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Med Surg ATI Review Form A: Basic Care and Comfort
Med Surg ATI Review Form A: Basic Care and Comfort
increased with dehyrdation. Vital signs: hyperthermia, tachycardia, thready pulse, hypotension,
orthostatic hypotension, decreased central venous pressure. Neuromuscular: dizziness,
syncope, confusion, weakness and fatigue. GI: thirst, nause/vomiting, anorexia. Renal: oliguria.
Other signs: diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened
neck veins.
Q: what assessment finding would lead you to believe a pt suffers from Hypovolemia?
Increased blood osmolarity
Pharmacological and Parenteral Therapies (16)
Cancer: Side Effects of Chemotherapy- Most significant adverse effect is immunosuppression
(bone marrow suppression). Nausea, vomiting, alopceia, mucositis are common side effects.
Oral inflammation and inflammation of the mucous membrane.
Q: What would you expect from a client receiving chemotherapy?
Decreased WBC
Hypertension: Client Teaching Regarding ACE Inhibitors- Teach to change positions slowly
because of orthostatic hypotension. Monitor signs for heart failure such as edema. Also report a
cough. Hypotension is a common side effect.
Q: Which of the following would lead you to believe that a client understands his teachings
about using his ACE inhibitors?
I put that they should use salt substitutes and I got it wrong, my guess is the answer
is to decrease K and Na intake.
Pain Management: Client Teaching Regarding Opioid Use- Client is the only person who should
push the PCA for administration of opioids. An occlusive sterile dressing should be maintained
over the catheter site for an epidural analgesic. Oral route is the preferred route for opioid
administration.
Q: what would you include in your education of a client receiving opioids?
Increase you fiber intake (because of the constipation it causes)
Pain Management: Recognizing Adverse Effects- Constipation: preventative measures- monitor
BM's, fiber intake, excercise, stool softeners, stimulant laxatives and enemas. Urinary retention:
monitor intake and output, assess for distention, and catheterize. Nause/vomiting: administer
antiemetics such as compazine, reglan, zorfran. lie still and or move slwoly during first hours
after initiation. Sedation: monitor LOC and take safety precautions. Respiratory depression:
monitor respiratory rate prior to and following administration. Initial treatment is a reducation in
opioid dose. If necessary slowly administer diluted naloxone to reverse opioid effects. Pruritus:
can be treated with a small dose of naloxone (narcan).
Q: what nursing interventions would you implement to address adverse effects of opiods?
Laxatives and enemas
Blood Transfusions: Managing Reaction- Acute hemolytic reaction is immediate and includes
chills, fever, lower back pain, tachycardia, flushing, hypotension, chest tightening, tachypnea,
nausea, anxiety. Febrile reaction is 30 min to 60 min and include chills, fever, flushing,
headache and anxiety and should use a white blood cell filter administer antipyretics. Mild
allergic reaction is during or up to 24 hours and include itching, urticaria, flushing and should
administer antihistamines such as diphenhydramine (benadryl). Anaphylactic reaction is
immediate and include wheezing, dyspnea, chest tightness, cyanosis, hypotension and should
maintain airway and administer oxygen and iv fluids and antihistamines and corticosteriods and
vasopressors. Stop the infusion immediately and initiate a saline infusion and be put on a
separate line. Also save the blood bag with the remaining blood and the tubing for testing.
Circulatory overload signs would be chest tightness, dyspnea, tachycardia,tachypnea,
headache, hypertension, jugular vein distention, peripheral edema, orthopnea, sudden anxiety
and crackles in base of lungs and should administer oxygen and monitor vitals and also slow the
infusion rate and administer a diuretic and notify primary care provider. Sepsis and Septic Shock
include fever, nausea, vomiting, abdominal pain, chills and hypotension and should maitain
airway and administer oxygen, administer antibiotic therapy, obtain blood cultures, administer
vasopressors such as dopamine and elevate clients feet.
Q: which symptoms indicate adverse effects from the blood transfusion?
I put lower back pain and chills and got it wrong (Understand Immediate reaction
symptoms)
Blood Transfusions: Priority Nursing Intervention- Assess lab values such as hgb and hct, verify
order with doctor, obtain blood samples for compatibility, inititate large bore IV access, assess
history of blood transfusion reactions, inspect blood bag for bubbles, cloudiness or discoloration,
confirm identity, blood compatibility, expiration time with another nurse, prime the blood
administration set with normal saline, obtain vital signs, begin trasnfusion. Remain with client for
the first 15 minutes of transfusion (reactions are most likely to occur at this time), take vital
signs, rate of infusion, respiratory status, monitor anxiety, breath sounds, neck vein distention.
