ATI RN Adult Medical Surgical Retake 1 (2023/2024)

ATI RN Adult Medical Surgical Retake 1 Seizures and Epilepsy: Seizure precautions (62) – ans During a seizure: Position client on the floor and provide a patent airway, turn client to side and loosen restrictive clothing Cancer treatment options: Protective Isolation (999) - ansIf WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions. - Have client remain in his room unless be needs to leave for a diagnostic procedure, in case of transport place a mask on him - Protect from possible sources of infection (plants, change water in equipment daily) - Have client, staff and visitors perform frequent hand hygiene, restrict ill visitors - Avoid invasive procedures (rectal temps, injections) - Administer (neupogen, neulasta) to stimulate WBC production Infection control: Appropriate room assignment - ansStandard Precautions: 1. applies to all patients 2. Hand washing a. alcohol based preferred unless hands visually soiled 3. Gloves - when touching anything that has the potential to contaminate. 4. Masks, eye protection & face shields when care may cause splashing or spraying of body fluids Droplet: 1. private room or with someone with same illness 2. masks Airborne: 1. private room 2. masks or respiratory protection devices a. use an N95 respirator for tuberculosis 3. Negative pressure airflow 4. full face protection if splashing or spraying is possible Contact: 1. private room or room with same illness 2. gloves & gowns 3. disposal of infections dressing materials into a single, nonporous bag without touching the outside of the bag TB: Priority action for a client in the emergency department (249) - ans-Wear an N95 or HEPA respirator -Place client in negative airflow room and implement airborne precautions -use barrier protection when the risk of hand or clothing contamination exists Immunizations: Recommended vaccinations for older adult clients (943) - ansAdults age 50 or older: -Pneumococcal Vaccine (PPSV) - Influenza vaccine - Herpes Zoster Vaccine -Hepatitis A - Hepatitis B - Meningococcal Vaccine Pulmonary Embolism: Risk factors for DVT (258) - ans-Long term immobility - Oral contraceptives - Pregnancy - Tobacco use - Hypercoagulabilty - Obesity - Surgery - Heart failure or chronic A-Fib - Autoimmune hemolytic anemia (sickle cell) -Long bone fractures -Advanced age Disorders of the male reproductive system: Complications of continuous irrigation following Trans-urethral Resection (743) - ans-Urethral trauma -Urinary retention - Bleeding - Infection Stroke: Caring for a client who has left sided hemiplegia (155) - ans- Observe extremities for injury - Apply an arm sling if client is unable to care for the affected extremity - Ensure foot rest is on wheel chair and ankle brace is on the affected foot - Instruct client to dress the affected side first Fractures and immobilization devices: Prevent complications (787) - ans-Assess neurovascular status of the affected body part for every hour for 24 hours and Q4 hours after that - Maintain body alignment - avoid lifting or removing weights -Monitor pain level - Monitor for signs of infection - Support nutrition Pain Management: use of non pharmacological methods of pain relief - ans- Cutaneous (skin) stimulation- TENS, heat, cold, therapeutic touch and massage - Distraction (deep breathing, ambulation, visitors, TV and music) - Relaxation (meditation, yoga and progressive muscle relaxation -Imagery (focus on pleasant thoughts) - Elevation of extremities to promote venous return Acute Kidney injury and chronic kidney disease: Evaluating teaching about nutrition - ans-Restrict dietary intake of potassium, phosphate and magnesium during oliguric phase -K and Na is regulated according to stage of kidney injury - high protein diet to replace the high rate of protein breakdown due to the stress from the illness. Possible TPN Heart failure and pulmonary edema: Dietary teaching about sodium restriction - ansMaintain fluid and sodium restriction Increase dietary intake of potassium Pulmonary Embolism: Planning care for a client who is receiving enoxaparin - ans-Assess for contraindications (active bleeding, peptic ulcer disease, history of stroke, recent trauma) -Monitor bleeding times (PT, aPTT and INR) -Monitor for side effects such as thrombocytopenia, anemia and hemmorhage Rheumatoid Arthritis: Reviewing Laboratory Values - ans-Positive Anti- cyclic citrullinated peptide -RF Antibody (Diagnostic level for RA is 1:40-1:60) expected reference range 1:20 - Elevated ESR 20-40 mild inflammation 40-70 moderate 70-150 severe - Positive C-reactive protein - Positive ANA titier - Elevated WBC's Medications affecting coagulation: Heparin Contraindications - ansAvoid NSAIDS while on heparin Antibiotics affecting protein synthesis: Adverse effects of gentamicin - ans-Ototoxicity: cochlear damage (hearing loss) and vestibular damage (loss of balance). -Nephrotoxicity (proteinuria, elevated BUN, creatinine levels). -Hypersensitivity ( rash, pruritis, parathesia of hands and feet, and urticaria). Electrolyte imbalance: manifestations of hypokalemia - ansWeak, irregular pulse, hypotension, respiratory distress Premature ventricular contractions, bradycardia, inverted T waves, ST depression Decreased GI motility, abdominal distension, constipation, n/v, anorexia, polyuria Decreased K (<3.5) ABG: Metabolic alkalosis (pH > 7.45) Electrolyte imbalance: Priority assessment for hypokalemia - ansAssessing for a patent and open airway Blood and blood product transfusions: Administering Fresh Frozen Plasma - ansInitiate a large bore IV access: 20 gauge needle Complete transfusion withing 2-4 hours time frame If reaction occurs: -Stop transfusion immediately - Initiate 0.9% NaCl in a separate line - Save blood bag and blood tubing