Med Surg ATI review form A Basic Care and Comfort (5) Prostate Surgeries: Intervention for Complication of Continuous Bladder Irrigation- The irrigation should be a pink or lighter. If it is bright red (arterial) bleeding clots are observed and the nurse should increase the CBI rate. If the catheter becomes obstructed (bladder spasms, reduced irrigation outflow) the nurse should turn off the CBI and irrigate with 50ml of solution and contact the primary care provider if the clot is not dislodged. Q: If a pt is in complaining of pain and there is no irrigation fluid coming out of the catheter what the priority nursing action be? I put the answer on the first test as being to reduce the flow rate and the second test as administer an antispasmodic med and got it wrong both times….so by process of elimination I think the answer is to irrigate the catheter with saline solution (if the catheter is clotted) Q: If the pt has had their prostate removed and the irrigating 3 way catheter shows bright red clotted blood being released from the end what should you do? To increase the flow rate (this bleeding is an expected outcome) Immobilizing Interventions: Assessing for Complications- Acute compartment syndrome is a buildup of pressure within muscle that can cause circulatory obstructions that can cause ischemia or necrosis. Initial alterations are paresthesias, pallow, and diminshed pulses and the primary care provider should be notified. Interventions include relieving the pressure by loosening constricting dressings. Another complication is Osteomyelitis which is inflammation within the bone secondary to penetration of organisms. Characterisitcs are bone pain that worsens with movement. Initial symptoms are erythema, edema and fever. Q: what assessment finding would be a cause for concern in an immobile pt? Diminished pulses in the feet, redness and edema in the legs (understand symptoms) Pressure Ulcers: Appropriate Interventions for for a Stage III Ulcer- It is a deep crater and may have a foul smelling drainage, also yellow slough or necrotic tissue in wound bed. Clean and debride: wet to dry dressing, surgical interventions and proteolytic enzymes. Provide nutritional supplements, administer analgesics and administer antimicrobials (topical or systemic). Q: how would you care for a pt with a stage III pressure ulcer? Apply proteolytic enzymes Q: which of the following would be an appropriate nursing intervention for a stage II pressure ulcer in the heals? Increase IV fluids (pg 1049) Cholescystitis: Dietary Teaching to Prevent Acute Episodes- low fat diet (reduced dairy, avoid fried foods, chocolate and nuts). Promote weight reduction. Fat-soluble vitamins and bile salts can be prescribed to enhance absorption and aid in digesiton. Avoid gas forming foods (beans, cabbage, cauliflower and broccoli). Small more frequent meals are tolerated better. Q: what foods would you teach a pt suffering from cholescystitis to eliminate from their diet at home? Fried eggs Fluid Imbalances: Assessment Findings- Hypovolemia: increased Hgb and Hct. Dehydration can be increased. Dehydration can also cause increased protein, blood urea nitrogen (BUN), electrolytes and glucose. Urine specific gravity is increased with dehydration. Serum sodium is increased with dehyrdation. Vital signs: hyperthermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure. Neuromuscular: dizziness, syncope, confusion, weakness and fatigue. GI: thirst, nause/vomiting, anorexia. Renal: oliguria. Other signs: diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins. Q: what assessment finding would lead you to believe a pt suffers from Hypovolemia? Increased blood osmolarity Pharmacological and Parenteral Therapies (16) Cancer: Side Effects of Chemotherapy- Most significant adverse effect is immunosuppression (bone marrow suppression). Nausea, vomiting, alopceia, mucositis are common side effects. Oral inflammation and inflammation of the mucous membrane. Q: What would you expect from a client receiving chemotherapy? Decreased WBC Hypertension: Client Teaching Regarding ACE Inhibitors- Teach to change positions slowly because of orthostatic hypotension. Monitor signs for heart failure such as edema. Also report a cough. Hypotension is a common side effect. Q: Which of the following would lead you to believe that a client understands his teachings about using his ACE inhibitors? I put that they should use salt substitutes and I got it wrong, my guess is the answer is to decrease K and Na intake. Pain Management: Client Teaching Regarding Opioid Use- Client is the only person who should push the PCA for administration of opioids. An occlusive sterile dressing should be maintained over the catheter site for an epidural analgesic. Oral route is the preferred route for opioid administration. Q: what would you include in your education of a client receiving opioids? Increase you fiber intake (because of the constipation it causes) Pain Management: Recognizing Adverse Effects- Constipation: preventative measures- monitor BM's, fiber intake, excercise, stool softeners, stimulant laxatives and enemas. Urinary retention: monitor intake and output, assess for distention, and catheterize. Nause/vomiting: administer antiemetics such as compazine, reglan, zorfran. lie still and or move slwoly during first hours after initiation. Sedation: monitor LOC and take safety precautions. Respiratory depression: monitor respiratory rate prior to and following administration. Initial treatment is a reducation in opioid dose. If necessary slowly administer diluted naloxone to reverse opioid effects. Pruritus: can be treated with a small dose of naloxone (narcan). Q: what nursing interventions would you implement to address adverse effects of opiods? Laxatives and enemas Blood Transfusions: Managing Reaction- Acute hemolytic reaction is immediate and includes chills, fever, lower back pain, tachycardia, flushing, hypotension, chest tightening, tachypnea, nausea, anxiety. Febrile