Notify provider if any reaction signs occur. Complete transfusion within 2-4 hours to avoid
bacterial growth. After transfusion take vital signs again and dispose of blood administration set
appropriately (biohazard bags). Monitor lab values: cbc hgb and hct. hgb levels should rise 1g/dl
with each unit transfused.
Q: what would be your first intervention for a pt who has an adverse effect from a blood
transfusion?
Initiate saline infusion (separate line)
Vascular Access: Accessing Implanted Port- Used for long term access such as a year or more.
Surgically implanted into subclavian vein with the tip in the superior vena cava. To access apply
local anesthetic to skin if indicated. Palpate the skin to locate the port body septum to ensure
proper insertion of the needle. Clean the skin with alcohol for atleast 3 seconds and allow to dry.
Access with noncoring needle (Huber). Flush after every use and atleast once a month. Follow
facility protocol to flush when deceasing port (flush with 10ml of normal saline followed by 5 ml
of 100 units/ml of heparin.
Q: what type of needle would you use to access an implanted port?
A noncoring needle
Vascular Access: Verifying Tip Placement of PICC Line- Can be used up to 12 months. Inserted
into basilic or cephalic bein at lease one fingers breadth below or above the antecubital fossa
and the tip is positioned int the lower one-third of the superior vena cava. An inital xray should
be taken to ensure placement.
Q: how would you confirm placement of a picc line?
A chest x-ray
Diabetes Management: Determining Medication Adherence- 584
Q: what lab values indicate a diabetic client isnt compliant with his medication?
A1c is at 8% (should be <7%)
Diabetes Insipidus: Client Teaching Regarding Vasopressin- (Pitressin)its life long therapy, daily
weights, importance of reporting weight gain, polyuria and polydipsia to the care provider. Can
cause vasoconstriction so use with caution with people who have coronary artery disease.
Q: what would you include in your education to a client receiving vasopressin?
To expect less urine output
Heart Failure: Signs of Digoxin Toxicity- aka Lanoxin. Signs of toxicity are fatigue, muscle
weakness, confusion and loss of appetite. Have potassium and digoxin levels checked regularly.
If potassium is too low the digoxin will bind to the receptors that it usually competes with
potassium for and will cause digoxin toxicity.
Q: what signs would you exhibit in a pt that would lead you to believe digoxin toxicity?
Muscle fatigue and confusion
Heart Failure: Evaluating Client Understanding of Digoxin Administration- Count pulse a full
minute before administering If it is irregular or is less than 60 beats per minute or more than 100
beats per minute medication should be withheld. Take is at the same time each day. Do not take
digoxin at the same time as antacids separate by 2 hours.
Q: which of the following indicates client understanding?
I will not take my antacids at the same time as digoxin med
Heart Failure: Understanding Implications of NSAID Therapy- 331, 335
Osteoarthritis: Initiation of Medication Treatment- Acetaminophen, NSAIDS, Topical salicylates,
Glucosamine (rebuilds cartilage), Intra-articular injections of glucocorticoids (treat localized
inflammation). Instruct client on the use of analgesics and NSAIDS prior to activity and around
the clock as needed. If all other therapies fail client can undergo joint replacement surgery to
relieve pain and improve mobility.
Total Parenteral Nutrition: Calculating Components- Initiated with a weight loss of 7% of body
weight and NPO for 5-7 days. Gradually increase the rate during initiation and then ween off.
Standard IV therapy is < or equal to 700 calories a day. 5 day rule (has not eaten for 5 days and
is not expected to eat within the next 5 days). Also a hypermetabolic state.
Formula: Be able to calculate lbs to kg/ml (remember 2.2 lbs per kg)
Total Parenteral Nutrition: Monitoring for Fluid Overload- Monitor the lungs for crackles and
other evidence of respiratory distress, daily weights and intake/output, use a controlled infusion
pump to administer TPN, Do not speed up the infusion to catch up, gradually increase the flow
rate until the prescribed infusion rate is achieved.
Q: which assessment finding indicates fluid overload?
