLIENT EDUCATION ●Advise the client to drink at least 2 L of fluid daily. ●Advise the client to notify the provider if hearing declines

Isoniazid (INH)

Is bactericidal and inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall. NURSING CONSIDERATIONS ●This medication should be taken on an empty stomach. ●Monitor for hepatotoxicity (jaundice, anorexia, malaise, fatigue, and nausea) and neurotoxicity (such as tingling of the hands and feet). ●Vitamin B6 (pyridoxine) is used to prevent neurotoxicity from isoniazid. ●Liver function testing should be completed prior to and monthly after starting INH. CLIENT EDUCATION ●Advise the client not to drink alcohol while taking isoniazid because it can increase the risk for hepatotoxicity. ●Advise the client to report any manifestations of hepatotoxicity.

What are the diagnostic procedures for TB?

Mantoux test: intradermal injection that should be read in 48-72 hours. Chest xray Acid‑fast bacilli smear and culture: A positive acid‑fast test suggests an active infection. The diagnosis is confirmed by a positive culture for Mycobacterium tuberculosis.

GI Procedure Complications

Oversedation Use of moderate sedation places the client at risk for oversedation. MANIFESTATIONS: Difficult to arouse, poor respiratory effort, evidence of hypoxemia, tachycardia, and elevated or low blood pressure NURSING ACTIONS ●Be prepared to administer antidotes for sedatives administered prior to and during the procedure. ●Administer oxygen, and monitor vital signs. Maintain an open airway until awake. ●Notify the provider immediately, and call for assistance. CLIENT EDUCATION: Driving and major decision‑making are restricted until the effects of the sedation have worn off. This varies with the type of agent used. Hemorrhage MANIFESTATIONS: Bleeding, cool and clammy skin, hypotension, tachycardia, dizziness, and tachypnea NURSING ACTIONS ●Assess for hemorrhage from the site. Monitor vital signs. ●Monitor diagnostic test results (particularly Hgb andHct) ●Notify the provider immediately. CLIENT EDUCATION: Report fever, pain, and bleeding to the provider Aspiration Using moderate sedation or topical anesthesia can affect the gag reflex. MANIFESTATIONS: Dyspnea, tachypnea, adventitious breath sounds, tachycardia, and fever NURSING ACTIONS ●Keep the client NPO until the gag reflex returns. Ensure that the client is awake and alert prior to consuming food or fluid. Encourage the client to deep breathe and cough to promote removal of secretions. ●Notify the provider if there is a delay in gag reflex return. CLIENT EDUCATION: Report any respiratory congestion or compromise to the provider. Perforation of the gastrointestinal tract Manifestations include chest or abdominal pain, fever, nausea, vomiting, and abdominal distention. NURSING ACTIONS: Monitor diagnostic tests for evidence of infection, including elevated WBC, and notify the provider of unexpected findings. CLIENT EDUCATION: Report fever, pain, and bleeding to the provider.

GI Series GI studies are done with or without contrast and help define anatomic or functional abnormalities. ●These include radiographic imaging of the esophagus, stomach, and entire intestinal tract. ●Upper GI imaging is done by having the client drink a radiopaque liquid (barium). For small bowel follow‑through, barium is traced through the small intestine to the ileocecal junction. ●A barium enema is done by instilling a radiopaque liquid into the rectum and colon.

PreProcedure NURSING CONSIDERATIONS ●Inform the client about medications, food and fluid restrictions (clear liquid and/or low residue diet, NPO after midnight), and avoiding smoking or chewing gum (increases peristalsis). ●Assess the client's understanding of bowel preparation (laxatives, enemas) so the image will not be distorted by feces. ●Barium enema studies must be scheduled prior to upper GI studies. ●Assess for contraindications to bowel preparation (possible bowel perforation or obstruction, inflammatory disease). CLIENT EDUCATION ●Tell the client to restrict food and fluids for bowel preparation. ●Inform the client that if the small intestine is to be visualized, additional radiographs will be done over the next 24 hr. PostProcedure NURSING ACTIONS ●Monitor elimination of contrast material, and administer a laxative if prescribed. ●Increase fluid intake to promote elimination of contrast material. CLIENT EDUCATION ●Instruct the client to monitor elimination of contrast material and to report retention of contrast material (constipation) or diarrhea accompanied by weakness. ●Discuss the possible need for an over‑the‑counter medication to prevent constipation resulting from the barium. ●Instruct the client that stools will be white for 24 to 72 hr until barium clears. The client should report abdominal fullness, pain, or delay in return to brown stool

TB Teaching

Provide the client and family education because TB is often treated in the home setting. ●Airborne precautions are not needed in the home setting because family members have already been exposed. ●Exposed family members should be tested for TB. ●Educate the client and family to continue medication therapy for its full duration of 6 to 12 months, even up to 2 years for multidrug‑resistant TB. Emphasize that failure to take the medications can lead to a resistant strain of TB ●Instruct the client to continue with follow‑up care for 1 full year. ●Inform the client that sputum samples are needed every 2 to 4 weeks to monitor therapy effectiveness. Clients are no longer considered infectious after three consecutive negative sputum cultures, and may return to former employment. ●Encourage proper hand hygiene. ●Instruct the client to cover mouth and nose when coughing or sneezing. ●Inform the client that contaminated tissues should be disposed of in plastic bags. ●Advise clients who have active TB to wear a mask when in public places or in contact with crowds.