reaction is 30 min to 60 min and include chills, fever, flushing, headache and anxiety and should use a white blood cell filter administer antipyretics. Mild allergic reaction is during or up to 24 hours and include itching, urticaria, flushing and should administer antihistamines such as diphenhydramine (benadryl). Anaphylactic reaction is immediate and include wheezing, dyspnea, chest tightness, cyanosis, hypotension and should maintain airway and administer oxygen and iv fluids and antihistamines and corticosteriods and vasopressors. Stop the infusion immediately and initiate a saline infusion and be put on a separate line. Also save the blood bag with the remaining blood and the tubing for testing. Circulatory overload signs would be chest tightness, dyspnea, tachycardia,tachypnea, headache, hypertension, jugular vein distention, peripheral edema, orthopnea, sudden anxiety and crackles in base of lungs and should administer oxygen and monitor vitals and also slow the infusion rate and administer a diuretic and notify primary care provider. Sepsis and Septic Shock include fever, nausea, vomiting, abdominal pain, chills and hypotension and should maitain airway and administer oxygen, administer antibiotic therapy, obtain blood cultures, administer vasopressors such as dopamine and elevate clients feet. Q: which symptoms indicate adverse effects from the blood transfusion? I put lower back pain and chills and got it wrong (Understand Immediate reaction symptoms) Blood Transfusions: Priority Nursing Intervention- Assess lab values such as hgb and hct, verify order with doctor, obtain blood samples for compatibility, inititate large bore IV access, assess history of blood transfusion reactions, inspect blood bag for bubbles, cloudiness or discoloration, confirm identity, blood compatibility, expiration time with another nurse, prime the blood administration set with normal saline, obtain vital signs, begin trasnfusion. Remain with client for the first 15 minutes of transfusion (reactions are most likely to occur at this time), take vital signs, rate of infusion, respiratory status, monitor anxiety, breath sounds, neck vein distention. Notify provider if any reaction signs occur. Complete transfusion within 2-4 hours to avoid bacterial growth. After transfusion take vital signs again and dispose of blood administration set appropriately (biohazard bags). Monitor lab values: cbc hgb and hct. hgb levels should rise 1g/dl with each unit transfused. Q: what would be your first intervention for a pt who has an adverse effect from a blood transfusion? Initiate saline infusion (separate line) Vascular Access: Accessing Implanted Port- Used for long term access such as a year or more. Surgically implanted into subclavian vein with the tip in the superior vena cava. To access apply local anesthetic to skin if indicated. Palpate the skin to locate the port body septum to ensure proper insertion of the needle. Clean the skin with alcohol for atleast 3 seconds and allow to dry. Access with noncoring needle (Huber). Flush after every use and atleast once a month. Follow facility protocol to flush when deceasing port (flush with 10ml of normal saline followed by 5 ml of 100 units/ml of heparin. Q: what type of needle would you use to access an implanted port? A noncoring needle Vascular Access: Verifying Tip Placement of PICC Line- Can be used up to 12 months. Inserted into basilic or cephalic bein at lease one fingers breadth below or above the antecubital fossa and the tip is positioned int the lower one-third of the superior vena cava. An inital xray should be taken to ensure placement. Q: how would you confirm placement of a picc line? A chest x-ray Diabetes Management: Determining Medication Adherence- 584 Q: what lab values indicate a diabetic client isn’t compliant with his medication? A1c is at 8% (should be <7%) Diabetes Insipidus: Client Teaching Regarding Vasopressin- (Pitressin)its life long therapy, daily weights, importance of reporting weight gain, polyuria and polydipsia to the care provider. Can cause vasoconstriction so use with caution with people who have coronary artery disease. Q: what would you include in your education to a client receiving vasopressin? To expect less urine output Heart Failure: Signs of Digoxin Toxicity- aka Lanoxin. Signs of toxicity are fatigue, muscle weakness, confusion and loss of appetite. Have potassium and digoxin levels checked regularly. If potassium is too low the digoxin will bind to the receptors that it usually competes with potassium for and will cause digoxin toxicity. Q: what signs would you exhibit in a pt that would lead you to believe digoxin toxicity? Muscle fatigue and confusion Heart Failure: Evaluating Client Understanding of Digoxin Administration- Count pulse a full minute before administering If it is irregular or is less than 60 beats per minute or more than 100 beats per minute medication should be withheld. Take is at the same time each day. Do not take digoxin at the same time as antacids separate by 2 hours. Q: which of the following indicates client understanding? I will not take my antacids at the same time as digoxin med Heart Failure: Understanding Implications of NSAID Therapy- 331, 335 Osteoarthritis: Initiation of Medication Treatment- Acetaminophen, NSAIDS, Topical salicylates, Glucosamine (rebuilds cartilage), Intra-articular injections of glucocorticoids (treat localized inflammation). Instruct client on the use of analgesics and NSAIDS prior to activity and around the clock as needed. If all other therapies fail client can undergo joint replacement surgery to relieve pain and improve mobility. Total Parenteral Nutrition: Calculating Components- Initiated with a weight loss of 7% of body weight and NPO for 5-7 days. Gradually increase the rate during initiation and then ween off. Standard IV therapy is < or equal to 700 calories a day. 5 day rule (has not eaten for 5 days and is not expected to eat within the next 5 days). Also a hypermetabolic