Crackles in the lungs upon auscultation (indicates fluid in lungs)
Physiological Adaptation (38)
Heart Failure: Client Teaching for Home Management- If experiencing respiratory distress place
the client in high fowlers position and give oxygen. Encourage bed rest until the client is stable,
encourage energy conservation by assisting with care and ADL's, restrict fluid intake/restrict
sodium intake, Take medications as prescribed, Take diuretics early in the morning and early
afternoon, increase intake of potassium (cantaloupe and bananas), daily weights and notify the
care provider for weight gain of 2lbs in 24 hours or 5 lbs in a week, schedule regular follow ups
with the doctor and get vaccinations.
followed by normal saline. Clearn in circular motion from stoma site outward. Using surgical
aseptic technique remove and clean the inner cannula, use hydrogen peroxide to clearn the
cannula and the sterile saline to rinse it. Replace the inner cannula if it is disposable. Clearn the
stoma site and then the trach plate with hydrogen peroxide followed by sterile saline. Place split
4x4 dressings around trach. Change trach ties if they are soiled. Secure new ties in place before
removing soild ones to prevent accidental decannulation. 1-2 fingers should be able to be
placed between the ties and the neck. Change non-disposable trach tubes every 6-8 weeks.
Reposition client every 2 hours to prevent atelectstasis and pneumonia. Provide oral hygiene
every 2 hours to maintain mucosal integrity.
Q: which of the following is an appropriate nursing intervention?
Remove and replace ties with dry, crusted secretions
Wound Management: Promoting Healing- Healing occurs rapidly if tissue is hydrated,
oxygenated and contains few organisms, Nutrition provides elements required for wound
healing, also meet protein and calorie needs. Encourage intake of 2,000-3,000 ml of water per
day. Provide education of high protein foods such as meet, fish, poultry, eggs, dairy products,
beans, nuts and whole grains.
Q: how would you promote healing in an elderly client?
Increase fluid intake
Electrolyte Imbalances: Evaluation of Potassium Chloride Therapy- Serum potassium is <3.5,
have metabolic alkalosis ph >7.45 and or dysrhythmias. Encourage foods high in potassium
(avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas), IV potassium: Never do IV
push, maximum rate is 5-10 meq/hr. Monitor phlebitis, respiratory rate, breath sounds and
cardiac rhythm.
Q: which of the following is an expected outcome of a pt receiving KCL?
Doesnt experience any dysrithmias (means what was low K is now at a therapeutic
level)
Electrolyte Imbalances: Sodium Imbalance- Hyponatremia is less than 135, net gain of water or
loss of sodium, water moves from ECF into the ICF which causes cells to swell, Risk factors are
vomiting, ng suctioning, diarrhea and tap water enemas, diuretics, kidney disease, adrenal
insufficiency, burns, wound drainage, gi obstruction, peripheral edema, ascites. Signs are
hypothermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, headache,
confusion, lethargy, muscle weakness, respiratory compromise due to muscle weakness,
fatigue, decreased deep muscle reflexes, hyperactive bowel sounds, abdominal cramping and
nausea. Treatment is administer hypertonic oral and IV fluids, encourage cheese, milk and
condiments. Complications are seizures and respiratory arrest. Hypernatremia is greater than
145. Is a shift of water out of the cells making the cells dehydrated. Risk factors- water
deprivation, NPO, excessive sodium intake, hypertonic IV fluids, renal failure, cushings
syndrome, fever, diaphoresis, respiratory infection, diabetes insipidus, hyperflycemia. Signshyperthermia, tachycardia, orthostatic hypotension, restlessness, irratibility, muscle twitching,
increased deep muscle reflexes, seizures, coma, thirst, dry mucous membranes, hyperactive
bowel sounds, abdominal cramping, nausea, edema, warm flushed skin, oliguria. Administer
hypotonic IV fluids (0.45% sodium chloride), Administer Isotonic IV fluids (0.9% sodium
chloride). Encourage water intake, administer diurectics.
Q: which of the following is an indication of a pt at risk of developing a sodium imbalance?
vomiting, diarrhea, enemas and diuretics
Fluid Imbalances: Evaluating Fluid Replacement Therapy- Hypovolemia- increased hgb and hct,
increased urine specific gravity, increased serum sodium. Place the client in shock position (on
back with legs elevated). Administer oral and IV fluids such as Ringers Lactate or blood
transfusions as ordered. Monitor intake and output, alert care provider to urine output less than
0.5 ml/kg/hr for 2 consecutive hours. Encourage to change positions slowly.
Q: which of the following lab values indicates a pt suffers from hypovolemia?
I put increased hgb and hct and got it wrong, I think the right answer is something to
do with the amount of urine being excreted.
Dysrhythmias: Recognizing Abnormal Findings- Perform CPR for asystole or pulseless rhythms.
Pulmonary Embolism- dyspnea, chest pain, air hunger, decreasing SaO2. Stroke/CVAdecreased LOC slurred speech, muscle weakness/paralysis. MI- chest pain, ST segment
depression or elevation. Monitor for decreased cardiac output and HF such as hypotension,
syncope, increased heart rate, dyspnea, productive cough, edema, venous distention.