A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (select all that apply.) a. Persistent cough b. Weight gain c. Fatigue d. Night sweats e. Purulent sputum

a. CORRECT: The nurse should include in the teaching that a persistent cough is a manifestation of tuberculosis. c. CORRECT: The nurse should include in the teaching that fatigue is a manifestation of tuberculosis. d. CORRECT: The nurse should include in the teaching that night sweats is a manifestation of tuberculosis. e. CORRECT: The nurse should include in the teaching that purulent sputum is a manifestation of tuberculosis.

A nurse is having difficulty arousing a client following an esophagogastroduodenoscopy (eGD). Which of the following is the priority action by the nurse? a. Assess the client's airway. b. Allow the client to sleep. c. Prepare to administer an antidote to the sedative. d. Evaluate preprocedure laboratory findings

a. CORRECT: When using the airway, breathing, and circulation priority‑setting framework, assessing and maintaining an open airway is the priority action the nurse should take

A nurse is reviewing bowel prep using polyethylene glycol with a client scheduled for a colonoscopy. Which of the following instructions should the nurse include in the teaching? a. Check with the provider about taking current medications when consuming bowel prep. b. Consume a normal diet until starting the bowel prep. c. Expect the bowel prep to not begin acting until the day after all the prep is consumed. d. Discontinue the bowel prep once feces start to be expelled

a. CORRECT: the nurse should instruct the client to check with the provider about taking current medication, because some medications can be withheld when taking polyethylene glycol due to their lack of absorption.

A nurse is completing preprocedure teaching for a client who will undergo a sigmoidoscopy. Which of the following information should the nurse include in the teaching? (select all that apply.) a. Increased flatulence can occur following the procedure. B. NPO status should be maintained preprocedure. c. Conscious sedation is used. D. Repositioning will occur throughout the procedure. e. Fluid intake is limited the day after the procedure.

a. CORRECT: the nurse should teach the client that increased flatulence can occur due to the instillation of air during the procedure. b. CORRECT: the nurse should instruct the client to remain NPO after midnight the night before the procedure

A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg Po daily, rifampin 500 mg Po daily, pyrazinamide 750 mg Po daily, and ethambutol 1 mg Po daily. Which of the following client statements indicate the client understands the teaching? (select all that apply.) a. "I can substitute one medication for another if I run out because they all fight infection." b. "I will wash my hands each time I cough." c. "I will wear a mask when I am in a public area." d. "I am glad I don't have to have any more sputum specimens." e. "I don't need to worry where I go once I start taking my medications."

b. CORRECT: The client should wash her hands each time she coughs to prevent spreading the infection. c. CORRECT: The client should wear a mask while in public areas to prevent spreading the infection. The client has active Tb, which is transmitted through the airborne route

A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? a. "You will need to continue to take the multi medication regimen for 4 months." b. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." c. "You will need to remain hospitalized for treatment." d. "You will need to wear a mask at all times."

b. CORRECT: The client who has tuberculosis needs to provide sputum samples every 2 to 4 weeks to monitor the effectiveness of the medication

What are nursing interventions for TB?

●Administer heated and humidified oxygen therapy as prescribed. ●Prevent infection transmission. -Wear a N95 HEPA filter or powered air purifying respirator when caring for clients who are hospitalized with TB. (23.2) -Place the client in a negative‑airflow room, and implement airborne precautions. -Use barrier protection when the risk of hand or clothing contamination exists. -Have the client wear a surgical mask if transportation to another department is necessary. The client should be transported using the shortest and least busy route. -Teach the client to cough and expectorate sputum into tissues that are disposed of by the client into provided plastic bags or no‑touch receptacles. ●Administer prescribed medications. ●Promote adequate nutrition. -Encourage fluid intake and a well‑balanced diet for adequate caloric intake. -Encourage foods that are rich in protein, iron, and vitamins C and B. ●Provide emotional support

Manifestations of TB.

●Persistent cough lasting longer than 3 weeks ●Purulent sputum, possibly blood‑streaked ●Fatigue and lethargy ●Weight loss and anorexia ●Night sweats and low‑grade fever in the afternoon PHYSICAL ASSESSMENT FINDINGS: Older adult clients often present with atypical symptoms of the disease (altered mentation or unusual behavior, fever, anorexia, weight loss)