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Nursing Interventions: A nurse is planning care for a client who is post-
op for a radical mastectomy.
- Begin exercises with the client 1 day after the procedure.
- Exercises that do not stress the incision site can promote lymphatic
return and mobility.
Pre-Operative Teaching: For a client that is scheduled for a "total knee
arthroplasty"
- Teach that elastic stockings worn after surgery will help prevent
venous embothrobolism
Highest Risk Factor: Bladder Cancer
- Tobacco use
Pre-procedure Client Education: Cardiac Catheterization
- The client should remain flat for 2-6 hours following the procedure.
- The client will receive mild sedatives for relaxation/comfort
- The client will need to keep their leg straight following the procedure.
Priority Nursing Actions: A client is being admitted with frequent
coughing and frothy pink sputum. The client has a Hx of night sweats,
anorexia, and weight-loss.
- Assign the client to a private, NEGATIVE-PRESSURE room
- Initiate AIRBORNE precautions
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- Wear N95 mask when entering the client's room
Nursing Interventions to be Included in a plan of care for a client who
has deep partial-thickness burns over 40% of his body and is in the
acute phase of the burn injury.
- Begin performing active/passive range of motion exercises with the
client.
- Maintains mobility and prevents contractures
"RIFLE" Classification for AKI: Risk of Renal Dysfunction
- < 0.5 mL/kg/hr of urine output for 6 hours
"RIFLE" Classification for AKI: Injury to Kidney
- < 0.5 mL/kg/hr of urine output for 12 hours
"RIFLE" Classification for AKI: Failure or Loss of Kidney function
- no urine (anuria) output for 12 hours or
- < 0.3 mL/kg/hr for 24 hours
"RIFLE" Classification for AKI: Loss
- no urine output without renal replacement therapy for 4 to 12 weeks
"RIFLE" Classification for AKI: End-Stage Renal Failure
- no urine output without renal replacement therapy for more than 3
months
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Assessment Finding: Acute Intravascular Hemolytic Reaction
- sudden oliguria
- this type of transfusion reaction causes acute kidney injury (AKI)
resulting in sudden oliguria and hemoglobinuria
Nursing Plan of Care: A nurse is caring for a client with SIADH with mild
symptoms. What Rx will be anticipated?
- tolvaptan (Samsca) which is a vasopressin antagonist that promotes
the excretion of water and corrects the fluid imbalance in clients who
have SIADH.
Drug Name: Chlorpropamide
- an anti-diabetic agent with antidiuretic effects that is used to treat
diabetes insipidus
Drug Name: Vasopressin
- exogenous form of antidiuretic hormone that is used to treat diabetes
insipidus
Drug Name: Demopressin
- a synthetic form of antidiuretic hormone that is used to treat diabetes
insipidus
Adverse Effect: Lasik eye surgery
, ATI MEDICAL-SURGICAL CMS REVIEW ALL
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- dry eyes
- blurred vision
Procedure: Lasik Eye Surgery
- A procedure that can correct (1) nearsightedness, (2) farsightedness,
and (3) astigmatism
- The procedure changes the shape of the cornea to correct vision.
Nursing Actions: For a client who is 3 days post-op following a below-
the-knee operation.
- rewrap the residual limb with a pressure bandage 3x daily which
ensures the residual limb will shrink and also provides an opportunity to
assess the skin for redness/breakdown
Drug Assessment Finding: Theophylline Toxicity
- tremors (an early manifestation of toxicity is CNS stimulation, often
seen as tremors
- seizures can occur if blood levels continue to rise
Pressure Ulcer: Stage I
- The skin is intact, with an area of persistent, non-blanchable redness
and typically over a bony prominence
Pressure Ulcer: Stage II
ANSWERS 100% ACCURATE LATEST DOWNLOADED
2025/2026 BEST COMPLETE SOLUTION RATED A+
FOR SUCCESS
Nursing Interventions: A nurse is planning care for a client who is post-
op for a radical mastectomy.
- Begin exercises with the client 1 day after the procedure.
- Exercises that do not stress the incision site can promote lymphatic
return and mobility.