state. Formula: Be able to calculate lbs to kg/ml (remember 2.2 lbs per kg) Total Parenteral Nutrition: Monitoring for Fluid Overload- Monitor the lungs for crackles and other evidence of respiratory distress, daily weights and intake/output, use a controlled infusion pump to administer TPN, Do not speed up the infusion to catch up, gradually increase the flow rate until the prescribed infusion rate is achieved. Q: which assessment finding indicates fluid overload? Crackles in the lungs upon auscultation (indicates fluid in lungs) Physiological Adaptation (38) Heart Failure: Client Teaching for Home Management- If experiencing respiratory distress place the client in high fowlers position and give oxygen. Encourage bed rest until the client is stable, encourage energy conservation by assisting with care and ADL's, restrict fluid intake/restrict sodium intake, Take medications as prescribed, Take diuretics early in the morning and early afternoon, increase intake of potassium (cantaloupe and bananas), daily weights and notify the care provider for weight gain of 2lbs in 24 hours or 5 lbs in a week, schedule regular follow ups with the doctor and get vaccinations. Q: what would you educated your pt with HF? Increase intake of K Monitoring Intracranial Pressure: Signs and Symptoms- severe headache, deteriorating LOC, restlessness, irritability, dilated or pinpoint pupils, slow to react or nonreactive, alterations in breathing patterns (Cheyne-strokes respirations, apnea), deterioration in motor function, abnormal posturing, cushings reflex is a late sign characterized by severe hypertension with widening pulse pressure, bradycardia. Normal ICP is 10-15 mmhg. Q: which assessment finding indicates an increase in ICP? Decreased level of consciousness Make sure not to put constricted pupils as answer as I almost did Ostomies: Recognizing Complications- Stoma should appear pink/red and moist. Monitor hgb, hct, potassium, sodium, chloride, BUN and creatinine. Notify provider for abnormal or unexpected findings. Empty bag when its 1/4 or 1/2 way full. Signs of stomal ischemia are pale pink or bluish/purple in color and a dry appearance, this requires immediate attention and the nurse should obtain vital signs, pulse ox, and current lab results. Surgeon or provider should be notified immediately because the client may require additional surgical intervention. Also monitor for intestinal obstruction. Monitor the output from the stoma, also assess the client for symptoms such as abdominal pain, hypoactive or absent bowel sounds, distention, nausea and vomiting if present the nurse should notify the surgeon. Q: which assessment findings would you expect in a pt who is 24hr post op receiving an ostomy? The stoma is bright red, smooth and moist (turns pink after 2-3 weeks) Prostate Surgeries: Managing Bladder Irrigation- Already stated. Seizures: Intervene to Prevent Aspiration- Protect from injury, maintain patent airway, prepare to suction, turn the client on the side to decrease risk of aspiration, loosen clothing, do not restrain the client, do not open the jaw, do not use padded tongue blades. Q: you find a pt seizing on the floor what is your first nursing intervention to prevent aspiration? Open pt’s mouth and maintain airway (remember ABCs) Q: How do you prevent a pt who is post seizure from aspirating? Turn client on their side (recovery position) and prepare to suction Suctioning: Appropriate Oropharyngeal Procedure- Encourage client to deep breathe and cough in attempt to clear the secretions, if they remain continue with procedure, place hte client in semi or high fowlers position, oropharyngeal suctioning is often performed using a Yankauer or tonsil- tipped rigid suction catheter, insert the catheter into the clients mouth, apply suction and move the catheter around the mouth-gumline and pharynx, monitor clients SaO2 level, clear the catheter and tubing, repeat as needed. Allow client to perform own suction if possible. Q: select all that apply Encourage pt to deep breathe and cough prior, monitor O2 stats, store catheter in clean dry place for reuse, perform care 3 times a day (every 8 hrs.) Tracheostomy: Providing Appropriate Care- Provide care every 8 hours. Suction trach tube if necessary using sterile-suctioning technique, remove old dressings and excess secretions, apply oxygen source loosely if the client desaturates during the procedure, use cotton tipped applicatorsand gauze pads to clearn exposed outer cannula surfaces. Use hydrogen peroxide followed by normal saline. Clearn in circular motion from stoma site outward. Using surgical aseptic technique remove and clean the inner cannula, use hydrogen peroxide to clearn the cannula and the sterile saline to rinse it. Replace the inner cannula if it is disposable. Clearn the stoma site and then the trach plate with hydrogen peroxide followed by sterile saline. Place split 4x4 dressings around trach. Change trach ties if they are soiled. Secure new ties in place before removing soild ones to prevent accidental decannulation. 1-2 fingers should be able to be placed between the ties and the neck. Change non-disposable trach tubes every 6-8 weeks. Reposition client every 2 hours to prevent atelectstasis and pneumonia. Provide oral hygiene every 2 hours to maintain mucosal integrity. Q: which of the following is an appropriate nursing intervention? Remove and replace ties with dry, crusted secretions Wound Management: Promoting Healing- Healing occurs rapidly if tissue is hydrated, oxygenated and contains few organisms, Nutrition provides elements required for wound healing, also meet protein and calorie needs. Encourage intake of 2,000-3,000 ml of water per day. Provide education of high protein foods such as meet, fish, poultry, eggs, dairy products, beans, nuts and whole grains. Q: how would you promote healing in an elderly client? Increase fluid intake Electrolyte Imbalances: Evaluation of Potassium Chloride Therapy- Serum potassium is <3.5, have