Exam (elaborations)
ATI MEDICAL-SURGICAL CMS REVIEW
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ATI MEDICAL-SURGICAL CMS REVIEW
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ATI MEDICAL-SURGICAL CMS REVIEWNurse is planning care for client who is post-op for radical mastectomy - nursing
interventions - answers-begin exercises with the client 1 day after procedure
Exercises that do not stress the incision site can promote lymphatic return and mobility
Pre-operative teaching for a client scheduled for total knee arthroplasty - answers-
elastic stockings worn after surgery will help prevent venous embothrobolism
Bladder cancer - highest risk factor - answers-tobacco use
Cardiac catheterization - preprocedure client teaching - answers-client should remain
flat for 2-6 hours following procedure
Client will receive mild sedative for relaxation/comfort
Client will need to keep the leg straight following the procedure
Client is being admitted with frequent coughing, frothy pink sputum. Client has hx of
night sweats, anorexia, and weight loss - priority nursing actions - answers-assign the
client to a private, negative-pressure room
Initiate airborne precautions
Wear n95 mask when entering client's room
Planning care for a client who has deep partial-thickness burns over 40% of his body
and in the acute phase of burn injury - nursing intervention that should be included in
the plan of care - answers-begin performing active/passive range of motion exercises
with client
Maintains mobility and prevents contractures
Rifle classification of aki - risk - answers-< 0.5 ml/kg/hr of urine output for 6 hours
Rifle classification of aki - injury - answers-< 0.5 ml/kg/hr of urine output for 12 hours
Rifle classification of aki - failure - answers-no urine (anuria) output for 12 hours
Or
< 0.3 ml/kg/hr for 24 hours
,Rifle classification of aki - loss - answers-no urine output without renal replacement
therapy for 4 to 12 weeks
Rifle classification of aki - end stage renal failure - answers-no urine output without renal
replacement therapy for more than 3 months
Acute intravascular hemolytic reaction - assessment finding - answers-sudden oliguria
This type of transfusion reaction causes acute kidney injury (aki) resulting in sudden
oliguria and hemoglobinuria
Nursing is planning care for client with siadh with mild symptoms - rx that will be
anticipated - answers-tolvaptan (samsca)
This rx is a vasopressin antagonist that promotes the excretion of water
Corrects the fluid imbalance in clients who have siadh
Chlorpropamide - answers-anti-diabetic agent with antidiuretic effects
Used to treat diabetes insipidus
Vasopressin - answers-exogenous form of antidiuretic hormone
Used to treat diabetes insipidus
Demopressin - answers-synthetic form of antidiuretic hormone
Used to treat diabetes insipidus
Lasik surgery - adverse effect - answers-dry eyes
Blurred vision
Lasik surgery - answers-procedure that can correct:
- nearsightedness
- farsightedness
- astigmatism
Changes the shape of the cornea to correct vision
Client with below-the-knee amputation who is 3 days postoperative - nursing action -
answers-rewrap the residual limb with a pressure bandage 3x daily
This ensures the residual limb will shrink
,Also provides an opportunity to assess the skin for redness/breakdown
Theophylline toxicity - assessment finding - answers-tremors
An early manifestation of toxicity is cns stimulation, often seen as tremors
Seizures can occur if blood levels continue to rise
Stage i pressure ulcer - answers-skin is intact, with an area of persistent, non-
blanchable redness
Usually over a bony prominence
Stage ii pressure ulcer - answers-involves partial-thickness skin loss of the epidermis
and dermis
Ulcer is visible and superficial
Can look like an abrasion, blister, or shallow crater
Stage iii pressure ulcer - answers-involves full thickness tissue loss with damage or
necrosis of subcutaneous tissue
Damage might extend down to, but not through the underlying fascia
Looks like a deep crater
Stage iv pressure ulcer - answers-full thickness tissue loss
Visible damage to muscle, bone and supporting structures
Sinus tracts, deep pockets of infection and tunneling may occur
Peripheral vascular disease - assessment findings - answers-ankle swelling
Skin is warm to touch
Skin appears thick/brownish
Hair is present
Ulcers appear moist/bleeding
Edges of ulcers are uneven
Liver biopsy - lab to monitor prior to procedure - answers-prothrombin time
, Major complication of liver biopsy is hemorrhage
Clients who have liver disease have clotting factor defects and increased risk for
bleeding
Lumbar puncture for client who has manifestations of bacterial meningitis - expected lab
findings - answers-elevated protein
Elevated wbc
Decreased glucose
Elevated csf pressure
Cloudy csf
Client is receiving chemotherapy - adverse effects that the nurse should anticipate -
answers-pancytopenia
Pancytopenia (deficiency of wbcs, rbcs, and platelets) is an expected adverse effect of
chemotherapy
Heterograft dressings are obtained from... - answers-pig skin
Heterografts are obtained from an animal, usually a pig
Client is scheduled to have arthroscopy - statement that indicates client understands the
preprocedure teaching - answers-"the doctor will be able to see if i have signs of
rheumatoid arthritis"
Arthroscopy helps with diagnosing musculoskeletal disorders such as rheumatoid
arthritis, osteoarthritis and internal joint injuries
A nurse is asesssing for disseminated intravascular coagulation (dic) in a client with
septic shock secondary to an untreated foot wound - expected assessment findings -
answers-bleeding at the venipuncture site
Petechiae on chest and arms
Abdominal distension (due to internal bleeding)
Probenicid - drug interaction - answers-aspirin
Aspirin decreases effectiveness of probenecid
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