Med-Surg ATI Exam Concepts Study Guide
o Crutches
Place body weight on crutches
Advance unaffected leg onto the stair
Shift weight from
... [Show More] crutches to unaffected leg
Bring crutches and affected leg up to the stair
o Closed-suction drain nursing interventions
Negative-pressure device
Doesn't require wall suction
*Compress the drain reservoir after emptying (creates negative pressure)
Do not need to put below bed (doesn't use gravity)
o External fixation device
Surgeon applies the external fixation device directly to the client's bone to form a rigid structure around the affected extremity
• Casts, boots, or splints are applied directly to the leg for internal fixation
Client should wear external fixation device continuously for a period of 4-6 weeks
• Nurse should teach the client to perform care of the wound and pin sites at home
Use crutches with rubber tips
• Prevents the client from slipping and decreases fall risks
Only the provider should adjust the client's external fixation device in order to maintain bone alignment
o Long-term mechanical ventilation complications
Decreased cardiac output and hypotension, related to positive pressure from mechanical ventilation inhibiting blood return to the heart
Fluid retention related to decreased cardiac output
Stress ulcers, related to elevated levels of HCl in the stomach
• Increase risk for systemic infection and require pharmacological treatment
Hyponatremia, secondary to fluid retention
o Postoperative nursing interventions following mastectomy
Instruct client that the drain will remain in place for 1-3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hour period
Instruct client to start exercising the arm on side of surgery 24 hours after surgery
Elevate arm on surgical side on a pillow to promote lymphatic fluid return
Nurse should elevate the head of the client's bed to at least 30 degrees to promote drainage from the surgical site and facilitate breathing
o Patient teaching for active tuberculosis
Sputum specimens are necessary every 2-4 weeks until there are three negative cultures
• After 3 negative cultures, the client is no longer considered infectious
Client's infection is usually no longer contagious after taking TB medications for 2-3 weeks
Family members do not need to follow airborne precautions because they have already been exposed to TB
A follow-up evaluation of the client's TB should be performed using a chest x-ray because the TB skin test is no longer considered accurate after a person has tested positive
o Nursing interventions following total hip arthroplasty
Assist client to maintain legs in abduction
Client should not flex hip greater than 90 degrees to prevent hip dislocation
Nurse should place a pillow between client's legs to prevent hip dislocation
Nurse should not keep client's hip internally rotated, as this can lead to hip dislocation
o Patient teaching on kidney organ donation
Client who is recipient of organ donation will require lifelong immunosuppressive therapy to protect against transplant rejection
A healthy donor who has one kidney can manage the body's urinary excretion requirements
Client's nonfunctioning kidney remains in the body until transplant surgery, unless the client has chronic kidney infection or pain
A client who receives a kidney from live donor has a lower rate of transplant rejection
• Client who receives a kidney from a live donor has a lower rate of transplant rejection because the donor is often more medically compatible than a donor who is deceased
o Patient teaching about prevention of atherosclerosis
Smoking cessation
Maintain an appropriate weight
Eat a low-fat diet
o MRSA precautions for health care professionals
Client should wear an isolation gown and wash hands before being transported from the room to prevent spread of micro-organisms
Nurse should bathe client using warm water and a chlorhexidine solution to prevent the spread of micro-organisms
Use dedicated assessment equipment when assessing the client and leave in room to prevent cross-contamination with other clients
Mode of transmission = contact
o Nephrostomy expected findings
Red-tinged urine during the first 12-24 hours
Normal BUN
Increased urine output (notify provider for decreased UO)
NOTIFY PROVIDER FOR BACK PAIN
• Can indicate the tube is dislodged or clogged
o Nursing interventions for dysrhythmias
Defibrillation for ventricular tachycardia or ventricular fibrillation
Cardioversion for all other dysrhythmias
CPR for a client who is pulseless or not breathing
Lidocaine IV bolus for a client who has ventricular dysrhythmia
o Seizure precautions
Client should limit intake of alcohol or caffeine, minimize stress, fever, and fatigue to prevent triggering a seizure
Nurse should keep 2-3 side rails up to prevent falls
Keep client's bed in lowest position to prevent falls
Ensure client has patent IV access in the event that the client requires medication to stop seizure activity
o Nursing interventions for blood transfusions
Priority = check for the type and number of units of blood to administer
Obtain baseline vital signs for comparison
Describe blood transfusion to promote client understanding
Ensure client has a large-bore IV access to prevent hemolysis during transfusion
o Patient teaching for insulin lispro
Rapid-acting insulin that the client can use in conjunction with intermediate or long- acting insulins
Client should inject the medication subcutaneously into the abdomen, upper thigh, or arm
Nurse should instruct client that insulin lispro is rapid-acting and the client should administer immediately before eating or immediately after eating
Instruct the client to continue taking insulin lispro as prescribed during times of illness, and notify provider of the illness
o Patient teaching for metformin
Decreases the amount of glucose produced in the liver and increases tissue sensitivity to insulin
Client should take metformin with or immediately following meals to improve absorption and to minimize GI distress
Clients typically lose weight when beginning metformin due to N/V
Adverse effect = rash
o Evisceration nursing interventions
Priority = call for help
Cover the wound with sterile, saline-moistened dressing to protect organs
Monitor client's vital signs to monitor for complications
Place client in supine position to promote blood flow to organs
o Blood transfusion complication interventions
Bacterial transfusion reaction = antibiotic
• Manifestations: hypotension, tachycardia, shock
Febrile transfusion reaction = antipyretic, acetaminophen
• Manifestations: tachycardia, fever, hypotension, chills
Circulatory overload from transfusion: loop-diuretic, furosemide
• Manifestations: dyspnea, hypotension, hypertension, distended neck veins
Allergic transfusion reaction: antihistamine, diphenhydramine
• Manifestations: urticarial, itching, flushing, bronchospasms, anaphylaxis
o Central venous catheter nursing interventions
Place client in Trendelenburg position with a rolled towel between client's shoulder blades
• Position facilitates the insertion of the catheter by dilating blood vessels of the client's neck and shoulders
Goes into subclavian vein [Show Less]