ATI Medsurge

IV heparin Precaution
– The anticoagulant effect of heparin increases the risk of bleeding.

therefore, the client should use an electric razor to reduce the risk of cuts and bleeding during shaving

– client should not use suppositories for constipation because suppository use increases the risk of bleeding

– client should avoid flossing because bleeding can easily occur

-Green leafy vegetables do not interfere with the effects of heparin, so client can have green leafy vegetables

Premature ventricular contractions
The nurse should administer lidocaine, an antidysrhythmic for short-term treatment of ventricular dysrhythmias

The nurse should defibrillate the client’s heart for a ventricular tachycardia or ventricular fibrillation

supraventricular tachycardia
The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia
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hypokalemia
Decreased peristalsis is a clinical manifestation of hypokalemia
hyperkalemia
Facial twitching is a clinical
manifestation of hyperkalemia

Bounding peripheral pulses are a clinical manifestation of hypernatremia

Hyperreflexia is a clinical manifestation of hyperkalemia

Respiratory alkalosis
Hyperreflexia is an expected finding in a client who has respiratory alkalosis

Hypertension

Tetany is an expected finding in a client who has respiratory alkalosis

Kussmaul respirations
respiratory acidosis with manifestations of Kussmaul respirations

Kussmaul respirations are an effort to rid the body of increased CO2 levels and usually occur with hyperglycemia

The client should take an antacid to manage
The client should take an antacid to manage symptoms of gastric reflux and dyspepsia
Monitor client with heart failure and is receiving a blood transfusion for
Crackles in the lungs indicate fluid overload, which is a risk during blood transfusions for older adult clients who have heart failure

Tachycardia is more likely to occur for an older adult client who has heart failure and is receiving a blood transfusion

telemetry monitoring
This identifies if pacemaker cells of my heart are working properly

Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle

peripheral venous disease
keep my legs elevated when I’m not wearing the stockings

put the stockings on before I get out of bed in the morning

ake the stockings off every day and check my skin

autonomic dysreflexia
Bradycardia is a manifestation of autonomic dysreflexia
aortoiliac disease
The greatest risk to this client is injury from decreased perfusion to the lower extremities

therefore, the first pulse site the nurse should palpate is the femoral pulse

General anesthesia
Hypothermia is an expected finding in a client following general anesthesia

Expectoration of thick, clear sputum is an expected finding due to intubation for general anesthesia

Absent bowel sounds is an expected finding in a client following general anesthesia

Deep-vein thrombosis
A warm, red area on the calf may indicate the presence of a deep-vein thrombosis

The nurse should report this finding to the provider

Client with sealed radiation implant
The nurse should keep a lead-lined container and forceps in the client’s room in case of accidental dislodgement of the implant

the nurse should limit each visitor to 30 min per day to prevent exposure

The nurse should wear a dosimeter badge to monitor exposure to radiation

The nurse should keep all soiled linens in the client’s room until the client has the radioactive source removed

client who has chronic kidney disease should avoid protein
Salmon contains high in protein
Dehydration
check clients BUN, when BUN is increased client can be dehydrated
when a client’s blood pressure is low and also complains of nausea, the nurse should
Place the client on side lying position

To prevent any further drop in blood pressure, the nurse should keep the client’s head flat and maintain the client in a side-lying position to prevent aspiration if vomiting occurs

Febrile blood reaction
The nurse should plan to administer an antipyretic such as acetaminophen for a febrile reaction to a blood transfusion
Febrile reaction
– a reaction to the white blood cells in the donated blood

– more common in clients who have had previous transfusions and in multi-para women

Findings:

fever within 24 hours of the transfusion

including headache, nausea, chills, or a general feeling of discomfort

may be treated with antipyretic
acetaminophen

Give Furosemide when client experience overload from blood transfusion
The nurse should plan to administer a loop-diuretic such as furosemide if the client displays manifestations of circulatory overload due to a blood transfusion
Give Diphenhydramine for mild allergic reaction
Diphenhydramine
The nurse should plan to administer an antihistamine such as diphenhydramine if the client displays a mild allergic reaction during a blood transfusion
Allergic reaction
most common type of reaction

findings:

hives and itching

may be treated with antihistamines,

diphenhydramine

Give cephalexin for sepsis
The nurse should plan to administer an IV antibiotic such as cephalexin if the client displays manifestations of sepsis due to receiving contaminated blood from a transfusion
Right hemispheric cerebrovascular accident
Visual spatial deficits is correct

– Visual spatial deficits occur secondary to a right hemispheric cerebrovascular accident.

