Critical Care ATI CMS | GRADED A
Sign of pulmonary embolsim Correct Answer: Stabbing chest pain, dyspnea
The client reports sudden shortness of
... [Show More] breath, stabbing chest pain, and feelings of doom. what is this patient experiencing? Correct Answer: pulmonary embolsim
they might also exhibit, tachycardia, chest petechiae and decreased SaO2
Who is at increase risk for breast cancer? Correct Answer: -AGE OVER 5O YEARS
-Increase breast density,
-BMI of 32,
-1-2 alcoholic beverages per week.
peripheral arterial disease Correct Answer: hair loss
dependent rubor
painful ulcerations to the toes
pain when resting
A nurse is caring for a patient who is receiving radiation therapy for breast cancer and reports a metallic taste in the mouth. which recommendation would you give? Correct Answer: Offer mints which can overcome the metallic taste
-ADD coffee to sweet beverages or milk
-SHOULD consume citrus/tart flavors
nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of of receiving blood transfusions. which of the following complications should the nurse monitor for? Correct Answer: Iron toxicity: a client who is received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body
Autonomic Dysreflexia due to a C5 spinal cord injury Correct Answer: (potentially life threatening emergency!) HOB elevate 90 degrees, (HIGH FOWLERS) loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)
Health fair a pt blood pressure is 150/90 which action should the nurse take? Correct Answer: Give the client a written record of his BP to bring to the provider within 2 MONTHS
Lupus, what should the nurse expect to be increased? Correct Answer: erythrocyte sedimentation rate --> indicated inflammation
what can cause Lupus exacerbation? Correct Answer: Pregnancy
Sunlight
Infection
NOT: exercise
which medications would the nurse administer for lupus? Correct Answer: Corticosteroids such as prednisone
Pancreatitis what lab is elevated? Correct Answer: AMYLASE begins to increase in 3-6 hours
Amylase typically shows elevation within 12-24 hours and remain elevated for 2-3 days
**LIPASE is also elevated
Hypocalcemia & hypo magnesium is expected
Meniere's disease Correct Answer: condition of the inner ear in which excess fluid distorts the inner ear canal system
It affects the COCHLEA
AVOID sudden movements
an adolescent has recurrent external otitis, what instructions should the nurse give? Correct Answer: instill a diluted alcohol solution into the ear after swimming to decrease bacteria and dry the external ear canal
DKA Expected findings Correct Answer: Kussmaul respirations
urine positive for ketones
Hypotension becasue of dehydration
Cervical Cancer manifestation Correct Answer: Vaginal Bleeding
Unplanned weight loss
Dysuria
Pelvic pain and chest pain
Gastric surgery and an NG tube was inserted, which finding should be reported to the provider? Correct Answer: 200 mL of bright red drainage
what is the purpose of the NG type? Correct Answer: Prevents excessive pressure on the suture lines. it drains the air
-pt will began with taking clear liquids by mouth and progress accordingly
diabetes insipidus Correct Answer: Polyuria, polydipsia
Low specific gravity, Na will be high, serum osmo is high
Post total knee arthroplasty Correct Answer: wear elastic stockings on both of my legs
Risk factor for osteoporosis Correct Answer: Anorexia nervosa because inadequate protein intake --> decreased bone density
Risk factors for bone loss Correct Answer: small body frame
low vitamin D intake
smoking
Treatment for osteoporosis medication = alendronate. what teaching is needed for this medication? Correct Answer: I will sit upright for 30 min after taking the medication to prevent esophageal irritation and ulceration
-TAKE IN MORNING
-Calcium supplement at a DIFFERENT time of day
-TAKE 3O MIN BEFORE FOOD
what to recommend a patient with osteoporosis Correct Answer: perform weight bearing exercises
such as walking
what food will the nurse recommend to promote calcium absorption? Correct Answer: fortified milk
Strategies for preventing bone loss Correct Answer: begin a program of brisk walking
Leg amputation. Correct Answer: "I will lie on my stomach for 20-30 min a few times a day to help reduce risk of developing hip flexion contractures
Rewrap the residual limb with a bandage 3 times per days
AIDS. Correct Answer: -Seperate plastic bag to dispose of soiled tissues
-Implement handwashing to prevent spread of infection
-Wash soiled clothes in hot water along with 1 cup of bleach
- CLEAN BLOOD UP WITH BLEACH SOLUTION AND GLOVES
AIDS precautions Correct Answer: Discard food after 24 hour
thaw frozen food in the refrigerator
-USE A SEPARATE CUTTING BOARD FOR RAW POULTRY
-store cold foot at 4.4 celcius or less
Primary open-angle glaucoma (POAG). Include in teaching: Correct Answer: -Driving can be dangerous due to the loss of peripheral vision
-Laser surgery can help reestablish the flow of aqueous humor
Hep A: understanding teaching Correct Answer: Hep A: transmitted via the fecal oral route through consumption of contaminated fruits, vegetables, water, milk or uncooked shellfish.
