NURSING 11 FINAL EXAM EXAMINATION STUDY GUIDE 2023 FINAL EXAM CONTENT GUIDE LATEST UPDATE., Exams of Nursing

Download NURSING 11 FINAL EXAM EXAMINATION STUDY GUIDE 2023 FINAL EXAM CONTENT GUIDE LATEST UPDATE. and more Exams Nursing in PDF only on Docsity! 1/18 ATI ADULT MEDICAL SURGICAL RETAKE 1 FLASHCARDS EXAMINATION STUDY GUIDE 2023 ATI Adult Medical Surgical Retake 1 90 terms Adult Med Surg ATI Terms in this set (90) 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: 1. applies to all patients 2. Hand washing a. alcohol based preferred unless hands visually soiled 2/18 ATI ADULT MEDICAL SURGICAL RETAKE 1 FLASHCARDS EXAMINATION STUDY GUIDE 2023 3. Glo ves - when touch ing anyth ing that has the poten tial to conta minat e. 5/18 ATI ADULT MEDICAL SURGICAL RETAKE 1 FLASHCARDS EXAMINATION STUDY GUIDE 2023 - Obesity - Surgery - Heart failure or chronic A-Fib - Autoimmune hemolytic anemia (sickle cell) -Long bone fractures -Advanced age Disorders of the male -Urethral trauma reproductive system: -Urinary retention Complications of - Bleeding continuous irrigation - Infection following Trans-urethral Resection (743) Stroke: Caring for a client who has left sided hemiplegia (155) - Observe extremities for injury - Apply an arm sling if client is unable to care for the affected extremity - Ensure foot rest is on wheel chair and ankle brace is on the affected foot - Instruct client to dress the affected side first Fractures and -Assess neurovascular status of the affected body part for immobilization devices: every hour for 24 hours and Q4 hours after that Prevent complications - Maintain body alignment (787) - avoid lifting or removing weights -Monitor pain level - Monitor for signs of infection - Support nutrition 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 6/18 ATI ADULT MEDICAL SURGICAL RETAKE 1 FLASHCARDS EXAMINATION STUDY GUIDE 2023 Acute Kidney injury and chronic kidney disease: -Restrict dietary intake of potassium, phosphate and magnesium during oliguric phase 11/30/2018 ATI Adult Medical Surgical Retake 1 Flashcards | Quizlet https://quizlet.com/285843339/ati-adult-medical-surgical-retake-1-flash-cards/ 7/18 ossible TPN peptic ulcer penia, 60) tired ng in, mebook. Evaluating teaching -K and Na is regulated according to stage of kidneUypignrjaudreyto remove ads about nutrition Heart failure and pulmonary edema: Dietary teaching about sodium restriction Pulmonary Embolism: Planning care for a client who is receiving enoxaparin Rheumatoid Arthritis: Reviewing Laboratory Values - high protein diet to replace the high rate of protein breakdown due to the stress from the illness. P Maintain fluid and sodium restriction Increase dietary intake of potassium -Assess for contraindications (active bleeding, disease, history of stroke, recent trauma) -Monitor bleeding times (PT, aPTT and INR) -Monitor for side effects such as thrombocyto anemia and hemmorhage -Positive Anti- cyclic citrullinated peptide -RF Antibody (Diagnostic level for RA is 1:40-1: expected reference range 1:20 - Elevated ESR 20-40 mild inflammation 40-70 moderate 70-150 severe - Positive C-reactive protein - Positive ANA titier - Elevated WBC's Only $1/month Medications affecting Avoid NSAIDS while on heparin coagulation: Heparin Contraindications 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 Weak, irregular pulse, hypotension, respiratory distress Premature ventricular contractions, bradycardia, inverted T 11/30/2018 ATI Adult Medical Surgical Retake 1 Flashcards | Quizlet 10/18 -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: Managing acute severe pain with short term around the Interventions to clock administration of opiods promote postoperative parental route is best for immediate short term relief recovery 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 GI therapeutic procedures: Shortage of TPN Solution Clients receiving TPN frequently need supplemental regular insulin. Keep dextrose 10% in water at the bedside in case the solution runs out. this minimizes the risk of hypoglycemia Nutrition Assessment: Caring for a client with pancreatitis -increased serum glucose -reduce pancreatic stimulation through NPO; NG tube is inserted to suction gastric contents -snacks high in calories in order to maintain weight ECG and Dysrthymia monitoring: Analyzing ECG Watch for manifestations of dysrhythmias (chest pain, decreased LOC, SOB) and hypoxia. Remove leads, print ECG report and notify the provider ECG and Dysrthymia monitoring: Performing 12 lead ECG Prepare client for 12 lead if prescribed - Position client in supine position with chest exposed - wash skin to remove oils - Attach one electrode to each of the clients extremities by 11/30/2018 ATI Adult Medical Surgical Retake 1 Flashcards | Quizlet 11/18 applying electrodes to flat surfaces above the wrist and ankles and the other 6 electrodes to the chest, avoiding chest hair. Instruct client to remain still Neurologic Diagnostic Procedures: Preparing for a lumbar puncture -Instruct client to void before procedure and have them stretch over an overbed table if sitting is preferred - Monitor the puncture site for several hours to ensure the site clots and to decrease the risk of post lumbar puncture headaches COPD: Expected ABG results Hypoxemia (decreased PaO2, less than 80) Hypercarbia (increased PaO2, greater than 45) Respiratory acidosis, metabolic alkalosis compensation Hematologic RBC: 4.2-5.4 and 4.7-6.1 Diagnostic Procedures: WBC: 5-10,000 Laboratory findings to Platelets: 150-400,000 report Hgb: 12-16 and 14-18 Hct: 37-47% and 42-52% PT: 11-12.5 sec aPPT: 1.5-2 times normal range of 30-40 INR: 2-3 on warfarin Acid base imbalance: Interpreting ABG results 1) Look at pH <7.35 acidosis >7.45 Alkalosis 2) PaCo2 and HCO3 <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 Hypokalemia and client receiving digoxin increases the risk 11/30/2018 ATI Adult Medical Surgical Retake 1 Flashcards | Quizlet 12/18 Imabalances: Increasing the risk for digoxin toxicity for digoxin toxicity Respiratory Diagnostic Position the client sitting upright with his arms and Procedures: Client shoulders raised and supported on pillows and/or on an positioning for overbed table and with his feet and legs well supported thoracentesis 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/ Daily weights Syndrome: Priority Monitor I&O Actions 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 Necrosis: Therapeutic pale pink or bluish/purple in color Procedures: Ostomy intestinal obstruction: complications abdominal pain, absent bowel sounds, distention, n/v Burns: Priority action during resuscitation phase Maintain airway and ventilation rapid fluid resuscitation (0.9% NaCl or LR's) 11/30/2018 ATI Adult Medical Surgical Retake 1 Flashcards | Quizlet 15/18 - Abnormal posturing Hemodialysis and -Rceepreobsirtoiosnpicnlaiel nfltuid leakage Peritoneal Dialysis: -milk tubing Intervening for -check tubing for kinks or closed clamps decreased dialysate -Tell client to avoid constipation by taking stool softeners flow rate and consuming a diet high in fiber Respiratory Maintain a patent airway management and -assess the position and placement of tube mechanical ventilation: - Suction oral and tracheal secretions to maintain tube caring for a client who patency has an ET tube - Soft wrist restraints - Maintain cuff pressure below 20mm Hg TB: Discharge teaching about TB -Continue medication therapy for its full duration of 6-12 months -continue with follow-up care for 1 year -Sputum samples every 2-4 weeks, no longer contagious after 3 neg samples -proper hand hygiene -wear N95 Electrolyte imbalances: Treatment of hypokalemia IV potassium supplement Never administer IV bolus 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 11/30/2018 ATI Adult Medical Surgical Retake 1 Flashcards | Quizlet 16/18 muscle weakness headache ascites orthopnea crackeles distended neck veins Fluid Imbalances: Hyperthermia Clinical manifestations tachycardia of Dehydration 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 Pallor of anemia 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 11/30/2018 ATI Adult Medical Surgical Retake 1 Flashcards | Quizlet 17/18 Anemias: Administering Epoetin Alfa Monitor for an increase in blood pressure Monitor Hgb and Hct twice a week Hepatitis and Cirrhosis: Priority findings to report Supine position for liver biopsy Report: Hepatitis - Fever - Vomiting - Dark-colored urine - clay colored stools - Jaundice Cirrosis - Cognitive changes - Ascities -Jaundice - Petechiae - Palmar erythema -fruit or musty odor Heart failure and Loop Diuretics (Lasix) pulmonary edema: Afterload reducing agents: Ace Inhibitors (Enalapril) treatment of Inotropic agents: Digoxin cardiomyopathy Beta Blockers: Metoprolol Vasodilators: Nitroglycerine Disorders of the eye: Age related macular degeneration Number 1 cause of vision loss in people <60 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 11/30/2018 ATI Adult Medical Surgical Retake 1 Flashcards | Quizlet 20/18 - Difficulty chewing and swallowing - Drooling - Dysarthria - Difficulty with ADL's - Mood swings - Dementia Rheumatoid Arthritis: Pain at rest with movement Client teaching about Morning stiffness early indications fatigue joint swelling warmth and erythema Acute kidney injury and chronic kidney disease: Metabolic changes associated with chronic kidney disease Metabolic acidosis Heart Failure and - Dyspnea, Orthopnea (SOB while laying down), nocturnal Pulmonary Edema: dyspnea Recognizing - Fatigue manifestations of left - Displaced apical pulse (hypertrophy) sided heart failure - S3 heart sound (gallop) - Pulmonary congestion - Frothy sputum - Altered mental status - Decrease in urine output Respiratory Failure: Manifestations of Acute respiratory failure ABG values: Room air, PaO2 <60 and SaO2 <90 PaO2 >50 in conjunction with a pH less than 7.30 - lack of perfusion to the capillary bed Blood and blood product transfusions: Monitoring for adverse response to multiple blood transfusions cute Hemolytic: chills, fever, low back pain, tachycardia, flushing, hypotension Febrile: chiils, fever, flushing, headache Mild Allergic: itching, urticaria and flushing 11/30/2018 ATI Adult Medical Surgical Retake 1 Flashcards | Quizlet 21/18 Anaphylactic: wheezing, dyspnea, chest tightness cyanosis Hemodialysis and and hypotension - Alert nurse of signs of disequilibrium syndrome such as Peritoneal Dialysis: nausea and headache Assessment of an - Check for thrill or bruit arteriovenous fistula - Eat well balanced meals that include foods high in folate (beans, green vegetables) and increase protein