metabolic alkalosis ph >7.45 and or dysrhythmias. Encourage foods high in potassium (avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas), IV potassium: Never do IV push, maximum rate is 5-10 meq/hr. Monitor phlebitis, respiratory rate, breath sounds and cardiac rhythm. Q: which of the following is an expected outcome of a pt receiving KCL? Doesn’t experience any dysrithmias (means what was low K is now at a therapeutic level) Electrolyte Imbalances: Sodium Imbalance- Hyponatremia is less than 135, net gain of water or loss of sodium, water moves from ECF into the ICF which causes cells to swell, Risk factors are vomiting, ng suctioning, diarrhea and tap water enemas, diuretics, kidney disease, adrenal insufficiency, burns, wound drainage, gi obstruction, peripheral edema, ascites. Signs are hypothermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, headache, confusion, lethargy, muscle weakness, respiratory compromise due to muscle weakness, fatigue, decreased deep muscle reflexes, hyperactive bowel sounds, abdominal cramping and nausea. Treatment is administer hypertonic oral and IV fluids, encourage cheese, milk and condiments. Complications are seizures and respiratory arrest. Hypernatremia is greater than 145. Is a shift of water out of the cells making the cells dehydrated. Risk factors- water deprivation, NPO, excessive sodium intake, hypertonic IV fluids, renal failure, cushings syndrome, fever, diaphoresis, respiratory infection, diabetes insipidus, hyperflycemia. Signs- hyperthermia, tachycardia, orthostatic hypotension, restlessness, irratibility, muscle twitching, increased deep muscle reflexes, seizures, coma, thirst, dry mucous membranes, hyperactive bowel sounds, abdominal cramping, nausea, edema, warm flushed skin, oliguria. Administer hypotonic IV fluids (0.45% sodium chloride), Administer Isotonic IV fluids (0.9% sodium chloride). Encourage water intake, administer diurectics. Q: which of the following is an indication of a pt at risk of developing a sodium imbalance? vomiting, diarrhea, enemas and diuretics Fluid Imbalances: Evaluating Fluid Replacement Therapy- Hypovolemia- increased hgb and hct, increased urine specific gravity, increased serum sodium. Place the client in shock position (on back with legs elevated). Administer oral and IV fluids such as Ringers Lactate or blood transfusions as ordered. Monitor intake and output, alert care provider to urine output less than 0.5 ml/kg/hr for 2 consecutive hours. Encourage to change positions slowly. Q: which of the following lab values indicates a pt suffers from hypovolemia? I put increased hgb and hct and got it wrong, I think the right answer is something to do with the amount of urine being excreted. Dysrhythmias: Recognizing Abnormal Findings- Perform CPR for asystole or pulseless rhythms. Pulmonary Embolism- dyspnea, chest pain, air hunger, decreasing SaO2. Stroke/CVA- decreased LOC slurred speech, muscle weakness/paralysis. MI- chest pain, ST segment depression or elevation. Monitor for decreased cardiac output and HF such as hypotension, syncope, increased heart rate, dyspnea, productive cough, edema, venous distention. Q: which of the following is an expected finding? I put no inverted t waves and got it wrong, I think the answer might have been U waves, I didn’t know what that was, look it up Hemodialysis: Monitoring an AV Graft- Presence of bruit, palpable thrill, distal pulses and circulation. Assess site for bleeding or infection. Elevate the extremity following surgical development of an AV fistula to reduce swelling. Q: what’s an complication from an av graft? Weak pulses in the leg or feet (capillary filling in the toe 6) Hemodynamic Monitoring: Assessing Arterial Line- Place in radial (most common), brachial or femoral artery. Monitor circulation in the limb with the aterial line such as capillary refill, temp and color. Monitor for infection. Place client in supine or trendelenburg position for insertion. Obtain xray to assess placement. Monitor and secure connections between pressure tubing, transducers and catheter ports. Hemodynamic Monitoring: Client Positioning in Response to Complication- Trendelenberg/supine for insertion. Supine for obtaining readings. Monitor circulation: capillary refill, temp, color COPD: Managing Shortness of Breath- Practice breathing techniques such as Diaphragmatic or abdominal breathing and pursed lip breathing. Position in high fowlers. Encourage use of incentive spirometer. Structure activities to have rest periods. Q: what would you teach a pt suffering from COPD? Do pursed lip breathing Diabetes Management: Client Education Regarding Exercise Guidelines- Restrict exercise when blood glucose levels are >250mg/dl. Exercise 10,000 steps/day. Q: what would you teach a pt about exercise when they suffer from diabetes? They should eat a snack during unexpected activity Diabetes Management: Client Education Regarding Oral Hypoglycemic Agents- Administer as prescribed such as 30 minutes before first main meal for most oral blood glucose lowering agents or with the first bite of each main meal for alpha-glucosidase inhibitors. Avoid alcohol with sulfonylurea agents. Monitor renal function, liver function. Taken by Type II diabetics. Infections: Evaluation of Treatment- Q: which pt is most at risk of developing an infection? Low WBC (know norm levels 5,000-10,000 in older adult 3,000-9,000) Postoperative Nursing: Assessing Drainage- Should progress from sanguineous (blood) to serosanguineous to serous (water look). Site should have pink wound edges, slight swelling under sutures/staples, slight crusting of drainage. Report redness, excessive tenderness and purulent drainage. Report increases in drainage (possible hemorrhage). Q: what would be an expected finding? Tracheostomy: Evaluating Client Education- Stated earlier. Also if patient is permitted to eat place patient in upright position and tip the clients chin to chest to enable swallowing. Q: which of the following statements