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What would you do for wound Evisceration ( removal of internal organs) , Emergency management? Saline cover wound What would you do for an ASTHMA emergency management of a bee sting allergies? Epi Pen
GRADE BOOSTER- 2024 - 202
PROCTORED EXAM 2025 -
MEDICAL SURGICAL ATI
Seizures and Epilepsy: Seizure precautions During a seizure: 1 ) Position client on the floor 2)Provide a patent airway
- Turn client to side
- Loosen restrictive clothing Cancer treatment options: Protective Isolation If WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions.
- Have client remain in his room unless he needs to leave for a diagnostic procedure, in that case transport patient and 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 Standard Precautions:
- applies to all patients
- Hand washing a. alcohol based preferred unless hands visually soiled ( then soap and water )
- Gloves - when touching anything that has the potential to contaminate.
- Masks, eye protection & face shields when care may cause splashing or spraying of body fluids
Pulmonary Embolism: Risk factors for DVT
- 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 Transurethral Resection - Urethral trauma
- Urinary retention
- Bleeding
- Infection Non-modifiable risk factors ( Page 3 ATI )
- Age
- Gender
- Genetics
- Developmental level Modifiable risk factors ( Page 3 ATI )
- Smoking
- Exercise
- Health education and awareness
- Nutrition
- Sex practices
Emergency nursing - Triage BASED ON ACUITY
- Emergent- Life threatening situation going on.
- Urgent - Need to be treated soon but not life threatening.
- Non urgent- The patient can wait for an extended period of time , without big issues. Mass casualty event Class 1 - RED TAG - Immediate threat to life Examples:
- Breathing issues
- Chest pain
- Heart attack coming on
- Airway problem Class II - YELLOW TAG - Major injuries that require immediate treatment but not life threatening. Examples:
- Major fracture Class III - GREEN TAG - Minor injury that does not require immediate attention. EXAMPLES:
- Abrasion
- Laceration Class IV - BLACK TAG - Expected to die EXAMPLES:
- Penetrating head wound
- Whole bowel irrigation *** DO NOT INDUCE VOMITING OR SYRUP OF IPECAC Call rapid response team when client is rapidly declining. Cardiac Emergencies If V fib or ventricular tachycardia you would initiate:
- Basic life support ( BLS) and CPR
- Establish IV access
- Epinephrine is used to get the heart up and moving. Alpha 1 receptors Activation Causes the skin , mucus membranes and veins to vasoconstrict. Help with:
- Congestion
- Superficial bleeding
- In general help raise blood pressure by constricting the veins. DRUG: Epinephrine:Triggers the Alpha 1 receptors Causing vasoconstriction and increase blood pressure. Epinephrine side effects Increases blood pressure
- Hypertensive crisis
- Dysrhythmia
- Angina
Dopamine side effects
- Dysrhythmia
- Angina Dobutamine side effects Increased heart rate Beta 1 receptors Help stimulate the heart Beta I - You have 1 heart Stimulate the heart and increase the heart rate Used for treating:
- AV block
- Cardiac arrest DRUG: Epinephrine:Triggers the Beta 1 receptors Cause increase heart rate Beta II receptors Help stimulate the heart and lungs Beta II You have 2 Lungs Causes:
- Bronchodilation in the lungs
- Causes uterine smooth muscle to relax
- Dull, throbbing pain is an expected finding for a client who has a bone fracture.
- A capillary refill of 3 seconds in the nail beds of the toes is slowed but still within the expected reference range after application of a cast.
- Cool, bilateral extremities are an indication of the client's overall body temperature and general circulatory status and are an expected finding. A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated with this client?
- Combination oral contraceptives
- Intrauterine device
- Latex condom
- Contraceptive sponge
- Combination oral contraceptives
- The nurse should identify that combination oral contraceptives are contraindicated for this client because they increase estrogen levels, which can stimulate the growth of any remaining cancerous breast cells.
- The nurse should identify that the use of an intrauterine device requires the client to check the placement monthly and is not contraindicated for this client.
- The nurse should identify that the use of latex condoms is contraindicated for clients, or their partners, who are allergic to latex. However, it is not contraindicated for this client.
- The nurse should identify that prolonged use of a contraceptive sponge can increase the risk for toxic shock syndrome. However, it is not contraindicated for this client. A nurse is collecting data from a client who has heart failure and is on digoxin. Which of the following outcomes from the medication should the nurse expect?
- Increased heart rate
- Decreased urinary output
- Decreased shortness of breath
- Increased weight
- Decreased shortness of breath
- The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion.
- The nurse should expect the client's heart rate to decrease because digoxin decreases the client's sympathetic nerve tone, which slows the heart rate.
- The nurse should expect the client to have an increase in urinary output because digoxin improves cardiac output and increases the client's renal blood flow through the kidneys, which results in an increased excretion of urine.
- The nurse should expect the client's weight to decrease because of the increased excretion of fluid that is caused by improved cardiac output. A nurse is reinforcing teaching with a client who has Systemic Lupus Erthematosus (SLE) and is to begin taking mythylprednisolone orally. Which of the following statements should the nurse include in the teaching?
