MedSurg ATI Final (remediation)** Questions & Answers

Postoperative Nursing Care: Prophylactic DVT Care - ANSWERS●● Deep-vein thrombosis ◯◯ Caused by dehydration, stress response that leads to hypercoagulability of the blood, obesity, trauma, malignancy, history of thrombosis, hormones, and use of indwelling venous catheter ■■ Nursing Actions: Prophylactic measures include administration of lower-molecular-weight or low-dose heparin or low-dose warfarin (Coumadin), antiembolism stockings, pneumatic compression devices, range of motion exercises, and early ambulation. ■■ Avoid any form of pressure behind the knee with a pillow or blanket, which can cause constriction of blood vessels and decreased venous return. ■■ Avoid dangling client for long periods of time. ■■ Provide adequate hydration by administering IV fluids or encouraging increased oral fluid intake. -Assess and compare peripheral pulses -Caused by dehydreation, obesity, trauma, malignacy, Hx of thrombosis, hormones, and use of indwelling cath -Nursing actions: prevention, avaoid dangling pt for long periods, anticoagulants, provide adequate hydration Hemodynamic Shock: Ventricular fibrillation - ANSWERS■■ Cardiogenic and obstructive shock ☐ ECG XX Assess for ECG changes associated with MI and dysrhythmias. ☐ Echocardiogram XX Diagnostic procedure used for cardiomegaly, cardiomyopathy, the evaluation of cardiac contractility and function, ejection fraction, and valve function ☐ Computerized tomography (CT) XX Diagnostic procedure used for cardiomegaly, cardiac tamponade, pulmonary emboli, cardiomyopathy, aortic dissection or aneurysm, and pericardial effusion ☐ Cardiac catheterization XX Diagnostic procedure used to identify cardiac artery blockage ☐ Chest x-ray XX Diagnostic procedure used to diagnose cardiomegaly, pneumothorax, and to evaluate lungs -can cause cardiogenic shock -Dx- ECG, Ech, CT, Cardiac cath, chest x ray -Tx- Cardiac cath, Anticoagulants, defib shock to fix rythem Cardiovascular Diagnostic and Therapuetic procedure: Assessing arterial line - ANSWERS◯◯ Arterial lines are placed in the radial (most common), brachial, or femoral artery. ■■ Arterial lines provide continuous information about changes in blood pressure and permit the withdrawal of samples of arterial blood. Intra-arterial pressures can differ from cuff pressures. ■■ The integrity of the arterial waveform should be assessed to verify the accuracy of blood pressure readings. ■■ Monitor circulation in the limb with the arterial line (capillary refill, temperature, color). ■■ Arterial lines are not used for IV fluid administration. ◯◯ Nursing Actions ■■ Line Insertion ☐ Ensure the client's understanding of the procedure prior to obtaining signed informed consent form. ☐ Assemble the pressure monitoring system. Purge air from system and maintain sterility of connections. ☐ Place the client in supine or Trendelenburg position. ☐ Administer sedation and pain medications as prescribed. ☐ Level transducer with phlebostatic axis (4th intercostal space, midaxillary line), which corresponds with the right atrium. ☐ Zero system with atmospheric pressure, because the hemodynamic pressure lines must be calibrated to read zero atmospheric pressure. ☐ Obtain initial readings as prescribed. Compare arterial blood pressure to noninvasive cuff pressure (NIBP). ☐ Document the client's response. ●● Postprocedure ◯◯ Nursing Actions ■■ Obtain chest x-ray to confirm catheter placement. ■■ Continually monitor respiratory and cardiac status (vital signs, heart rhythm, SaO2). ☐ Observe respiratory pattern and effort. ☐ Compare noninvasive cuff pressure (NIBP) to arterial blood pressure. ■■ Maintain line placement and integrity. ☐ Observe and document waveforms. Report changes in waveforms to the provider, as this can indicate catheter migration or displacement. ☐ Document catheter placement each shift and as needed (a Cardiac Glycosides and Heart Failure: Eval. pt understanding of digoxin administration - ANSWERS■■ Client Education ☐ Teach clients who are self-administering digoxin to: XX Count pulse for 1 min before taking the medication. If the pulse rate is irregular or the pulse rate is outside of the limitations set by the provider (usually less than 60/min or greater than 