DYANAMIC NOTES FOR MS ATI
● Nurse is providing instructions to the client with DM2 and a new prescription for metformin. Which of the statements
... [Show More] indicates an understanding?
○ “I should take this medication with a meal”
● Nurse is teaching a client with CKD and a new prescription of erythropoietin. Which statement indicates an understanding?
○ “I am taking this medication to increase my energy level”
■ The goal of erythropoietin is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue & improvement in activity tolerance.
● Adverse effect of enalapril
○ Orthostatic hypotension → the nurse should identify that dilation of arteries and veins causes orthostatic hypotension
● A nurse is caring for a client who has hypothyroidism. Which manifestation should the nurse expect?
○ Constipation
■ A client w/hypothyroidism can experience constipation d/t a decrease in the client’s metabolism, resulting in slow motility of the GI tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation.
● Charge nurse teaching new nurse about caring for a client with MRSA. Which statement by the new nurse indicates understanding of the teaching?
○ “I will leave assessment equipment in the room to use on this client”
■ MRSA should follow contact precautions
● Nurse is providing teaching to a client w/IBS (irritable bowel syndrome). Which instructions should the nurse include in teaching?
○ Consume at least 2L water daily to promote normal bowel function
○ Increase fiber intake to at least 30 g/day
■ Dietary fiber helps produce bulky, soft stools and establish a regular bowel pattern.
● Expected findings with hyperthyroidism:
○ Restlessness
○ Elevated T3 level
○ Decreased weight
■ Elevated BP could be indicative of at risk for thyroid storm
● For a thoracentesis, what intervention should be included in the plan of care?
○ Thoracentesis → procedure to remove air or fluids from the lungs
○ **Encourage client to take deep breaths after the procedure
■ Does not to be NPO
■ Client can resume activity within 1 hour following procedure
● Dysphagia → difficulty swallowing; client is at greatest risk for aspiration d/t impaired sensation and function within the oral cavity
● Aphasia → communication impairment risk
○ Loss of ability to understand or express speech
● Ataxia → At risk for injury from falling
○ The loss of full control of bodily movements
● Hemianopsia → at risk for injury when ambulating
○ Blindness over half the field of vision
● A client with advanced COPD, what ABG results should the nurse expect?
○ PaCO2 = 56 → client with COPD retains PaCO2 d/t weakening and the collapse of alveolar sacs, which decreases area in the lungs for gas exchange and causes PaCO2 to increase above the expected range
○ pH = 7.38 → Normal (7.35-7.45)
■ Client with COPD will have pH less than 7.35 d/t poor gas exchange from elevated PaCO2 and HCO3 levels, along w/low O2 levels for an extended period of time
○ HCO3 = 24 → Normal (22-26)
■ A client with COPD will have high HCO3 levels as a result of the kidneys’ inability to excrete metabolic acids, leading to a retention of HCO3 in the blood and an increase in pH
○ PaO2 = 90 (45-35 - Normal)
■ Client with COPD will have low oxygen level d/t the weakening and collapse of alveolar sacs, which decreases the surface area in the lungs for gas exchange
● A client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy - skin in the radiation path is especially sensitive to sun damage
● Compartment Syndrome:
○ Client with CS experiences pain that increases w/passive movement
■ CS results from decrease in blood flow in the extremity because of a decrease in the muscle compartment size d/t cast that is too tight
○ Diminished pulse or pulselessness d/t lack of distal perfusion caused by a decrease in the muscle compartment size
○ Cap. refill greater than 2 seconds d/t lack of distal perfusion & venous congestion caused by a decrease in muscle compartment size
● Omeprazole (PPI) → suppresses gastric acid production
● Antacids; aluminum hydroxide → neutralize gastric acid
● Antibiotics; amoxicillin → reduce the growth of ulcer-causing bacteria
● Anti-ulcer medications (sucralfate) → coats the stomach lining and adheres to the ulcer site
● Gentamicin → used to treat serious bacterial infection
○ N/V, stomach upset or loss of appetite = Side effects
○ HOLD MED is serum creatinine levels are high b/c this med is nephrotoxic
● Psyllium → (bulk-forming laxative) used to treat constipation
○ Absorbs liquid in the intestine, swells, and forms a bulky stool
○ Tell client to drink ~240 mL of fluid w/each dose
○ Should expect results in 12-24 hours & regularity in 2-3 days
● PAD (Peripheral Artery Disease), what finding should the nurse expect?
○ Hair loss on lower legs
○ Painful ulcerations on the ends of toes and between the toes
○ Pain when resting (as result of outflow of blood in lower extremities at rest)
■ This pain is relieved by dangling the lower extremities off a bed
○ Dependent rubor (redness as a result of dangling or ambulation)
● Client has a complication w/hemodialysis; which finding should you report to the nurse as a priority?
○ Restlessness → could be an indication the client is experiencing disequilibrium syndrome
■ Disequilibrium syndrome is caused by the rapid removal of electrolytes
from the client’s blood and can lead to dysrhythmias or seizures.