Q: which of the following is an expected finding?
I put no inverted t waves and got it wrong, I think the answer might have been U
waves, I didnt know what that was, look it up
Hemodialysis: Monitoring an AV Graft- Presence of bruit, palpable thrill, distal pulses and
circulation. Assess site for bleeding or infection. Elevate the extremity following surgical
development of an AV fistula to reduce swelling.
Q: whats an complication from an av graft?
Weak pulses in the leg or feet (capillary filling in the toe 6)
Hemodynamic Monitoring: Assessing Arterial Line- Place in radial (most common), brachial or
femoral artery. Monitor circulation in the limb with the aterial line such as capillary refill, temp
and color. Monitor for infection. Place client in supine or trendelenburg position for insertion.
Obtain xray to assess placement. Monitor and secure connections between pressure tubing,
transducers and catheter ports.
Hemodynamic Monitoring: Client Positioning in Response to ComplicationTrendelenberg/supine for insertion. Supine for obtaining readings.
Monitor circulation: capillary refill, temp, color
COPD: Managing Shortness of Breath- Practice breathing techniques such as Diaphragmatic or
abdominal breathing and pursed lip breathing. Position in high fowlers. Encourage use of
incentive spirometer. Structure activities to have rest periods.
Q: what would you teach a pt suffering from COPD?
Do pursed lip breathing
Diabetes Management: Client Education Regarding Exercise Guidelines- Restrict exercise when
blood glucose levels are >250mg/dl. Exercise 10,000 steps/day.
Q: what would you teach a pt about exercise when they suffer from diabetes?
They should eat a snack during unexpected activity
Diabetes Management: Client Education Regarding Oral Hypoglycemic Agents- Administer as
prescribed such as 30 minutes before first main meal for most oral blood glucose lowering
agents or with the first bite of each main meal for alpha-glucosidase inhibitors. Avoid alcohol
with sulfonylurea agents. Monitor renal function, liver function. Taken by Type II diabetics.
Infections: Evaluation of Treatment-
I put the hgb and hct and got it wrong, it was something about how this question was
worded, know these values back and forth.
Renal Failure: Pathophysiology Related to Metabolic Acidosis- Metabolic Acidosis is a
complication of renal failure and should prepare client for hemodialysis.
Q: which pt is suffering from metabolic acidosis?
Know ph and co2 levels
Cancer: Internal Radiation- Place client in a private room and bath. Put a sign on the door.
Healthcare workers should wear a dosimeter film badge that records amount of radiation
exposure. Visitors are limited to 30 minutes and maintain a distance of 6 feet. Visitors and
Healthcare personnel who are pregnant or under the age of 16 should not come in contact with
the patient. A lead container should be kept in the clients room if the delivery method could allow
spontaneous loss of radioactive material. Side Effects are skin changes, hair loss and
debilitating fatigue.
Cancer: Teaching Regarding Radiation Therapy- Everything listed above. External radiation
therapy: wash skin over irradiated area gently, with mild soap and water and dry thoroughly
using patting motions. Do not remove radiation "Tatoos" that are used to guide therapy. Do not
apply powders, ointments, lotions or perfumes to irradiated skin. Wear soft clothing over
irradiated skin and avoid tight or constricting clothing. Do not expose irradiated skin to sun or a
heat source.
Q: which of the following statements indicates client understanding?
I will wash the area gently with soap and water
Acid-Base Imbalance: Prioritizing Postoperative Interventions to Treat Respiratory AcidosisOxygen therapy, maintain patent airway, enhance gas exchange (positioning and breathing
techniques, ventilatory support, bronchodilators, mucolytics). Hypoventilate. ABCs
Leukemia: Planning Care in Response to Pancytopenia- Neutropenia- secondary to disease
greatly increases risk for infection. Nurse must maintain a hygienic environment and encourage
the client to do the same. Constantly monitor for cought or alteration in breath sounds or urine
and feces. Report temperature that is greater than 100 degrees F. Administer antimicrobial,
antiviral, and antifungal medications. An absolute neutrophil count (ANC) less than 2,000
suggests and increase risk for infection. Less than 500 is a severe risk for infection.
Thrombocytopenia- greatly increases risk for bleeding. Obtain safe environment. Greatest risk if
platelet count is less than 50,000 and spontaneous bleeding may occur at less than 20,000.
Anemia- greatly increases risk for hypoxemia. Obtain a relaxing environment to decrease
energy use. Monitor RBC count. Provide a diet high in protein and carbs. Administer Epoetin
alfa.