100/min), instruct the client to hold the dose and contact the provider. XX Take the digoxin dose at the same time each day. XX Do not take digoxin at the same time as antacids. Separate the two medications by at least 2 hr. XX Report signs of toxicity, including fatigue, muscle weakness, confusion, and loss of appetite. XX Regularly have digoxin and potassium levels checked. ■■ Client Education ☐ Teach clients who are self-administering digoxin to: XX Count pulse for 1 min before taking the medication. If the pulse rate is irregular or the pulse rate is outside of the limitations set by the provider (usually less than 60/min or greater than 100/min), the client should hold the dose and contact the provider. XX Take the dose of digoxin at the same time every day. XX Do not take digoxin at the same time as antacids. Separate the two medications by at least 2 hr. XX Report signs of toxicity, including fatigue, muscle weakness, confusion, visual changes, and loss of appetite. ●● Digoxin - Instruct the client not to take medication within 2 hr of eating, and teach client how to take an apical pulse for 1 min. ●● Digoxin - Take apical pulse for 1 min, and monitor laboratory levels for signs of toxicity. -Hold if apical HR is <60bpm per min -Watch for N&V -Monitor ECG, BP -Take same time each day -take 2 hr before or after antacids - If you miss dose take it as soon as you remember Opioid Agonist and Antagonists: Expected findings following administering Narcan - ANSWERS●● Naloxone has rapid first-pass inactivation and should be administered IV, IM, or subcutaneously. Do not administer orally. ●● Observe clients for withdrawal symptoms and/or abrupt onset of pain. Be prepared to address the client's need for analgesia (if given for postoperative opioid-related respiratory depression). ●● Titrate dosage to achieve reversal of respiratory depression without full reversal of pain management effects. ●● Rapid infusion of naloxone may cause hypertension, tachycardia, nausea, and vomiting. ●● Half-life of opioid analgesic may exceed the half-life of naloxone (60 to 90 min). ●● Monitor respirations for up to 2 hr after use to assess for reoccurrence of respiratory depression and the need for repeat dosage of naloxone. Nursing Evaluation of Medication Effectiveness ●● Reversal of respiratory depression (respirations are regular, client is without shortness of breath, respiratory rate is 16 to 20/min in adults and 40 to 60/min in newborns) ●● Reduced euphoria in alcohol dependency and decreased craving for alcohol in alcohol dependency (naltrexone) ●● Severe opioid-caused constipation relieved (methylnaltrexone) -Increase Resp. -Pain returns -increase HR -increase BP Blood and Blood Products Transfusions: Allergic blood transfusion reactions - ANSWERS››Mild allergic reactions (flushing, itching, urticaria) ›› If manifestations occur, stop the transfusion and notify the provider immediately, keeping the IV line open with 0.9% sodium chloride. ›› If manifestations are very mild and there is no respiratory compromise, antihistamines may be prescribed and the transfusion restarted slowly Mild- Itching, urticaria, flushing- Administer benadryl Anaphylactic- wheezing, dyspnea, chest tightness, cyanosis, hypotension -maintain airway, admin. 02, IV fluids, antihistamines, corticosteroids, and vasopressors Acute and Chronic Kidney: Planning Dietary Restrictions - ANSWERS■■ Nutrition ☐ Restrict dietary intake of potassium, phosphate, and magnesium during oliguric phase (restriction is for the client not requiring dialysis). ☐ Potassium and sodium is regulated according to the stage of kidney injury. ☐ High-protein diet to replace the high rate of protein breakdown due to stress from the illness. Possible total parenteral nutrition (TPN). ☐ Identify and assist with correcting the underlying cause. ●● ◯◯ Instruct the client to monitor the daily intake of carbohydrates, proteins, sodium, and potassium, according to the provider. - Possible fluid restrictions -Restrict K+, phosphate, & magnesium - Potassium and sodium regulated -High pretine and possible TPN Acute kidney Injury and Chronic Kidney Disease: Evaluating pt understanding - ANSWERS● Health Promotion and Disease Prevention of Acute Kidney Injury ◯◯ Encourage clients to drink