Med-Surg ATI Study Guide

o Crutches  Place body weight on crutches  Advance unaffected leg onto the stair  Shift weight from crutches to unaffected leg  Bring crutches and affected leg up to the stair o Closed-suction drain nursing inte ...

o Crutches  Place body weight on crutches  Advance unaffected leg onto the stair  Shift weight from crutches to unaffected leg  Bring crutches and affected leg up to the stair o Closed-suction drain nursing interventions  Negative-pressure device  Doesn't require wall suction  *Compress the drain reservoir after emptying (creates negative pressure)  Do not need to put below bed (doesn't use gravity) o External fixation device  Surgeon applies the external fixation device directly to the client's bone to form a rigid structure around the affected extremity • Casts, boots, or splints are applied directly to the leg for internal fixation  Client should wear external fixation device continuously for a period of 4-6 weeks • Nurse should teach the client to perform care of the wound and pin sites at home  Use crutches with rubber tips • Prevents the client from slipping and decreases fall risks  Only the provider should adjust the client's external fixation device in order to maintain bone alignment o Long-term mechanical ventilation complications  Decreased cardiac output and hypotension, related to positive pressure from mechanical ventilation inhibiting blood return to the heart  Fluid retention related to decreased cardiac output  Stress ulcers, related to elevated levels of HCl in the stomach • Increase risk for systemic infection and require pharmacological treatment  Hyponatremia, secondary to fluid retention o Postoperative nursing interventions following mastectomy  Instruct client that the drain will remain in place for 1-3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hour period  Instruct client to start exercising the arm on side of surgery 24 hours after surgery  Elevate arm on surgical side on a pillow to promote lymphatic fluid return  Nurse should elevate the head of the client's bed to at least 30 degrees to promote drainage from the surgical site and facilitate breathing o Patient teaching for active tuberculosis  Sputum specimens are necessary every 2-4 weeks until there are three negative cultures • After 3 negative cultures, the client is no longer considered infectious  Client's infection is usually no longer contagious after taking TB medications for 2-3 weeks  Family members do not need to follow airborne precautions because they have already been exposed to TB  A follow-up evaluation of the client's TB should be performed using a chest x-ray because the TB skin test is no longer considered accurate after a person has tested positive o Nursing interventions following total hip arthroplasty  Assist client to maintain legs in abduction  Client should not flex hip greater than 90 degrees to prevent hip dislocation  Nurse should place a pillow between client's legs to prevent hip dislocation  Nurse should not keep client's hip internally rotated, as this can lead to hip dislocation o Patient teaching on kidney organ donation  Client who is recipient of organ donation will require lifelong immunosuppressive therapy to protect against transplant rejection  A healthy donor who has one kidney can manage the body's urinary excretion requirements  Client's nonfunctioning kidney remains in the body until transplant surgery, unless the client has chronic kidney infection or pain  A client who receives a kidney from live donor has a lower rate of transplant rejection • Client who receives a kidney from a live donor has a lower rate of transplant rejection because the donor is often more medically compatible than a donor who is deceased o Patient teaching about prevention of atherosclerosis  Smoking cessation  Maintain an appropriate weight  Eat a low-fat diet o MRSA precautions for health care professionals  Client should wear an isolation gown and wash hands before being transported from the room to prevent spread of micro-organisms  Nurse should bathe client using warm water and a chlorhexidine solution to prevent the spread of micro-organisms  Use dedicated assessment equipment when assessing the client and leave in room to prevent cross-contamination with other clients  Mode of transmission = contact o Nephrostomy expected findings  Red-tinged urine during the first 12-24 hours  Normal BUN  Increased urine output (notify provider for decreased UO)  NOTIFY PROVIDER FOR BACK PAIN • Can indicate the tube is dislodged or clogged o Nursing interventions for dysrhythmias  Defibrillation for ventricular tachycardia or ventricular fibrillation  Cardioversion for all other dysrhythmias  CPR for a client who is pulseless or not breathing  Lidocaine IV bolus for a client who has ventricular dysrhythmia o Seizure precautions  