Pancytopenia: decreased RBC, WBC, and platelets
Metabolic Alkalosis: Identifying Clients at Risk- Oral ingestion of antacids, Blood transfusions,
TPN, Loss of gastric secretions such as prolonged vomiting or NG suction, Potassium depletion
due to thiazide diuretics, laxatives or Cushings Syndrome.
Q: which of the following pts is at risk for developing metabolic alkalosis?
Vomiting, ng suctioning, laxatives
Pressure Ulcers: Risk Assessment- inadequate nutrtion, anemia, fever, impaired circulation,
edema, sensory deficits, low diastolic blood pressure, im paired cognitive functioning,
neurological disorders, chronic disease like DM, CRF, CHF and chronic lung disease, and
sedation that impairs spontaneous repositioning.
Q: which of the following pts is at highest risk for developing a pressure ulcer?
I put the older pt with diabetes and got it wrong, I was going back and forth between
that and the older woman with a hip replacement, my guess is its that since I got it wrong.
(Older person with a colon problem is the answer)
Myocardial Infarction: Monitoring for Complications- Usually happens in the morning after rest,
lasts >30 minutes. Acute MI is a complication of angina that is not relieved by rest or
nitroglycerin. Cardiogenic shock often follows an MI symptoms are tachycardia, hypotension,
urinary output <30ml/hr, altered LOC, crackles in lungs, tachypnea, cool clammy skin,
decreased peripheral pulses and chest pain. Monitor vital signs every 15 minutes until stable
then every hour, Monitor ST segment of EKG, location and severity of pain, oxygen saturation
levels, hourly urine output- greater than 30ml/hr indicates renal perfusion, lab data cardiac
enzymes- electrolytes- and ABG's.
Q: what assessment indicates a complication from MI
Change/altered level of consiousness
Bronchoscopy: Postoperative Plan of Care- Continuously monitor the clients respirations, bp,
pulse ox, heart rate, and LOC. Asess LOC, gag reflex, ability to swallow- usually takes 2 hours.
Monitor for a fever less than 24 hours is not common, Monitor for productive cough, significant
hemoptysis indicative of hemorrhage, a small amount of blood tinged sputum is expected, and
hypoxemia. Be prepared to intervene for unexpected outcomes (aspiration, laryngospasm).
Provide oral hygiene. Encourage client to lmist or eliminate activities that may irritate the airway
like talking or coughing and smoking. Notify care provider for hoarseness, wheezing, coughing
up more than a little blood tinged sputum, shortness of breath, fever beyond 24 hours.
Q: what would cause you to notify physician/primary concern for a pt who just reveived an
bronchoscopy?
Changes in sputum color
Bypass Grafts: Cardiac Tamponade- results from bleeding and mediastinal chest tubes with
inadequate drainage. Cardiac Tamponade compresses the heart chambers and inhibits effective
pumping. Signs are a sudden decrease or cessation of chest-tube drainage following heavy
drainage, jugular vein distention with clear lung sounds, and equal PAWP and CVP values.
Treatment involves volume expansion (fluid administration) and emergency sternotomy with
drainage. Pericardiocentesis is avoided because blood may have clotted.
Q: what would lead you to believe that cardiac tamponade is occurring?
Sudden cessation of chest tube drainage (idea is that fluid is draining into the pericardium
instead of the chest tube as it should)
Cancer: Managing Adverse Effects of Treatment- for Neutropenia maintain a clean
environment, monitor for signs of infections, give antimicrobial, antiviral and antifungal
meidcations. Thrombocytopenia should minimize risk of trauma. Anemia should maintain an
environment that does not overly use the clients energy resources, provide a diet high in protein
and carbs.
Thoracentesis: Intervening for Postprocedure Complications- Shock- slow the rate of fluid
removal. Pneumothorax- monitor chest xrays. Bleeding- monitor for coughing and or
hemoptysis.
Bypass Grafts: Femoral Aneurysm Complications- do neuro checks, check feet or make sure
they feel feet? Check feet pulses
Meninigitis: Assessing for Kernig's Sign- a positive kernigs sign is resistance to extension of the
clients leg from a flexed position. (answer could be some test w/the neck)
Peripheral Venous Disease: Assessing for Chronic Venous Insufficiency- Signs are stasis
dermatitis or brown discoloration along the ankles and extending up to the calf, edema and ulcer
formation.
Q: what signs/symptoms would indicate PVD?
I put pt in pain and pallor and got wrong, I believe the answer is edema or elevated
temp (warm) and red