at least 2 to 3 L daily. Consult with the provider regarding prescribed fluid restriction if needed. ◯◯ Promote smoking cessation, weight loss, cautious use of NSAIDs, and control of diabetes and hypertension with prescribed medication. ◯◯ Instruct clients to take all antibiotics prescribed for infections. Health Promotion and Disease Prevention of Chronic Kidney Disease ●● Encourage clients to drink at least 3 L of water daily. Consult with the provider regarding any restrictions. ●● Promote smoking cessation. ●● Encourage diet and activities to control or prevent diabetes and hypertension. ●● Teach the client the importance of adherence to a medication regimen when prescribed. ●● Encourage yearly testing for albumin in the urine if the client has diabetes or hypertension. ●● Instruct the client to take all antibiotics until completed. ●● Limit over-the-counter NSAIDs. ●● Client Education ◯◯ Instruct the client to monitor the daily intake of carbohydrates, proteins, sodium, and potassium, according to the provider. ◯◯ Instruct the client to monitor fluid intake according to fluid restriction prescribed by the provider. ◯◯ Encourage the client who has diabetes mellitus to adhere to strict blood glucose control because uncontrolled diabetes is a major risk factor for chronic kidney disease. ◯◯ Instruct the client to avoid antacids containing magnesium. ◯◯ Encourage the client to take rest periods from activity. ◯◯ Educate the client who is receiving hemodialysis or peritoneal dialysis on an outpatient basis. ◯◯ Educate the client on how to measure blood pressure and weight at home. ◯◯ Encourage the client to ask questions and discuss fears. ◯◯ Encourage the client to diet, exercise, and take medication as prescribed. ◯◯ Advise Cardiovascular Diagnostic and Therapuetic Procedures: ECG abnormalities following myocardial infarction - ANSWERSClient who has MI - T-wave inversion indicates ischemia; ST-segment elevation indicates injury; abnormal Q-wave indicates necrosis. ECG changes produced (Q wave, non-Q wave); non-Q-wave MIs are more common in older adults, women, and clients who have diabetes mellitus. Client who has MI - T-wave inversion indicates ischemia; ST-segment elevation indicates injury; abnormal Q-wave indicates necrosis. Inflammatory Bowel: Dietary recommendations - ANSWERS◯◯ Ulcerative colitis and Crohn's disease ■■ Educate the client to eat foods that are high in protein and calories, and low in fiber. ■■ Assist the client in identifying foods that trigger clinical manifestations. ■■ Instruct the client to avoid caffeine and alcohol, and take a multivitamin that contains iron. ■■ Advise the client that small frequent meals may reduce the occurrence of manifestations. ■■ Inform the client that dietary supplements that are ◯◯ Diverticulitis ■■ Educate the client to consume a clear liquid diet until manifestations subside. The client may progress to a low-fiber diet as tolerated. ■■ Instruct the client to add fiber to the diet once solid foods are tolerated without other manifestations. The client should slowly advance to a high-fiber diet as tolerated. ■■ Teach client to avoid seeds or indigestable material, which can block diverticulum (nuts, popcorn, seeds). ■■ Instruct client to avoid irritating the bowel (avoid alcohol, limit fat to 30% of daily calorie intake). high in protein and low in fiber (elemental and semielemental products, canned nutrition beverages) may be used. low fiber increased protine decreased calories low fiber increased protine decreased calories Seizures and Epilepsy: Client teaching about Phenytoin (Dilantin) - ANSWERS●● Instruct the client to refrain from alcohol and other medications that cause CNS depression (e.g., barbiturates). ●● Encourage the client to use dental floss and massage gums daily. ●● Instruct the client to avoid pregnancy and use an alternate form of contraception. ●● Monitor INR if on warfarin (Coumadin) and blood glucose levels if taking a glucocorticoid. ●● Monitor therapeutic effects of warfarin and glucocorticoids. ●● Never abruptly discontinue antiepileptic medications. -If one med doesn't work dose is increased or another med is added -Therapeutic lvl determined by blood test -Med taken same time each day -No oral contraception or warfarin