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MedSurg II ATI

ATI study guide

QuestionAnswer
Cushing’s Syndrome Physical Symptoms (increased cortisol and androgens), lifelong therapy, eat high calcium/Vit D, avoid infection thin, fragile skin, bruising and petechiae, hypertension, tachycardia, weight gain, moon face, truncal obesity, buffalo hump, fractures, muscle wasting in extremities, Hirsutism, acne, red cheeks, striae, fever, swelling
Abnormal lab values revealing possibility of Cushing’s Syndrome hyperglycemia, hypernatremia, hypocalcemia, hypokalemia (also lymphocytopenia)
proper use of quad cane, which leg use on same side as affected leg
HF management, report weight gain of ___ pounds per ___ to HCP 2, day
a trach/intubated patient needs suction when an assessment of breath sounds is ___ and there is a presence of ___ abnormal, rhonchi
PICC line location into superior vena cava
PICC line dressing change schedule: opaque - change every ___ days; transparent - change every ___ 3 days, 24 hours
PICC line patient teaching – port used for long-term ___ ___ administration (antibiotic)
Nitro patient teaching – position, tablet placement, details of timing of use sit down, nitroglycerin tablet under tongue, If pain is unrelieved in 5 minutes, client should call 911 or be driven to ER, take up to 2 more doses at 5 minute intervals
Patient has a chest tube and the water seal chamber is low on water, nursing action? refill water
Family teaching of patient with conscious sedation NPO ā 6hrs, do not walk around, no driving, sign informed consent
expected side effect and a complication of dialysis hypotension is an expected side effect; hyperglycemia is a complication
contraindication of heparin use low platelet count (thrombocytopenia)
Accutane contraindicated in a client with a ___ rash
Nurse's role during seizure protect from injury, patent airway, prepare suction of oral secretions, turn client on side, loosen clothing, do not attempt to restrain client, do not open jaw or insert airway during seizure activity, do not use tongue blades, document onset, duration
Signs of digoxin toxicity muscle cramps, weakness (hypocalcemia)
COPD patient experiencing SOB, nursing action check ABC’s, check O2 saturation
First action when patient experiences VFIB shock first
patient on Lasik, sign that its working urine output >30mL/hr
How would you position a patient post liver biopsy? lie on right side (liver side) to allow for pressure on incision
sign treatment is effective for myxedema coma increase in O2 saturation, able to breathe
unexpected drainage color in NG tube red-blood
reason for compression wrap on below the knee amputation reduce swelling
Crohn's disease dietary recommendation ↑ fiber,↓ fat,↓ sugar
sign/symptom of retinal detachment – acute ___ ___ vision loss
ART line, arm at ___ ___, tube pressure must remain at same pressure as ___ ___ heart level, heart pressure
What color should the fluid exiting the bag during peritoneal dialysis be? clear
peritoneal dialysis bag placement Keep outflow bag lower than client’s abdomen (drain by gravity, prevent reflux)
patient has a positive Mantoux skin test, next action is to perform what diagnostic procedure chest x-ray
signs that patient has hearing difficulty loud TV, turning head when listening, asking to repeat
meningitis assessment finding nuchal rigidity
colostomy education, empty bag when? at 1/4-1/2 full
skin ulcer care rotate patient to relieve pressure
post-pacemaker implant precautions don’t lift arm up, keep arm in sling
sign of hypocalcemia muscle weakness
sign of circulation issue - decrease in? (2) decrease in pulses, decrease in capillary refill
patient receiving RBC transfusing, becomes flushed, first nursing action slow down infusion
signs, symptoms of hypervolemia pink frothy sputum, HTN, crackles
effective Epogen treatment will result in increased activity, RBC (used to treat anemia)
when to hold digoxin low heart rate (<60bpm), teach patient to check HR and hold medication if necessary
ABG's post surgery, check for increase in ___ CO2 (caused by not breathing enough, holding in carbon dioxide)
regular intervention for patients on TPN finger sticks for glucose (can cause hyperglycemia because they are NPO)
patient teaching for oxycontin long acting medication, do not crush
patient has esophageal varices, how are they fed? PEG tube
MI initial treatment MONA (morphine, oxygen, nitro, aspirin)
gastric bypass nutrition education 1 cup per meal, 2 servings of protein per day
best way to check placement of ET tube chest x-ray
gout is an excess of ___ ___ uric acid
What is hypervolemia? fluid overload
how to assess pain pain scale
identify STEMI on a ECG baseline elevated on S-T interval
total hip replacement, can never ___ ___ again cross legs
IV medication administration through PICC line, flush with ___ ___ normal saline
nursing actions with fractures (4) check pulses, capillary refill, pain, risk for compartment syndrome
an ostomy should appear ___, ___, ___ red, beefy, moist
actions for hemorrhagic shock stop bleeding, then administer isotonic fluid bolus
hormone replacement therapy side effect hypercalcemia
signs that fluid replacement is working no HTN, normal capillary refill, normal pulses
HF patients should avoid salt
post bronchoscopy important assessment oxygen saturation
(3) signs, symptoms of a perforated ulcer increased temperature, increased WBC, dark stools
lab value - hematocrit male 42-52, female 35-47
lab value - sodium 135-145
lab value - BUN 10-20
lab value - glucose 60-100
patient treated for DVT, you suspect PE because of increase in work required to breathe and SOB, nursing action (3) assess, ABC’s, treat with O2
priority assessment after endoscopic retrograde cholangiopancreatography (ERCP) gag reflex
teach patients with SLE to use sunblock
mucositis interventions examine mouth several times a day, document lesion location/size, avoid glycerin-based mouthwash, topical anesthetic prior to meals, discourage salty/acidic/spicy food, mouth care before/after meals, rinse-half 0.9% NaCl/peroxide, soft bristle toothbrush
Created by: BrandiLynn