ATI - Medical-Surgical Bundle

Diabetic Ketoacidosis - Answer - assessment: dehydration, ketosis, metabolic acidosis, hyperglycemia - admin fast acting insulin that can be effective within 10 min, admin IV - kussmaul resp Beta blockers (Propanolol) - Answer - monitor: sore throat, vision changes, blurred vision, dry eye...

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan A. Provide the client with a means of communication B. Maintain the head of the client's bed in a flat position C. Suction the client's endotrache...

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (Ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?: a. Headache b. Infection c. Aphasia d....

A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy? - Answer Lymphedema A nurse is prep...

A nurse on a med surg unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has an ulceration of the right heel whose blood glucose is 300 B. Client who reports right calf pain and shortness of breath C. Client w...

A nurse is reinforcing preoperative teaching with a client who is to undergo a pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery." Which of the following statements should the nurse make? - Answer "I will show you how to splint your incision while coughing....

side effect of cisplatin (treat multiple cancer) IV - Answer Tinnitus R: SE is ototoxicity COPD w/ pneumonia - Answer Respiratory acidosis R: common complication of COPD. this occurs because clients who have COPD are unable to exhale CO2 due to a loss of elastic recoil in the lungs p...

a nurse is caring for a client who's receiving mechanical ventilation when the low-pressure alarm sounds. which of the following situations should the nurse recognize as a possible cause of the alarm? A.) Excess secretions B.) Kinks in the tubing C.) Artificial airway cuff leak D.) Biting on ...

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 1...

Which of the following is part of the respiratory tract? Choose all that apply. A. Bronchi B. Pharynx C. Larynx D. Sinuses - Answer A. Bronchi B. Pharynx C. Larynx D. Sinuses Because the pressure of CO2 is higher in the blood vessels than the pressure of CO2 in the lungs, the CO2...

respiratory acidosis - Answer a nurse is caring for an older adult client who has COPD with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? respiratory acidosis - Answer ______________ occurs in clients who have COPD because clients are unable t...

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretion? A. The client is unable to speak B. The client's airway secretions were last suctioned 2 hr ago C. The c...

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following indicates that the nurse should suction the client's airway secretions? A. The client is unable to speak B. The client's airway secretions were last suctioned 2 hr ago C. The clien...

container of sterile water - Answer a nurse is caring for a client who has a chest tube following a lobectomy; which item should the nurse keep easily accessible for the client? container of sterile water - Answer the nurse should have a ____________ in a location that is easily accessible fo...