Left hemianopsia is correct

– Left hemianopsia occurs secondary to a right hemispheric cerebrovascular accident.

One-sided neglect is correct

– One-sided neglect occurs secondary to a right hemispheric cerebrovascular accident

Left hemispheric cerebrovascular accident
Expressive aphasia occurs secondary to a left hemispheric cerebrovascular accident

Right hemiplegia occurs secondary to a left hemispheric cerebrovascular accident

Diabetic ketoacidosis
Give Regular insulin 20 units IV bolus

1- Ketoacidosis indicates decreased insulin

– Regular insulin is a fast-acting insulin and may be effective within 10 min when given IV

Ketoacidosis indicates increased blood glucose and not enough insulin

NPH and Regular insulin
NPH insulin is a long-acting insulin and would not affect the client rapidly

Regular insulin is a fast-acting insulin and may be effective within 10 min when given IV

Endometrial biopsy
An endometrial biopsy involves removal of a sample of the endometrial tissue, which lines the uterus

The provider inserts an instrument through the vagina and cervix to obtain the specimen

The provider performs an endometrial biopsy in an outpatient setting under local anesthesia and the client is not hospitalized

Prevention of atherosclerosis
Follow a smoking cessation program

Smoking cessation is an important lifestyle modification to prevent atherosclerosis

Maintaining an appropriate weight is an important lifestyle modification to prevent atherosclerosis

Eating a low-fat diet is an important lifestyle modification to prevent atherosclerosis

with hepatic encephalopathy check blood ammonia for the effectiveness of the treatment
Toxic substances absorbed by the intestines that are not broken down, leading to increased ammonia levels
Blood urea nitrogen
BUN
Blood urea nitrogen levels increased as a result of liver or renal disease (kidney)
Serum aspartate aminotransferase
Serum aspartate aminotransferase levels are commonly elevated in liver disease because this enzyme is released from the liver as a result of hepatic inflammation
Serum total bilirubin
Total bilirubin levels increased if client have problem with liver, due to the inability of the liver to excrete bilirubin
client who has heart failure give Digoxin
The client takes digoxin to increase cardiac contractility
Nitroglycerine
The client takes nitroglycerin to dilate the coronary arteries and lower blood pressure
furosemide
The client takes furosemide to reduce circulating blood volume
Lovastatin
The client takes lovastatin to reduce cholesterol levels
Adverse effects of enalapril
Enalapril is an antihypertensive agent; therefore, the nurse should assess the client for orthostatic hypotension.
peripherally inserted central catheter (PICC)
can be inserted in the upper extremity

– Using this insertion site decreases the risk of infection because there are fewer types and numbers of organisms on the upper extremities as compared to the torso, where the client would have a nontunneled percutaneous central catheter

Clostridium difficile
– The nurse should implement contact precautions for a client who has C difficile because the mode of transmission is direct contact

– The nurse should use soap and water for hand hygiene when caring for a client who has C. difficile because alcohol-based cleansers do not kill the spores of this pathogen

A client with shingles
A client who has shingles requires airborne precautions and therefore requires a private room
Client with Pancreatitis
decreased serum calcium due to fat necrosis

increased serum amylase

increased alkaline phosphatase

increased serum bilirubin

ciprofloxacin for a urinary tract infection
The client should restrict caffeine intake to reduce CNS stimulation