indicated a need for further teaching? I will put water down my opening 3 times a day. AIDS: Managing Opportunistic Infections- Monitor for skin breakdown, maintain fluid intake, maintain nutrtion, teach client to report signs of infection immediately, practice safe sex, maintain well balanced diet. Fungal infections- candida albicans: red bleeding gums, Bacterial infections- mycobacterium avium: high fever, fatigue, anorexia, weight loss, abdominal pain, diarrhea, chest discomfort. Protozoan infections- Pneumocystis carinii: pneumonia, dyspnea, cough, fever, headache, blurred vision, crackles, cyanosis. Viral infections- cytomegalovirus: lung inflammation, colitis, blindness. Herpes Simplex Virus: painful vascular lesions, seizures, blindness, deafness. Q: what is a primary intervention in preventing infections in a pt with aids? I put wearing gloves and got it wrong Infections: Recognizing Communicable Diseases- 998? Q: which of the following diseases would you apply airborne precautions? Measles Infections: Respiratory Secretions- This is a way of leaving the host via respiratory tract. Droplet or airborne. Such as Myobacterium Tuberculosis and Streptococcus pneumoniae. Droplet- Sneezing, coughing or talking. Airborne- Sneezing, coughing. Q: what interventions would you apply for droplet precautions? Wear hospital gown and protective gear (gloves) Tuberculosis: Client Teaching Regarding Medication Therapy- Isoniazid (INH) should be taken on an empty stomach; monitor for hepatitis and neurtoxicity. Vitamin B6 (pyridoxine) is used to prevent toxicity. Rifampin: inform the client that urine and other secretions will be orange. To decrease drug resistance combine rifampin and isoniazed. Continue for its full duration of atleast 6 months. Follow up care for one full year. Sputum samples are needed every 2-4 weeks to monitor therapy effectiveness. 3 negative sputum cultures the patient is no longer considered infectious and is better to take the first morning specimen because its more accurate. Tuberculosis: Plan Care to Prevent Transmission- Wear an N95 or HEPA respirator when caring for client. Place client in a negative airflow room and implement airborne precautions. Where barrier protection when the risk of hand or clothing contamination exists. Have patient wear a mask when transporting to another department. Q: a pt has a positive TB skin test what would your first action be? Place a mask on either the pt or yourself Q: what precautions would you take with a person diagnosed with TB Place client in neg airflow room, wear mask when taking care of pt (pt only has to wear mask when being moved outside the room) Aneurysms: Signs and Symptoms of Aortic Dissection- can occur when blood accumulates within the aortic wall (hematoma) following a tear in the lining of the aorta. Clients are asymptomatic initially. Most significant risk factor is uncontrolled hypertension. Sudden onset of tearing, ripping, stabbing abdominal or back pain, hypovolemic shock: diaphoresis, nausea, vomiting, faintness, decreased or absent peripheral pulses, neurological effects, hypotension and tachycardia (intial). Q: what complaint of symptoms would lead you to believe they suffered an aneurysm? CPR: Prioritizing Interventions- AIRWAY- establish an airway, provide hemlich maneuver if theres a foreign object and use abdominal thrusts for unconscious clients, Breathing- provide artifical respirations to deliver oxygen, Circulation- check for a pulse and then provide chest compressions to deliver oxygen to the brain. Emergency Nursing Principles: Priority Intervention Following Trauma- Airway Breathing Circulation Disability Exposure (ABCDE). Airway- Unresponsive without suspicion of trauma; open airway with head tilt. Unresponsive with suspcion of trauma; head til to open airway and inspect for broken teeth, vomit, secretions if these are present do the finger sweep method or suction. Breathing- auscultate breath sounds, observe for chest expansion, note rate and rhythm, if not breathing on own manual ventilation such as bag-valve mask can be obtained. Circulation- assess heart rate, bp and perfusion. Hemorrhage control put pressure on visible bleeding, obtain IV access with large-bore needle and use lactated ringers or 0.9% normal intervention of stop listening saline. Shock will be increased heart rate and hypotension. Alleviate shock by giving oxygen, apply pressure to bleeding, elevate clients feet to shut blood to vital organs. Disability- assess neurological status by using AVPU: Alert, Response to voice, Response to pain, unresponsive. or use Glasgow Coma scale for eye opening, verbal response and motor response. Exposure- remove all clothing for a complete physical assessment. Prevent hypothermia by removing wet clothing, cover client with blankets, increase temperature in the room, infuse warm fluids as ordered. Wound Evisceration: Appropriate Response- Call for help, stay with client, apply a sterile dressing nonadherent or a saline soaked gauze dressing to the wound. DO NOT reinsert the organ. Place the client in supine position with hips and knees bent and observe the client for signs of shock. Burns: Expected Laboratory Values- Evaluate CBC, serum electrolytes, BUN, ABG's, fasting blood glucose, liver enzymes, urinanalysis, and clotting studies. Initial fluid shift within first 24 hours: hgb and hct are elevated, sodium is decreased, potassium is increased. Fluid mobilization (48-72 hours after injury) hgb and hct are decreased, sodium is decreased, potassium is decreased. WBC initially is an increase then decrease. Glucose is elevated. ABG's show slight hypoxemia and metabolic acidosis. Total protein and albumin are lowered. Q: if a pt suffered 18% burns what lab values would you expect to increase post 24hrs? I put the hgb and hct and got it wrong, it was something about how this question was worded, know these values back and forth. Renal Failure: Pathophysiology Related to Metabolic Acidosis- Metabolic Acidosis is a