ATI MEDICAL SURGICAL ASSESSMENT TEST

ATI MEDICAL SURGICAL ASSESSMENT TEST 1. Coordinated Care/Stoke: Planning Care for a Client Who Has Dysphagia: One of the complications of stroke is dysphagia. Clients who have a stroke may not necessarily experience this complication but should be evaluated by a speech-language pathologist to consume food and fluids. The client should be NPO until they get evaluated. Start the client on liquid consistency regiment and monitor the client for any signs of choking. The client should sit upright for about 45 minutes to an hour after eating. 2. Safety and Infection Control/ Respiratory Management and Mechanical Ventilation: Home Safety for Oxygen Therapy: Be aware that oxygen is a combustible agent. Clients should be taught not to smoke when using oxygen. They should inspect their electronic devices to make sure they are working properly and to also make sure that the electric machinery such as suctioning devices are grounded. 3. Health Promotion and Maintenance/ Diagnostic and Therapeutic Procedures for Female Reproductive Disorders: Reinforcing Teaching About Mammograms: Prior to the procedure educate the client not to wear any deodorant, lotions or powers. During the procedure the client should be aware of that some discomfort and pain is expected because of the compression of breast. Teach the client to practice self-breast examination and to follow up with provider. 4. Pharmacological Therapies/ Angina and Antilipemic Agents: Adverse Effects of Simvastatin to Report: Clients can experience muscle aches, pain and tenderness while on this medication. This may later progress to myositis (inflammation of muscle) or rhabdomyolysis (breakdown of muscle tissue and release of the content into the bloodstream). Clients can also experience liver toxicity, therefore they should get lab work done after 12 months and then every 6 months while on the medication. 2. Answer the following questions and review the suggested learning activities. Send me your answers here. 1. What are concepts nurses should consider when prioritizing care? When prioritizing care, the nurse should provider care based on his or hers assessment date, analyses and the plan of care of the patient. Identify immediate needs of the clients, and needs that are routine and must be completed by the end of shift. 2. A nurse is caring for a client who has been prescribed a medication that is listed on his allergy list. What action should the nurse take? If the client is prescribed a medication that is listed on the allergy list the nurse should hold the medication and contact the provider. 3. A nurse is caring for a client with MRSA. What cleaning guidelines should be used when removing equipment from the client's room? When cleaning contaminated equipment wear gloves and protective eye wear equipment. Wash the equipment with warm water and soap, use a brush in areas that are hard to reach by hand and rinse with warm water and dry. 4. A nurse is caring for a client with fluid overload. What respiratory findings should the nurse anticipate? When caring for a client with fluid overload the nurse should anticipate respiratory findings such as SOB, and crackles in the lungs 5. Explain how a client with COPD should be instructed to perform diaphragmatic breathing. When teaching the client with COPD about diaphragmatic breathing, the nurse should instruct the client to lie on their back with knees bent following by taking a deep breath in pushing their abdomen outward. To create resistance, instruct the client to rest their hands on their abdomen. To evaluate the client if their hand on the abdomen rises and falls upon inhalation and exhalation shows that diaphragmatic breathing is done correctly. 6. A nurse is caring for a client following vein stripping for treatment of varicose veins. What post-operative care should be provided? After vein stripping, the nurse should elevate the clients’ legs above the heart, and encourage the client to perform ROM exercises of the legs. Monitor the client the clients’ lower extremities for edema, warmth, color and peripheral pulses. Elastic bandages should be applied to the extremity, both the groin and leg should be monitored for breeding following procedure. 7. A client with pernicious anemia asks the nurse why his prescribed B12 supplement cannot be administered by mouth. How should the nurse respond? I would explain to my client that Vit B12 can be given orally if the problem lies with the inadequate dietary intake of Vit B12 however, his prescribed Vit B12 supplement cannot be administered by mouth because of malabsorption or that there is a lack of intrinsic factor being produced by the parietal cells of the stomach. 8. A nurse is assisting with care of a client with a pneumothorax. The client has a chest tube in place and the water seal chamber vigorous bubbling noted. What steps should the nurse take to troubleshoot the chest tube drainage system? If the water seal chamber is vigorously bubbling an air leak in the system is assumed. To troubleshoot the chest tube drainage system, the nurse should observe and try to locate the source of the air leak. Once air leak is found the nurse should tighten the connection, or replace the drainage system if necessary. 9. A client is experiencing chest discomfort. Identify three (3) clinical manifestations of a Myocardial Infarction (MI). Chest pain that radiates down the shoulder, feeling of impending doom, and nausea are three of the few manifestations of MI. 10. A nurse is caring for a client with right-sided heart failure. What are clinical manifestations of right-sided heart failure the nurse should identify during client care? Select all that apply. Jugular vein distention, dependent edema found in the legs, ankles and sacrum, nausea, anorexia, urinating at night, liver enlargement, and weight gain are manifestations of right sided heart failure that the nurse should identify during the client’s care. 11. A nurse is reinforcing teaching to a client regarding foods high in calcium. What foods should this include? Dairy products, canned salmon, sardines, fresh oysters, dark greens and leafy vegetables are foods high in calcium. 12. Identify five (5) manifestations of acute cholecystitis Sharp pain in the RUQ radiating to the right shoulder, rebound tenderness, dyspepsia, fever, jaundice are some of the manifestations of acute cholecystitis.