ATI Practice MedSurg 1 Graded A+ 2024

ATI Practice MedSurg 1 Graded A+ 2024 Acute pancreatitis The highest priority finding is absent bowel sounds Nontunneled percutaneous central venous catheter (CVC) Nurse should place pt in Trendelenburg position Conscious sedation Nurse should intervene if pt's O2 is 90% because respiratory depression is a side effect of the meds used during conscious sedation Increased ICP Indicated by sleepiness, widening pulse pressure and decerebrate/decorticate posturing Diabetes and illness Patient should continue medication regimen (insulin) when ill to prevent hyperglycemia Tracheostomy suctioning Nurse should pre oxygenate the pt with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia Cholecystitis Indicated by pain that radiates to the right shoulder Hepatitis A Eating contaminated food increases the risk of contracting Hep A SBO and NG tube Nurse should assess for the passage of flatus because that indicates that the intestines are resuming appropriate function IV with discomfort and coolness First action the nurse should take is to compare the site to the opposite extremity Hormone replacement Pt should notify provider of calf pain (indication of DVT), numbness in the arms (indication of a CVA) and intense headache (indication of CVA) Left sided heart failure Nurse should expect to see oliguria during the day because of decreased blood flow to the kidneys Peritoneal dialysis If the fluid is sluggish in draining, nurse should turn the pt onto their side to reposition the catheter (if it's against the peritoneal wall) or move the catheter (if it's kinked) Diabetic ketoacidosis Improvement in condition would be a glucose of under 300mg/dL COPD If pt has SOB, cough and fatigue along with thick mucus secretions, nurse should administer guaifenesin (mucolytic med that thins secretions and promotes airway clearance) as prescribed Pt should be drinking 2-3L/day to thin mucus secretions Hypoglycemia Cool, clammy skin is an indication of hypoglycemia Pericardial friction rub Scratchy, high-pitched sound associated with acute pericarditis Tension pneumothorax Indicated by chest asymmetry. The air that is forced into the chest cavity causes the affected lung to collapse, and the air that enters the pleural space during inspiration does not exit during expiration. HIV treatment A decreased viral load indicates a positive response to prescribed HIV treatment, because viral load testing measures the presence of HIV viral genetic material Detached retina Pts who have a retinal detachment typically report the sensation of a curtain being pulled over part of the visual field External fixation device Pt should use crutches with a rubber tip. The device is applied by the surgeon directly to the bone to form a rigid structure on the affected extremity. Rheumatoid arthritis Application of heat and cold decreases joint inflammation and pain Right hemisphere stroke Impulsive behavior is an indication Chemo Nurse should report a high temp. because it can indicate an infection due to myelosuppression Radical mastectomy Nurse should include the presence of one or more surgical drains the the plan of care. Pt should start exercise of the arm 24hr after surgery Above-the-knee amputation with temporary prosthesis Pt should sleep on a soft mattress. Pt should keep the residual limb in extension to prevent hip flexion contracture Hearing aids The amplification of background noise is often a challenging aspect of adjusting the a hearing aid Fluid volume overload Indicated by distended neck veins Pacemaker The pacemaker should discharge to maintain the programmed heart rate Tonic-clonic seizure It is not unusual for a pt to become cyanotic and it is generally self-limiting. In the event of a tonic-clonic seizure, nurse should turn the pt onto their side Skin breakdown A 5% loss of total body weight in 30 days or a 10% loss of total body weight in 6 month indicates poor nutrition which places a pt at risk for skin breakdown. A pre albumin level of 5mg/dL also places a pt at risk for skin breakdown. Magnesium sulfate Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate Ibuprofen Older adult w/ pain common side effect of ibuprofen is GI bleeding Prednisone inhaler Pt should wait at least 20-30 seconds between puffs Morphine Nausea and vomiting are common adverse effects IV blood transfusion Should be done with 0.9% sodium chloride Gastric lavage Pt should lie on the left side to decrease the amount of 0.9% sodium chloride that leaves the stomach and to prevent aspiration. Nurse should insert a large-bore NG tube Lactulose Works by stimulating the production of excess stools to rid the body of excess ammonia- these excessive stools can result in hypokalemia and dehydration Cholinergic crisis Pt exhibits increase muscle weakness and twitching after administration of a cholinesterase inhibitor Metformin Used for type II diabetes Should be taken with a meal Hemolytic transfusion reaction Indicated by low back pain and apprehension Implantable cardioverter/defirbrillator (ICD) Pt should tell dentist about ICD Pt should avoid airport metal detectors Arterial line Place a pressure bag around the flush solution While recording values obtained from arterial line the best position for the pt is supine with head elevated 60% degrees Dumping syndrome To prevent dumping syndrome the pt should lie in a supine position after meals to slow the movement of food within the intestines. Pt should not drink fluids with meals and for 1 hour prior to and following meals Stage II Lyme disease Pt can experience joint pain, cardiac and neurological complications. If not treated during this state the disease can become chronic and cause arthritis, peripheral neuropathy, vasculitis and myocarditis. Iron supplements Pt should eat more high-fiber foods to help prevent constipation, which is a