complication of renal failure and should prepare client for hemodialysis. Q: which pt is suffering from metabolic acidosis? Know ph and co2 levels Cancer: Internal Radiation- Place client in a private room and bath. Put a sign on the door. Healthcare workers should wear a dosimeter film badge that records amount of radiation exposure. Visitors are limited to 30 minutes and maintain a distance of 6 feet. Visitors and Healthcare personnel who are pregnant or under the age of 16 should not come in contact with the patient. A lead container should be kept in the clients room if the delivery method could allow spontaneous loss of radioactive material. Side Effects are skin changes, hair loss and debilitating fatigue. Cancer: Teaching Regarding Radiation Therapy- Everything listed above. External radiation therapy: wash skin over irradiated area gently, with mild soap and water and dry thoroughly using patting motions. Do not remove radiation "Tatoos" that are used to guide therapy. Do not apply powders, ointments, lotions or perfumes to irradiated skin. Wear soft clothing over irradiated skin and avoid tight or constricting clothing. Do not expose irradiated skin to sun or a heat source. Q: which of the following statements indicates client understanding? “I will wash the area gently with soap and water” Acid-Base Imbalance: Prioritizing Postoperative Interventions to Treat Respiratory Acidosis- Oxygen therapy, maintain patent airway, enhance gas exchange (positioning and breathing techniques, ventilatory support, bronchodilators, mucolytics). Hypoventilate. ABCs Leukemia: Planning Care in Response to Pancytopenia- Neutropenia- secondary to disease greatly increases risk for infection. Nurse must maintain a hygienic environment and encourage the client to do the same. Constantly monitor for cought or alteration in breath sounds or urine and feces. Report temperature that is greater than 100 degrees F. Administer antimicrobial, antiviral, and antifungal medications. An absolute neutrophil count (ANC) less than 2,000 suggests and increase risk for infection. Less than 500 is a severe risk for infection. Thrombocytopenia- greatly increases risk for bleeding. Obtain safe environment. Greatest risk if platelet count is less than 50,000 and spontaneous bleeding may occur at less than 20,000. Anemia- greatly increases risk for hypoxemia. Obtain a relaxing environment to decrease energy use. Monitor RBC count. Provide a diet high in protein and carbs. Administer Epoetin alfa. Pancytopenia: decreased RBC, WBC, and platelets Metabolic Alkalosis: Identifying Clients at Risk- Oral ingestion of antacids, Blood transfusions, TPN, Loss of gastric secretions such as prolonged vomiting or NG suction, Potassium depletion due to thiazide diuretics, laxatives or Cushings Syndrome. Q: which of the following pts is at risk for developing metabolic alkalosis? Vomiting, ng suctioning, laxatives Vascular Access: Extravasation (move into surrounding tissue) of Vesicant Solution(causes tissue damage)- This is known as infiltration. It is caused by improper IV insertion, Improper vein selection (too small, too fragile, poor location), improper taping that allows IV catheter movement and vein compromise, tape too tight. Signs and symptoms: Swelling, edema, blanching of the skin, sensation of coolness, the rate may slow and the IV will set the alarm, leading at the site from tube connections. Preventative measures: do not sue MLC or PICC in teh arms for blood pressure readings, Do not use hand veins in older adults, Do not use hand veins for vesicant medications. Treatment: Remove with direct pressure with gauze sponge until bleeding stops, Use a cool compress, elevate, avoid starting a new IV site in the same extremity. Q: which of the following pt complaints would lead you to suspect extravasation? I put edema and redness and got it wrong, my guess it was pt complaint of pain (or it could be edema or coolness) Reduction of Risk Potential (28) Bacterial Infections: Appropriate Intervention for Suspected Septicemia- Obtain a blood culture for diagnosis. Mechanical ventilation and dialysis may be needed for treatment. Systemic antimicrobials will be prescribed accordingly. Encourage increaed fluid intake, use consistent hand washing, implement protective precautions Dysrhythmias: Analyzing an ECG Strip- Q: what would be an appropriate finding? Absent inverted T waves Thoracentesis: Prioritizing Postprocedure Interventions- Apply a dressing over the puncture site and position the client on the unaffected side for atleast an hour, monitor the clients vitals and respiratory status hourly for the first several hours, encourage deep breathing to assist with lung expansion, normal activity can be resumed after an hour if no signs of complications are present. Obtain a post procedure chest xray to rule out a pneumothorax, provide client teaching and instruct the client to report dyspnea, cought, and hemoptysis to the primary care provider. Q: what would be your primary intervention for a pt following a thoracentesis? I put encourage deep breathing exercises and got it wrong, I believe the answer is apply dressing over the puncture site Tuberculosis: Interpreting a Mantoux Skin Test- Induration of 10mm or greater indicates a positive skin test. Induration of 5mm is considered positive test for immunocompromised clients. Is read in 48-72 hours. It does not confirm the active disease it only indicates either exposure to TB or presence of inactive disease. Need a chest xray to evaluate the presence of active TB infection. Q: A pt comes to the hospital with a TB induration of 10mm what would be your following nursing action? I put need a chest x-ray and got it wrong, I believe the answer is you need 3 negative sputum readings Acid-Base Imbalances: Interpreting ABG's- Reports the status of oxygenation and acid-base balances of the blood. Measures pH 7.35-7.45, PaO2 80-100, PaCO2 35-45, HCO3 22-26, SaO2 95-100%. Respiratory Acidosis- <7.35 pH, >45 PaCO2, 22-26 