The client should avoid products containing calcium for 6 hr before or 2 hr after taking ciprofloxacin because it interferes with absorption of the medication

Omeprazole
The nurse should administer omeprazole for GERD
Ranitidine
The nurse should administer ranitidine for peptic ulcer disease
Hydromorphone
The nurse should administer hydromorphone to manage the client’s pain caused by biliary colic

– Biliary colic is the term used to describe a type of pain related to the gallbladder that occurs when a gallstone transiently obstructs the cystic duct and the gallbladder contracts

Phenytoin
The nurse should administer phenytoin for seizures
If client is schudled for allergy testing and is taking glucocorticoid the nurse should:
nurse should postpone the testing

– The client should discontinue prednisone, a glucocorticoid, for up to 4 weeks before allergy testing to avoid suppressing the immune response

In case of sezuire the nurse should:
The client’s airway can become obstructed and the nurse may need to suction to clear the client’s airway after the seizure

Loosen restrictive clothing on the client

The nurse should not insert anything into the client’s mouth

The nurse should keep the client flat on her back or turned onto her side during a seizure to prevent aspiration

MI
Troponin I and is a specific marker of myocardial infarction
client who is taking carvedilol for heart failure
if client gain weight, the nurse should notify the provider. That means the medication is not effective.
carvedilol, for heart faliure
Fatigue is an expected finding for a client who is taking carvedilol

Diarrhea is an expected finding for a client who is taking carvedilol

Orthostatic hypotension is an expected finding for a client who is taking carvedilol

total hip arthroplasty
The nurse should place a pillow between the client’s legs to prevent hip dislocation

The client should not flex the hip greater than 90° to prevent hip dislocation

The nurse should assist the client to maintain abduction of the client’s legs

lumbar puncture
The nurse should maintain the client in a dorsal recumbent position

The nurse should not place a pillow under the client’s knees because it can impede circulation

The nurse should encourage fluid intake to replace lost cerebrospinal fluid

The client should be maintained in a supine position for 1 to 12 hr following the procedure

Intra-arterial radial catheter
The nurse should check capillary refill distal to the catheter insertion site to monitor for impaired circulation

Monitor for bleeding

The nurse should place an occlusive dressing over the catheter insertion site

The nurse should maintain patency of the catheter with a continuous infusion of 0.9% sodium chloride

postoperative following a parathyroidectomy
1- The high priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is place a tracheostomy tray at the client’s bedside in case of airway obstruction.

2- The nurse should use sandbags to support the head and neck to prevent stress on the suture line

3- The nurse should place the client in semi-Fowler’s position to avoid neck extension

opioid analgesic
The client should take opioid analgesics with food to prevent nausea

should increase your fiber intake to prevent constipation

Partial thromboplastin Time (aPTT) (Heparin)
16-40 second
therapeutic range 1.5-2x normal or control value
Adverse reaction to furosemide
Look for serum sodium, if decreased is a adverse effect of it

weight loss is a expected finding

postoperative teaching following an ileostomy
Feces will gradually become thicker and more paste-like over time

The stoma should remain cherry red and moist

The client should expect a minimal or a sweet odor of the feces

The skin around the stoma should remain free of irritation and excoriation

When preparing the medications
The nurse should not open time-released medications because they will be absorbed into the gastrointestinal tract immediately, which defeats the purpose of a time-released capsule

The nurse should use a medicine cup to avoid handling the pills

The nurse should open the medication package at the bedside to reduce the risk for medication error.

complications of hypothermia
Hypertension, Hypothermia can cause vasoconstriction leading to hypertension

Metabolic acidosis can result from hypothermia due to shivering

Cast
The nurse should report an increase in drainage, which may indicate infection or an improperly fitting cast

The nurse should expect capillary refill of 3 to 4 seconds, which indicates adequate circulation to the extremity

The nurse should expect a bounding dorsalis pedis pulse, which indicates adequate circulation to the extremity