● Other S/Sx: nausea, vomiting, fatigue & headache
● Normal Lab Values/Ranges:
○ Serum Creatinine = 0.6-1.2 mg/dL
○ Hemoglobin
○ Hematocrit
○ WBC’s
○ RBC’s
● SLE (systemic lupus erythematosus) Manifestations:
○ facial butterfly fly → is common manifestation that appears as a dry, red rash on their cheeks and nose
○ Abdominal pain
○ Pericarditis
● Manifestations of Systemic Sclerosis:
○ Esophagitis
○ Interstitial fibrosis
● PVD vs. PAD:
○ PVD → warm to touch, thick/tough skin, brownish colored skin
■ Want to elevate legs - decreases welling & helps blood flow
■ Do NOT want to dangle or stand for long periods of time
○ PAD → cool to touch, thin/dry/scaly skin, hairless, thick toenails
■ Dr. EP = Dangle Legs: Rubor
● Elevate legs = Pale - makes pain worse
● Client with frequent premature ventricular contractions (PVCs), what QRS changes should the nurse expect to see on their ECG?
○ Much greater amplitude than the usual QRS complexes → QRS complexes unusually have greater amplitude in height and dept in clients with PVC’s
■ PVC clients have much wider QRS complexes
■ With PVC’s: a compensatory pause follows the PVC before the usual rhythm resumes, unless more PCV’s follow in immediate succession.
● A nurse is providing teaching to a client who has a new diagnosis of Meniere’s disease. What instruction should the nurse include in the teaching?
○ Avoid sudden movements
■ Meniere’s disease → disorder of the inner ear affecting balance and hearing. It’s characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.
● Should reduce Na+ intake and drink an evenly distributed amount
of fluids to stabalize fluid levels within the body & avoid caffiene
● Client in ED with pain in left leg following a MVA. The client’s leg is bruising, swelling a,d displacement of the bones. Which action should the nurse take first?
○ Check neurovascular status distal to the injury → d/t circulation
● Client had a gastric resection to treat adenocarcinoma of the stomach and has a tube in his nose. He asks why, what should the nurses response be?
○ “Prevnets excessive pressure on suture lines” → The NG remains in place after surgery to prevent excessive pressure on suture lines post- op. It drains the air and fluid that can cause pressure from inside the GI tract & it also prevents vomiting and GI distention.
○ Gastric lavage = therapy for upper GI bleeding
○ Client will NOT recieve enteral feedings following gastric resection
● Client with MG teaching should include:
○ “Set an alarm to ensure medication dosages are taken on time” → the nurse should instruct the client to take medication dosages on time to maintain the therapeutic blood level. Dosages should not be missed or postponed because this can cause an exacerbation of the disease (being hot can also cause an exacerbation)
■ Instruct them to also eat a high-calorie diet because weight loss often
occurs with MG as the muscles required for chewing and swallowing become weaker
● Types of cancers that typically demonstrates a familial tendency include:
○ Breast, colorectal, ovarian, and prostate
■ Bladder, skin & bone cancer are NOT posed for genetic risk
● What should a nurse expect w/a bleeding duodenal ulcer?
○ Emesis w/a coffee-ground appearance (or is bright red in color)
■ → Hematemesis indicates upper GI bleeding, occuring at or
above the duodenojeunal junction
● These clients will also have: decreased BP & HR (d/t bleeding & fluid loss), and melena stools (which are tarry/dark in color & sticky)
● Statement about type 2 DM:
○ “My cells are resistant to the effects of insulin” → Type 2 DM will have resistance to insulin and a decrease in the secretion of insulin by the pancreas
● A client taking alendronate (for osteoporosis) should sit upright 30 minutes after
administration to prevent esophageal irritation and ulceration.
○ Take in the morning
○ High-calcium foods can reduce its absorpency
○ Take at least 30 minutes before food
● Looking at labs for ES-liver failure; what result should the nurse expect?
○ Increased prothrombin time → clients with end-stage liver failure will have an inadequate supply of clotting factors and an increased PTT
■ Lactate dehydrogenase levels increase
■ Serum albumin levels decrease
■ Serum ammonia levels increase
● Client has a fractured left femur and is in skeletal traction, what should be reported to the provider?
■ Chest petechiae → indication of fat embolism syndrome
● Fat emboli typically occurs 12-48 hours after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. Clients who have fractures of long bones such as the femur are at increased risk of fat emboli.
● Nurse is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which instruction should the nurse plan to give the client?
○ Apply a cold compress to the extremity intermittently
■ → Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should instruct the client to apply cold compresses for no more than 20 minutes at a time
● The nurse should identify that older adults are prone to complications of MI from poor
tissue perfusion because of which of the following age-related factors?
○ Peripheral vascular resistance increases → older adult clients are more prone to complications from poor tissue perfusion following an acute MI b/c peripheral vascular resistance increases with aging. This results from calcification and loss of elasticity of the blood vessels
■ Older adults are more likely to develop toxicity from cardiac medications,
especially severe adverse effects from thrombolytic therapy
● Client had a transient ischemic attack (TIA), for discharge what should you teach them to monitor at home?
○ Blood pressure → a temporary disturbance of the blood supply causes the brain to have a TIA, which is a brief neurological function
■ The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; which is why the client should monitor their BP regularly to promote hypertension management & reduce the risk of another TIA or CVA [Show Less]