HCO3 Respiratory Alkalosis- >7.45 pH, <35 PaC02, 22-26 HCO3 Metabolic Acidosis- <7.35 pH, 35-45 PaCO2, <22 HCO3 Metabolic Alkalosis- >7.45, 35-45 PaCO2, >26 HCO3 Be able to identify what is normal, will ask you to pick which level is indicative of condition Hemodialysis: Interpreting Laboratory Values- Assess BUN, creatinine, electrolytes and hematocrit. These levels will decrease following dialysis as well as blood pressure and weight. Q: which of the following is an expected lab value for a pt following hemodialysis? Know these norm levels so you can identify which is low Preoperative Nursing: Interpreting Laboratory Values- Know Potassium, Sodium, Creatinine, Prothrombin time, Glucose level, WBC count Q: which lab value would cause nurse to notify physician that pt isn’t ready for surgery? too high of INR (know INR should be 2-3) Conscious Sedation: Education of the Family- Will be able to respond to verbal stimuli, retains protective reflexes and is easily arousable. The registered nurse is with the client the entire time they under sedation. The only thing they are to do is take vitals continuously. Q: what would you tell a pt’s family to expect? (to drive the patient home) pain and full stop listening Conscious Sedation: Recognizing Complications- Airway obstruction-insert airway, suction. Respiratory depression- administer oxygen and reversal agents such as naloxone. Cardiac arrhythmias- setup 12lead ECG, provide antidysrhythmics and fluid. Hypotension-provide fluids, vasopressors. Anaphylaxis- administer epinephrine. Diabetes Management: Evaluating Client Teaching Regarding Foot Care- Inspect the feet daily, Wash feet daily with mild soap and warm water, pat feet dry gently and especially between the toes, use mild foot powder (powder with cornstarch) on sweaty feet, do not use commercial remedies to remove calluses or corns, Cut toenails even with rounded contour of toes, Do not cut down corners, seperate overlapping toes with cotton or lambs wool, avoid open toe, open heel shoes, leather shoes are preferred over plastic ones, wear slippers with soles, do not go barefoot, wear clean absorbent cotton or wool socks or stockings, do not use hot water bottles or heating pads to warm feet, avoid prolonged sitting or standing or crossing of legs. Q: which of the following indicates understanding of teaching? “I will wear cotton socks” Gastroenteral Feedings: Priority Complication- Q: what is coming out of the ng tube that would cause concern/notify physician? Red secretions (Know green, brown and clear are ok) Q: if pt just received an ng tube what is your next priority action? Receive a chest x-ray (to check placement) Intestinal Obstruction: Findings to Report- Q: what assessments would cause you to think pt suffers from an obstruction? Abdomen hard and distended Pressure Ulcers: Risk Assessment- inadequate nutrtion, anemia, fever, impaired circulation, edema, sensory deficits, low diastolic blood pressure, im paired cognitive functioning, neurological disorders, chronic disease like DM, CRF, CHF and chronic lung disease, and sedation that impairs spontaneous repositioning. Q: which of the following pts is at highest risk for developing a pressure ulcer? I put the older pt with diabetes and got it wrong, I was going back and forth between that and the older woman with a hip replacement, my guess is it’s that since I got it wrong. (Older person with a colon problem is the answer) Myocardial Infarction: Monitoring for Complications- Usually happens in the morning after rest, lasts >30 minutes. Acute MI is a complication of angina that is not relieved by rest or nitroglycerin. Cardiogenic shock often follows an MI symptoms are tachycardia, hypotension, urinary output <30ml/hr, altered LOC, crackles in lungs, tachypnea, cool clammy skin, decreased peripheral pulses and chest pain. Monitor vital signs every 15 minutes until stable then every hour, Monitor ST segment of EKG, location and severity of pain, oxygen saturation levels, hourly urine output- greater than 30ml/hr indicates renal perfusion, lab data cardiac enzymes- electrolytes- and ABG's. Q: what assessment indicates a complication from MI Change/altered level of consiousness Bronchoscopy: Postoperative Plan of Care- Continuously monitor the clients respirations, bp, pulse ox, heart rate, and LOC. Asess LOC, gag reflex, ability to swallow- usually takes 2 hours. Monitor for a fever less than 24 hours is not common, Monitor for productive cough, significant hemoptysis indicative of hemorrhage, a small amount of blood tinged sputum is expected, and hypoxemia. Be prepared to intervene for unexpected outcomes (aspiration, laryngospasm). Provide oral hygiene. Encourage client to lmist or eliminate activities that may irritate the airway like talking or coughing and smoking. Notify care provider for hoarseness, wheezing, coughing up more than a little blood tinged sputum, shortness of breath, fever beyond 24 hours. Q: what would cause you to notify physician/primary concern for a pt who just reveived an bronchoscopy? Changes in sputum color Bypass Grafts: Cardiac Tamponade- results from bleeding and mediastinal chest tubes with inadequate drainage. Cardiac Tamponade compresses the heart chambers and inhibits effective pumping. Signs are a sudden decrease or cessation of chest-tube drainage following heavy drainage, jugular vein distention with clear lung sounds, and equal PAWP and CVP values. Treatment involves volume expansion (fluid administration) and emergency sternotomy with drainage. Pericardiocentesis is avoided because blood may have clotted. Q: what would lead you to believe that cardiac tamponade is occurring? Sudden cessation of chest tube drainage (idea is that fluid is draining into the pericardium instead of the chest tube as it should) Cancer: Managing Adverse Effects of Treatment- for Neutropenia maintain a clean environment, monitor for signs of infections, give antimicrobial, antiviral and antifungal meidcations. Thrombocytopenia should