The nurse should expect to find cold areas on the cast as the cast dries

Dehydration
When caring for client with dehydration always look and monitor muscle strenght. The greatest risk to this client is injury from falls; therefore, the priority assessment is muscle strength to prevent falls

Assessing skin turgor is important to monitor hydration status

Assessing weight is important to monitor hydration

Assessing urine specific gravity is important to monitor hydration

Adverse effect of mannitol
Muscle rigidity is an adverse effect of mannitol
Nephrostomy tube
The nurse should notify the provider if there is a decrease in urinary output, which can indicate impaired renal function or dysfunction of the nephrostomy tube

The nurse should report back pain, which can indicate that the nephrostomy tube is dislodged or clogged

Red-tinged urine is an expected finding for the first 12 to 24 hr following a nephrostomy tube insertion

A low-grade fever is expected in the first 24 hr following a nephrostomy tube insertion

Mechanical ventilation
When providing nursing care, the nurse should first use the least restrictive intervention

Because anxiety and restlessness indicate that the client is “fighting the ventilator,” the nurse should first provide verbal instructions and emotional support to help the client relax and allow the ventilator to work

Many factors can cause a high-pressure alarm to sound. In the event of a ventilator failure, the nurse may need to disconnect the machine and manually ventilate the client

total parenteral nutrition (TPN)
if running out of TPN and the next bag is not ready, administer 10% dextrose
in water until the new bag arrives

TPN solutions have a high concentration of dextrose. If a TPN solution is temporarily unavailable, the nurse should administer 10% or 20% dextrose in water to avoid a precipitous drop in the client’s blood glucose level

Keeping the line open with 0.9% sodium chloride can cause injury to the client, so only 10% to 20% dextrose in water

Acetylcysteine
Acetylcysteine thins pulmonary secretions, which increases the client’s ability to cough up secretions, is a good thing
with a client history of anxiety disorder reports numbness and tingling in the fingertips and pulse rate is increased and respirations is increased too
Apply a nonrebreather mask without oxygen

The greatest risk to the client is hypocapnia and subsequent development of respiratory alkalosis; therefore, the priority intervention is to assist the client to retain more carbon dioxide, minimizing the potential for development of respiratory alkalosis by using a nonrebreather mask

client who has a Stage III pressure ulcer
The nurse should use a hydrocolloid dressing to keep the wound bed moist

The nurse should use a nonadherent gauze dressing for a wound that has little to no drainage

The nurse should use adhesive transparent film over intact skin

The nurse should use a wet-to-damp dressing for mechanical debridement

bowel obstruction
Insert a nasogastric tube

Inserting a nasogastric tube will decompress the bowel and may alleviate the obstruction

A client who has a small bowel obstruction should not receive enemas

The nurse should place the client in semi-Fowler’s position to promote peristalsis and facilitate breathing

Administering RBCs to a client
Prime the administration set with only 0.9% sodium chloride solution

The nurse should administer blood with 0.9% sodium chloride solution and Never with lactated Ringer’s solution or with a solution that contains dextrose These solutions cause clotting or lysis of RBC

The nurse should stay with the client for at least 30 min, as most transfusion reactions manifest during the infusion of the first 50 to 100 mL of the blood product

The nurse should administer blood products as soon as possible after obtaining them from the blood bank to decrease the risk of bacterial growth

Blood components are too viscous to infuse properly through a needle with a lumen any narrower than 20 gauge. The nurse should use an 18- or 19-gauge needle

Heart Faluire
The nurse should report a weight gain of 3 lb or more per week
UTI
A client who is at risk for developing UTIs should increase her intake of ascorbic acid to acidify the urine

A client who is at risk for developing UTIs should take showers rather than baths because bacteria in the bath water can enter the urethra

A client who is at risk for developing UTIs should urinate on a regular basis, at least every 4 hr

A client who is at risk for developing UTIs should wipe from the front to the back after voiding to avoid bacterial contamination.

Omeprazole
Omeprazole is a proton pump inhibitor, which relieves symptoms of gastric ulcers by suppressing gastric acid production

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