- Limit contact with large groups of people.
- Take medication on a empty stomach
- Follow a low- protein diet
- Avoid taking over the counter calcium supplements
- Limit contact with large groups of people.
- The nurse should monitor the client's lower extremities for tenderness, warmth, or redness. However, massaging the client's lower extremities is contraindicated because, if there is a blood clot formation in the a lower extremity, it can loosen the clot and cause a pulmonary embolism. What are the signs and symptoms of pulmonary embolism?
- Hypotension
- Tachycardia
- Tachypnea A nurse is reinforcing teaching with a client who has Multiple Sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching?
- Take this medication on an empty stomach
- Avoid stopping this medication suddenly.
- Use Chamomile tea to alleviate insomnia.
- Consume a low- purine diet
- Avoid stopping this medication suddenly.
- The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations.
- The nurse should instruct the client to take baclofen with milk or food to minimize gastric upset.
- The nurse should instruct the client to avoid chamomile because it can interact with baclofen to increase CNS depression.
- The nurse should recommend a low-purine diet for a client who has gout and a prescription for colchicine.
A nurse is reviewing the laboratory results of a client who has type II diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing?
- Prealbumin 12mg/dl
- HBA1c 6%
- WBC 8,000/mm
- Creatinine 0.8 mg/dl
- Prealbumin 12mg/dl
- This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that he is at risk for delayed wound healing due to malnutrition.
- This laboratory value indicates glycemic control and does not indicate that the client is at risk for delayed wound healing. The nurse should identify that elevated HbA1c levels can increase the risk for delayed wound healing.
- This laboratory value is within the expected reference range and indicates immune function. The nurse should identify that an elevated WBC count increases the risk for delayed wound healing. This laboratory value is within the expected reference range and indicates adequate kidney function. The nurse should identify that the client who is diabetic is at increased risk for the development of renal failure, which can increase the risk for infection and delayed wound healing. Prealbumin normal range 23 - 43 Sodium normal level 136 - 145 Calcium normal level
(Low platelets-risk for bleeding) Hemoglobin 12- Hematocrit 37%-52% INR 0.7-1.8; 2-3 if on warfarin (coumadin) therapy aPTT 30- (<30=risk for clots, >40=risk for bleeding) Heparin pH 7.35-7. HbA1c (glycosylated hemoglobin) <6% *>6.5% indicated DM BUN 10-20 mg/dL
Dehydration <<<< Fluid overload Creatinine 0.6 - 1. A nurse is assisting with discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan?
- Avoid lying on the operative side.
- Expect decreased sensation for the first postoperative week.
- Cross legs at the ankles
- Obtain a raised toilet seat 4) Obtain a raised toilet seat
- The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation.
- The nurse should instruct the client that lying on the operative side is allowed but the client should place pillows between the legs to prevent dislocation of the hip.
- The nurse should instruct the client to report decreased sensation in the affected foot or leg because this can indicate neurovascular compromise.
- The nurse should instruct the client to avoid crossing her legs to prevent dislocation of the hip. A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration.
- Instill 10ml of air through the NG tube
A nurse is reinforcing teaching with a client who has asthma. Which of the following statements indicates an understanding of the use of budesonide and albuterol inhalers? Select all that apply
- I should use my budesonide inhaler before I use my albuterol inhaler.
- I use my albuterol inhaler before I go swimming
- Between office visits, I keep a record of how many times I use my albuterol inhaler.
- I should expect to feel sleepy after using my albuterol inhaler.
- I never forget to rinse my mouth after using my budesonide inhaler. 2) I use my albuterol inhaler before I go swimming
- The client should use the albuterol inhaler before exercise to prevent exercise-induced bronchospasms.
- Between office visits, I keep a record of how many times I use my albuterol inhaler.
- The client should record the number of times that he uses his albuterol inhaler. This information can assist the provider to determine the effectiveness of the medication.
- I never forget to rinse my mouth after using my budesonide inhaler.
- The client should rinse his mouth after using a budesonide inhaler to reduce the risk for oral fungal infection.
- The client should recognize that albuterol stimulates the sympathetic nervous system, which can cause nervousness and insomnia, along with increased heart rate and blood pressure.
- The client should first use the albuterol inhaler, a bronchodilator, to open the airway and enhance the absorption of the budesonide, which is an inhaled corticosteroid.
A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next?
- Monitor the client's vital signs
- Administer epinephrine
- Administer an antihistamine
- Monitor the client's oxygen saturation level.
- Administer epinephrine
- The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.
- The nurse should monitor the client's vital signs during the crisis to detect a decrease in blood pressure and an increase in respiratory effort. However, there is another action the nurse should take first.
- The nurse should administer an antihistamine to treat the hives and reduce the histamine release. However, there is another action the nurse should take first.
- The nurse should monitor the client's oxygen saturation level to ensure respiratory support. However, there is another action the nurse should take first. A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?
- I may develop excessive bruising
- I should call my doctor if I get a headache
- I may develop gastric reflux
- I should call my doctor if my ankles swell.