minimize risk of trauma. Anemia should maintain an environment that does not overly use the clients energy resources, provide a diet high in protein and carbs. Thoracentesis: Intervening for Postprocedure Complications- Shock- slow the rate of fluid removal. Pneumothorax- monitor chest xrays. Bleeding- monitor for coughing and or hemoptysis. Bypass Grafts: Femoral Aneurysm Complications- do neuro checks, check feet or make sure they feel feet? Check feet pulses Meninigitis: Assessing for Kernig's Sign- a positive kernigs sign is resistance to extension of the clients leg from a flexed position. (answer could be some test w/the neck) Peripheral Venous Disease: Assessing for Chronic Venous Insufficiency- Signs are stasis dermatitis or brown discoloration along the ankles and extending up to the calf, edema and ulcer formation. Q: what signs/symptoms would indicate PVD? I put pt in pain and pallor and got wrong, I believe the answer is edema or elevated temp (warm) and red Anesthesia: Response to Malignant Hyperthermia- Signs and symptoms of Hyperthermia are tachycardia, tachypnea, hypercabia and dysrhythmias. The nurse should notify the surgeon and anesthesiologist if any of the above signs and symptoms are noted. Asthma: Client Education on Dry Powder Inhaler- breathe in forcefully!! Chest Tube Monitoring: Intervening for Unsafe Practice- Maintain the water seal, chamber must be kept upright and below the chest tube insertion site at all times. Routinely check and monitor the water level due to possiblity of evaporation. The nuse should add fluid as needed to maintain 2 cm water seal and monitor levels every 2 hours. Tidaling (movement of water level with respiration) is expected in the water seal chamber. Water level will rise with inspiration and fall with expiration with negative pressure and vice versa with positive pressure. Continuous bubbling is a sign of an air leak. Chest tubes are only clamped per a primary care provider order or in a special circumstance. Do not strip or milk tubing routinely. Document on the chamber every 8 hours the date, hour, and drainage level. Position the client in semifowlers position to evacuate air and in high fowlers to drain fluid. Keep 2 hemostats, a bottle of sterile water and an occlusive dressing visible at bedside at all times. All connections should be taped! If continuous bubbling tighten the connection and replace drainage system. If tubing disconnects the client should push out as much air as possible and the nurse cleanses the tip and reconnects the tubing. If ches tube is accidentally removed the nurse should place an occlusive dressing over the insertion site taped on 3 sides. Q: which action by the nurse indicates safe practice? Measure drainage by holding container at eye level (Answer is to keep below abdomen) Q: pt received chest tube which is an appropriate action? I put don’t strip or milk tubing but got it wrong, I believe the answer is clamp chest tube as physician ordered or document every 8 hrs. Paracentesis: Appropriate Client Teaching- Have client void prior to the procedure. Explain the patient may experience pressure or pain with needle insertion. Put client on the unaffected side for 1-2 hours after the procedure. If unable to void prior to the procedure a foley must be in place. May sit up or in supine during the procedure. (don’t clamp) Peritoneal Dialysis: Nursing Management- Assess and monitor- prior: weight, serum electrolytes, creatinine, BUN, blood glucose. After: color (clear, light yellow is expected), and amount should equal or exceed amout of dialysate inflow. Monitor for signs of infection (fever, bloody, cloudy or frothy). Assess for complications regarding respiratory distress, abdominal pain, insufficient outflow and discolored outflow. Warm the dialysate prior to instilling. Maintain surgical asepsis. Keep the outflow bag lower than the clients abdomen. Reposition the client if inflow or outflow is inadequate. Milk PD catheter if fibrin clot forms. Tracheostomy: Evaluating Home Care- Giving the patient a way of communication without speaking. For cuffed tubes keep the presure below 20mmhg to reduce the risk of tracheal necrosis due to prolonged compression of tracheal capillaries. Provide trach care q8hours. Clean outer cannula with hydrogen peroxide then with normal saline. Use surgical aseptic technique with the inner cannula and clean with hydrogen peroxide and then with sterile saline. Clean the stoma site with hydrogen peroxide then with sterile saline. Change new ties if they are soiled and place new ones on before removing old ones. Change non-disposable trach tubes q 6-8 weeks. Reposition client every 2 hours. Provide oral hygiene every 2 hours. Place client in upright position to eat and tilt chin downward to swallow. Q: which of the following statements indicates client understanding? I will perform suctioning 3 times a day (every 8 hrs) Spinal Cord Injury: Autonomic Dysreflexia- Hypertension, bradycardia, sudden severe headache, flushing above level of SCI, pallor below level of SCI, nasal stuffiness, dilated pupils, blurred vision, diaphoresis, piloerection. Assess and treat cause- distended bladder, fecal impaction, cold stress, tight clothing. Monitor vitals for severe hypertension and bradycardia. Q: which assessment finding indicates a spinal cord injury? Dilated pupils Safety and Infection Control (3) Herpes Zoster: Infection Control Measures- Isolate the client until the vesicles are crusted. Maintain strict wound care precautions. It is potentially transmissabl and precautions should be exercised around children-pregnant women-people who have not had chicken pox- and immunocompromised clients. Antiviral agents such as acyclovir and valacyclovir shorten the clinical course. Q: what interventions would you apply for a pt diagnosed with Herpes? Contact precautions, wear gown and gloves Chest Tube Monitoring: Questioning Inappropriate Order- explained earlier Tuberculosis: Appropriate Care Plan- explained earlier.