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Exam (elaborations)

ATI med surg test A Review Guide With Complete Answers A+ Guaranteed|2024.

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Lack of bowel sounds as it would be inactive of paralytic ilieus....Elevated WBC, nausea , throwing up and jaundice is an expected finding - correct answer A Nurse is assessing a client who has acute pancreatic : what would be alarming - trendelenburg position for easier access to vessels and to decrease risk of an air emboli . - patient should remain motionless during procedure - sterile transparent dressing should be applied to the insertion site - nurse should cleanse the upper chest or neck for a CVC - correct answer what Position to you put a client when inserting a non tunneled percutaneous central venous catheter - sleepiness - increased systolic with concurrent decrease in diastolic ( widening pulse pressure) - decerebrate posturing (and decoriticate posturing) - correct answer PT has intraventricular catheter placed. What findings would indicates client is experiencing increased intracranial pressure ICP - every four hours -if blood glucose reaches 250mg/dl - correct answer When a type one diabetic is sick , how often should they check their blood glucose, and when should they call their provider - preoxygenate client for at least 3o seconds to 3 minutes to prevent hypoxemia. - nurse should limit each suction to 10/15 seconds to prevent hypoxia and mucosal injury - suction pressure 80-120 mmHG - x3 passes for each suction - correct answer a PT with a tracheostomy requires suctionining. what is the most important thing to do first pain radiating to the right shoulder - correct answer Cholecystitis normal finding flank pain extending to the perineum - correct answer urolithiasis normal finding rigid board like abdomen - correct answer peritonitis normal finding piercing abdominal pain - correct answer pancreatitis normal finding - assess client, compare the site to the opposite extremity, looking and measuring for edema as it is an indication of infiltration, then elevate arm and maybe apply a warm compress to reduce pain, and maybe after take the IV out - correct answer PT has a saline lock on clients forearm, client reports discomfort and coolness. what is the first most appropriate action - pain in calf ;DVT - intense headache and or numbness in the arms as they are both indicative of a possible CVA - correct answer a women who is perimenopausal and is going through hormonal replacement therapy is being taught what signs to report back with ASAP, name 3 oliguria DAytime due to decreased blood flow to the kidneys - correct answer Left sided heart failure findings - jugular vein distention, dependent edema, distended abdomen - correct answer Right sided heart failure findings turn PT on side - do not push catheter further into abdomen it can cause an infection, and head of bed should be elevated - correct answer when peritoneal fluid is sluggish when draining during peritoneal dialysis what should the nurse do the facilitate the drainage - if glucose reading is less then300 mg/dl it is improving - a low ph is an expected finding - potassium levels are above the expectant range of 3.5 mEq/L - HCO3 of 14mEq/L is an expected finding - correct answer Client has DKA diabetic ketone acidosis, what are some findings - administer a mucolytic medicatin to thin secretions , such as guaifenesin, and have client sit in orthopedic position, sitting up with arms resting on the over bed table, and encourage him to drink 2/3 L/day to help thin mucous secretions - correct answer A nurse is caring for a client who has COPD and reports shortness of breath bought and fatigue with this mucus secretions what is an appropriate for client - cramping, Kkussmaul (deep labored breathing attributed to severe acidosis) respirations, increased urine output - correct answer hyperglycemia symptoms cool clammy skin - correct answer Hypoglycemia symptoms - bag should be emptied when 1/3 full - diet low in fiber - use skin barrier to protect skin from enzymes and bile salts - pt should use mild soap and water to promote healing and infection - correct answer Iliostomy patient: what to educate on chest asymmetry, lack of breath sounds on the affected side - correct answer PT is one day postop thoracotomy ( incision into thorax) what is a sign of pneumothorax -Flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall - paradoxic chest movement which is the movement of the thorax on expiration and inward on inspiration - correct answer what is flail chest and a common finding - bloddy sputum that occurs with pulmonary infection and pulmonary embolism - correct answer what is hemoptysis and what is it common in -decreased viral load - an increase of T cells means increased manifestations of disease, and increased eosinophils indicates the presence of infection - correct answer Positive response to prescribed HIV medicine in Patient - a curtain being pulled over part of the viusal field, yet painless with a sudden onset, peripheral vision stays intact - correct answer retinal detachment common sensation in PT - use crutches with rubber tips to prevent slipping and decrease risk of falls - correct answer plan of care of PT with an external fixation device for a fracture of the lower extremitiys - application of heat and cold intervals - correct answer what is a non pharmacological intervention to reduce the pain in rheumatoid arthritis impulsive behavior - correct answer what is a manifestation of right hemisphere stroke anxiety , feelings of guilt, expressive aphasia - correct answer what is a manifestation of left hemisphere stroke - temperature of 38.3 or 100.9 because it could indicate an infection due to myelosuppression - correct answ

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