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ATI Adult Medical Surgical NursingA+ Solutions 2024
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ATI Adult Medical Surgical NursingA+ Solutions 2024
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ATI Adult Medical Surgical NursingA+Solutions 2024
aseptic technique - ANS-means clean technique
-hand hygiene, sterile gloves not used
bacterial meningitis - ANS-is an emergency and IV antibitoics are needed ASAP
stress fracture - ANS-a small crack in the bone that often develops from chronic,
excessive impact
adults body fluids - ANS-50-60% of total body weight is water
infants body fluids - ANS-15-80% of total body wt is water
2/3 body weight - ANS-is intracellular
1/3 body weight - ANS-is extracellular
1 kg (2.2 lb) of body weight - ANS-is approximately 1 L of fluid
older adults - ANS-have less body water and decreased thirst sensation
fluid volume deficit factors - ANS-excess GI and/or renal loss
diaphoresis
fever
long term NPO
hemorrhage
burns
fluid volume deficit manifestations - ANS-weight loss, dry mucus membranes, increased
HR and RR, thready pulse, capillary refill less than 3 seconds, weakness, fatigue,
orthostatic hypotension, poor skin turgor
-urine output less than 25 mL/hr
-high hematocrit (>45%)
-BUN >20
,-tenting of skin
fluid volume deficit LATE signs - ANS-oliguria, decreased CVP, flattened neck veins
hypertonic dehydration - ANS-less sodium than water is lost
-sodium >145
-spec graph >1.03
high urine specific gravity - ANS-body is dehydrated and conserving water
-concentrated urine
mild to moderate dehydration - ANS-dry skin and increased thirst
severe dehydration - ANS-pulse >100
cold extremities
central venous pressure - ANS-venous blood pressure within the right atrium that
influences the pressure in the large peripheral veins
normal output - ANS-0.5 mL/kg/hr
no more than 2000mL/day
isotonic IVF - ANS-treatment of vascular system fluid deficit
-concentration = to plasma
-prevent fluid shift between compartments
isotonic solutions - ANS-normal saline
lactated ringer's
5% dextrose in water
hypotonic IVF - ANS-treatment of intracellular dehydration
-lower osmolality than the ECF
-shift fluid from ECF to ICF
hypotonic solutions - ANS-0.45% NS
2.5% dextrose in 0.45% saline
small numbers --> big cells
,hypertonic IVF - ANS-used only when serum osmolality is critically low
-osmolality higher than the ECF
-shift fluid from ICF to ECF
hypertonic solutions - ANS-10% Dextrose in Water, 5% Dextrose in 0.45% Saline, 5%
Dextrose in 0.9% Saline
-big numbers --> shink cells
fluid volume excess - ANS-Fluid intake or fluid retention that EXCEEDS the fluid needs
of the body
fluid volume excess factors - ANS-kidney failure (late phase), heart failure, cirrhosis,
hypertonic fluids, burns, excessive water intake, long term *corticosteroid therapy*
fluid volume excess manifestations - ANS-• Pitting edema, sacral edema.
• Dyspnea, crackles, possible pulmonary edema.
• Bounding pulse, weight gain.
• Lethargy, dizziness, headache, confusion, weakness
• Increased CVP, jugular vein distention.
• Increased blood pressure, *tachycardia*, tachypenia
-decrease spec graph
-BUN <7
-Decreased hemoglobin and hematocrit
urine specific gravity - ANS-1.010-1.030
pitting edema scale - ANS-1+ (minimal) to 4+ (severe)
fluid volume excess NI - ANS-*first evaluate electrolytes*
measure abdominal girth
daily weights
strict I/O
maintain skin integrity
use semi-Fowler's position; reposition q 2hr
, Major intracellular electrolytes - ANS-potassium, phosphate, magnesium major
extracellular electrolytes - ANS-Sodium, Chloride, Calcium, and Bicarbonate.
hypokalemia risk factors - ANS-adverse effects: *corticosteroids*, diuretics (thiazide),
laxative abuse, terbutaline
body fluid loss: vomiting, diarrhea, wound drainage, NG suction
excessive diaphoresis, kidney disease, alkalosis
bulimia
hypokalemia symptoms - ANS-muscle weakness, cramps, *ileus*, hyporeflexia,
*parasthesias (numbness/tinging)*, flaccid paralysis, constipation, *flat/inverted T
waves*, dysrhythmias, fatigue
shallow respirations, orthostatic hypotension
hypokalemia interventions - ANS-monitor cardiovascular, respiratory, neuromuscular,
gastrointestinal, and *renal status*, and place on a cardiac monitor monitor
electrolytes values
administer potassium supplements *(not on empty stomach)* --> may need to be
discontinued if client complains of abdominal pain, distention, nausea, vomiting,
diarrhea, or gastrointestional bleeding; IV bolus must be diluted
Liquid potassium chloride has an unpleasant taste and should be taken with juice or
another liquid
*--do not administer K if patient is not peeing*
KCl administrationn - ANS-must not exceed 10 mEq per hr
hyperkalemia risk factors - ANS-decreased potassium excretion due to renal failure,
hypoaldosteronism, potassium-conserving diuretics or ACE inhibitors; high potassium
intake due to excessive use of potassium containing salt substitutes, excessive or rapid
IV potassium infusion, *potassium shift out of the tissue cells into the plasma due to
burns*, infections, or acidosis *(DKA specifically)*
hyperkalemia manifestations - ANS-* PEAKED T WAVES and WIDENED QRS *
- Ventricular dysrhythmias
- muscle twitching & paresthesia - numbness/tingling (EARLY)
- Ascending muscle weakness (LATE)
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