Pre-Operative Teaching: For a client that is scheduled for a "total knee
arthroplasty"
- Teach that elastic stockings worn after surgery will help prevent
venous embothrobolism
Highest Risk Factor: Bladder Cancer
- Tobacco use
Pre-procedure Client Education: Cardiac Catheterization
- The client should remain flat for 2-6 hours following the procedure.
- The client will receive mild sedatives for relaxation/comfort
- The client will need to keep their leg straight following the procedure.
Priority Nursing Actions: A client is being admitted with frequent
coughing and frothy pink sputum. The client has a Hx of night sweats,
anorexia, and weight-loss.
- Assign the client to a private, NEGATIVE-PRESSURE room
- Initiate AIRBORNE precautions
,ATI MEDICAL-SURGICAL CMS REVIEW ALL
ANSWERS 100% ACCURATE LATEST DOWNLOADED
2025/2026 BEST COMPLETE SOLUTION RATED A+
FOR SUCCESS
- Wear N95 mask when entering the client's room
Nursing Interventions to be Included in a plan of care for a client who
has deep partial-thickness burns over 40% of his body and is in the
acute phase of the burn injury.
- Begin performing active/passive range of motion exercises with the
client.
- Maintains mobility and prevents contractures
"RIFLE" Classification for AKI: Risk of Renal Dysfunction
- < 0.5 mL/kg/hr of urine output for 6 hours
"RIFLE" Classification for AKI: Injury to Kidney
- < 0.5 mL/kg/hr of urine output for 12 hours
"RIFLE" Classification for AKI: Failure or Loss of Kidney function
- no urine (anuria) output for 12 hours or
- < 0.3 mL/kg/hr for 24 hours
"RIFLE" Classification for AKI: Loss
- no urine output without renal replacement therapy for 4 to 12 weeks
"RIFLE" Classification for AKI: End-Stage Renal Failure
- no urine output without renal replacement therapy for more than 3
months
,ATI MEDICAL-SURGICAL CMS REVIEW ALL
ANSWERS 100% ACCURATE LATEST DOWNLOADED
2025/2026 BEST COMPLETE SOLUTION RATED A+
FOR SUCCESS
Assessment Finding: Acute Intravascular Hemolytic Reaction
- sudden oliguria
- this type of transfusion reaction causes acute kidney injury (AKI)
resulting in sudden oliguria and hemoglobinuria
Nursing Plan of Care: A nurse is caring for a client with SIADH with mild
symptoms. What Rx will be anticipated?
- tolvaptan (Samsca) which is a vasopressin antagonist that promotes
the excretion of water and corrects the fluid imbalance in clients who
have SIADH.
Drug Name: Chlorpropamide
- an anti-diabetic agent with antidiuretic effects that is used to treat
diabetes insipidus
Drug Name: Vasopressin
- exogenous form of antidiuretic hormone that is used to treat diabetes
insipidus
Drug Name: Demopressin
- a synthetic form of antidiuretic hormone that is used to treat diabetes
insipidus
Adverse Effect: Lasik eye surgery
, ATI MEDICAL-SURGICAL CMS REVIEW ALL
ANSWERS 100% ACCURATE LATEST DOWNLOADED
2025/2026 BEST COMPLETE SOLUTION RATED A+
FOR SUCCESS
- dry eyes
- blurred vision
Procedure: Lasik Eye Surgery
- A procedure that can correct (1) nearsightedness, (2) farsightedness,
and (3) astigmatism
- The procedure changes the shape of the cornea to correct vision.
Nursing Actions: For a client who is 3 days post-op following a below-
the-knee operation.
- rewrap the residual limb with a pressure bandage 3x daily which
ensures the residual limb will shrink and also provides an opportunity to
assess the skin for redness/breakdown
Drug Assessment Finding: Theophylline Toxicity
- tremors (an early manifestation of toxicity is CNS stimulation, often
seen as tremors
- seizures can occur if blood levels continue to rise
Pressure Ulcer: Stage I
- The skin is intact, with an area of persistent, non-blanchable redness
and typically over a bony prominence
Pressure Ulcer: Stage II
