Virtual ATI Med-Surg Set
A nurse is administering packed red blood cells to a client. What should the nurse do if a transfusion reaction is suspected? - correct answer Stop the infusion.
A nurse is caring for a client with skeletal traction following a fracture. How and when should skeletal pin care be provided? - correct answer One cotton swab with chlorhexidine is designated for each pin for pin care to be done once a shift.
A nurse is providing dietary teaching to a client newly diagnosed with constipation-predominant
irritable bowel syndrome. List two (2) teaching points the should share with the client about dietary practices. - correct answer Eat foods high in fiber
Increase fluids
Late Cushing's Triad manifestation - correct answer Severe hypertension with widening of pulse pressure and bradycardia
Identifying Basal cell cancer - correct answer small, waxy nodule with superficial blood vessels, well-defined borders
Teaching post Bronchoscopy - correct answer assess LOC, cough and gag reflex, and ability to swallow before consuming oral intake
Teaching how to prevent transmission of HIV - correct answer take antiretroviral medications to inhibit DNA synthesis and Viral replication
ABGs
Determine imbalance - correct answer Blood compatibility: Nursing Actions for Hemolytic transfusion reaction - correct answer Remove the blood tubing from the IV access site. Initiate an infusion of 0.9% of sodium chloride using new tubing. Monitor VS and fluid status. Send the blood bag and administrating set to the lab for testing.
Priority intervention for Complication of Central Venous Catheter - correct answer 1) look for safety risk; what is the risk for patient and how significant is the risk? 2)
Teaching about levothyroxine (overdose manifestations) - correct answer overmedication can result thyrotoxicosis (anxiety, tachycardia, heat intolerance, fever, diaphoresis, weight loss, palpatations, chest pain, abd pain, nervousness, tremors
Care of a perpherially inserted central catheter infusion system - correct answer access site for redness, swelling, drainage, tenderness, and condition of the dressing.
Evaluating effectiveness of fluid replacement - correct answer hematocrit, increase hypovolemia
Caring for pt with peritoneal dialysis: - correct answer monitor for signs of infection (bloody, cloudy or frothy dialysate return, monitor for complications: respiratory distress, abd pain, insufficient flow, and discolored outflow
Identifying reaction to radiation therapy - correct answer skin blanching, erthyma, sloughing, desquamous, hemorrhage
Priority action following surgical repair of abdominal aortic aneurysm - correct answer Look for risk, monitor incision site, report infection
Manifestations of diverticular Disease - correct answer acute onset of abdominal pain often in left lower quadrant
A nurse is administering packed red blood cells to a client. What should the nurse do if a transfusion reaction is suspected? - correct answer Stop the infusion.
A nurse is caring for a client with skeletal traction following a fracture. How and when should skeletal pin care be provided? - correct answer One cotton swab with chlorhexidine is designated for each pin for pin care to be done once a shift.
A nurse is providing dietary teaching to a client newly diagnosed with constipation-predominant
irritable bowel syndrome. List two (2) teaching points the should share with the client about dietary practices. - correct answer Eat foods high in fiber
Increase fluids
Late Cushing's Triad manifestation - correct answer Severe hypertension with widening of pulse pressure and bradycardia
Identifying Basal cell cancer - correct answer small, waxy nodule with superficial blood vessels, well-defined borders
Teaching post Bronchoscopy - correct answer assess LOC, cough and gag reflex, and ability to swallow before consuming oral intake
Teaching how to prevent transmission of HIV - correct answer take antiretroviral medications to inhibit DNA synthesis and Viral replication
ABGs
Determine imbalance - correct answer Blood compatibility: Nursing Actions for Hemolytic transfusion reaction - correct answer Remove the blood tubing from the IV access site. Initiate an infusion of 0.9% of sodium chloride using new tubing. Monitor VS and fluid status. Send the blood bag and administrating set to the lab for testing.
Priority intervention for Complication of Central Venous Catheter - correct answer 1) look for safety risk; what is the risk for patient and how significant is the risk? 2)
Teaching about levothyroxine (overdose manifestations) - correct answer overmedication can result thyrotoxicosis (anxiety, tachycardia, heat intolerance, fever, diaphoresis, weight loss, palpatations, chest pain, abd pain, nervousness, tremors
Care of a perpherially inserted central catheter infusion system - correct answer access site for redness, swelling, drainage, tenderness, and condition of the dressing.
Evaluating effectiveness of fluid replacement - correct answer hematocrit, increase hypovolemia
Caring for pt with peritoneal dialysis: - correct answer monitor for signs of infection (bloody, cloudy or frothy dialysate return, monitor for complications: respiratory distress, abd pain, insufficient flow, and discolored outflow
Identifying reaction to radiation therapy - correct answer skin blanching, erthyma, sloughing, desquamous, hemorrhage
Priority action following surgical repair of abdominal aortic aneurysm - correct answer Look for risk, monitor incision site, report infection
Manifestations of diverticular Disease - correct answer acute onset of abdominal pain often in left lower quadrant