****AVOID SHELLFISH if you have HEP A. **ENCOURAGE HER TO EAT FOODS HIGH IN CARBS
HIV Instructions to help with infection prevention Correct Answer: -Avoid large gatherings of people
-Clean the toothbrush by running through the dishwasher or beach followed by hot water
-Avoid digging in the garden --> increase risk of infection
HIV --> AIDS manifestation Correct Answer: You can expect a persistent fever and swollen glands
How is HIV transmitted ? Correct Answer: anyone who has had contact with infected blood
Variant (Prinzmetal's) Angina Correct Answer: -due to a coronary artery spasm, often occurring during periods of rest.
-results in less oxygen supplying the myocardium --> changes to the EKG
Expected finding with chemotherapy Correct Answer: Pancytopenia (deficiency of WBC'S, RBC's, and platelet count
Perforation of a peptic ulcer expected finding Correct Answer: BOARDLIKE ABDOMEN and severe pain in the abdomen or back that radiates to the RIGHT SHOULDER
malignant melanoma expected findings Correct Answer: -Commonly starts on exposed areas of body and then metastasizes to other areas
-CHANGE IN COLOR, SIZE, SHAPE OF A SKIN LESION WITH IRREGULAR BORDERS, in hues of BLUE, WHITE OR RED TONES.
liver cirrhosis with abdominal distention Correct Answer: Take serial measurements of the abdomen with a tape measure, obtain PT & INR, administer lactulose, administer daily multivitamin
Mesastasizing malignant neoplasm in the colon Correct Answer: I have cancer of the colon that has begun to spread
Post op frontal craniotomy Correct Answer: Semi fowlers
Bowel obstruction--> indication possible bowel perforation = Correct Answer: rigid abdomen tenderness
hypotension
TPN was stopped for physical therapy, the nurse is monitoring for which finding? Correct Answer: diaphoresis because of sudden withdrawal of TPN --> hypoglycemia
hypoglycemia Correct Answer: diaphoresis, irritability, mental confusion, double vision, hunger, tachy, palpitations, SLURRED SPEECH
TPN through a CENTRAL LINE, which action should the nurse perform? Correct Answer: Daily weights b/c pt is at risk for FLUID & ELECTROLYTE IMBALANCES
-Change tubing q24 hours
-Check glucose Q4 HOURS
- CHANGE DRESSING Q24-72 HOURS
Papules Correct Answer: small, solid, elevated lesion with distinct borders. It is usually smaller than 10mm in diameter. papules are common lesions of warts and elevated moles
Macule Correct Answer: change in the COLOR of the skin that is flat, cariably shaped, discolored, and small. freckles and the rash associated with rubella are type of macules
Wheals aka HIVES Correct Answer: are transient, elevated, irregularly shaped lesions caused by localized edema. common manifestation of an allergic reaction
Vesicles (chickenpox) Correct Answer: A circumscribed, elevated lesion or blister containing serous fluid. Vesicles typically arise in herpes simplex, poison ivy, and chicken pox
Herpes zoster or shingles --> viral infection --> what medication ? Correct Answer: ACYCLOVIR inhibits the replication of the virus
What are manifestations for herpes zoster or shingles exacerbation? Correct Answer: ACUTE, UNILATERAL INFLAMMATION OF THE DORSAL ROOT GANGLION
Dumping syndrome Correct Answer: increase fat and protein,
small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink [Show Less]