Client should limit intake of alcohol or caffeine, minimize stress, fever, and fatigue to prevent triggering a seizure  Nurse should keep 2-3 side rails up to prevent falls  Keep client's bed in lowest position to prevent falls  Ensure client has patent IV access in the event that the client requires medication to stop seizure activity o Nursing interventions for blood transfusions  Priority = check for the type and number of units of blood to administer  Obtain baseline vital signs for comparison  Describe blood transfusion to promote client understanding  Ensure client has a large-bore IV access to prevent hemolysis during transfusion o Patient teaching for insulin lispro  Rapid-acting insulin that the client can use in conjunction with intermediate or long- acting insulins  Client should inject the medication subcutaneously into the abdomen, upper thigh, or arm  Nurse should instruct client that insulin lispro is rapid-acting and the client should administer immediately before eating or immediately after eating  Instruct the client to continue taking insulin lispro as prescribed during times of illness, and notify provider of the illness o Patient teaching for metformin  Decreases the amount of glucose produced in the liver and increases tissue sensitivity to insulin  Client should take metformin with or immediately following meals to improve absorption and to minimize GI distress  Clients typically lose weight when beginning metformin due to N/V  Adverse effect = rash o Evisceration nursing interventions  Priority = call for help  Cover the wound with sterile, saline-moistened dressing to protect organs  Monitor client's vital signs to monitor for complications  Place client in supine position to promote blood flow to organs o Blood transfusion complication interventions  Bacterial transfusion reaction = antibiotic • Manifestations: hypotension, tachycardia, shock  Febrile transfusion reaction = antipyretic, acetaminophen • Manifestations: tachycardia, fever, hypotension, chills  Circulatory overload from transfusion: loop-diuretic, furosemide • Manifestations: dyspnea, hypotension, hypertension, distended neck veins  Allergic transfusion reaction: antihistamine, diphenhydramine • Manifestations: urticarial, itching, flushing, bronchospasms, anaphylaxis o Central venous catheter nursing interventions  Place client in Trendelenburg position with a rolled towel between client's shoulder blades • Position facilitates the insertion of the catheter by dilating blood vessels of the client's neck and shoulders  Goes into subclavian vein o Hormone replacement therapy adverse effects  Urgent effects (contact provider) • Calf pain (indicates DVT) • Numbness of the arms (indicates possible CVA) • Intense headache (indicates possible CVA)  Nonurgent effects (manifestation of menopause) • Night sweats • Vaginal dryness o Thoracentesis nursing interventions  After thoracentesis, client should deep breathe to re-expand lungs  Place client in upright position with arms resting on an overhead table to widen the intercostal space and spread ribs for tube insertion • Nurse should assist a client who cannot sit up into a side-lying position with the affected side up  Client should receive local anesthetic for the procedure and will not require NPO status after midnight  Instruct client to resume activity within 1 hour following procedure o Arterial lines nursing interventions  Used to obtain arterial blood gases and monitor hemodynamic pressures  Most appropriate position of a client while recording values obtained from an arterial line is supine with the head of the bed elevated up to 60 degrees  Nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line o Patient teaching of heparin  Instruct the client to report any bleeding or bruising to provider  Instruct the client to avoid flossing  Instruct client to apply firm pressure to injection site 1-2 minutes but to avoid massaging  Instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin o Patient teaching for ureterostomy  During procedure, client's bladder is removed and the ureters are brought to the skin surface of the abdomen to form a stoma from which urine will flow into ostomy bag • Client will not have urge to void  Drink 2-3 L of fluid per day to reduce mucus formation and maintain hydration  Client should cut the opening of the skin barrier 1/8-inch wider than the stoma to minimize irritation of the skin from exposure to urine  Client should avoid using moisturizing soaps to clean the skin around the stoma because it will prevent the pouch from adhering to the skin o COPD expected findings  Increase in PaCO2, because COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in lungs for gas exchange and causes the PaCO2 to increase above the expected reference range  pH below expected range  Increased HCO3 levels  Low oxygen level