Med-Surg ATI Study Guide.
Med-Surg Exam Concepts
o Crutches
Place body weight on crutches
Advance unaffected leg onto the stair
Shift weight from 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
,Med-Surg ATI Study Guide.
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
,Med-Surg ATI Study Guide.
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
, Med-Surg ATI Study Guide.
o Hormone replacement therapy adverse effects
Urgent effects (contact provider)
Calf pain (indicates DVT)
Numbness of the arms (indicates possible CVA)
Intense headache (indicates possible CVA)
Nonurgent effects (manifestation of menopause)
Night sweats
Vaginal dryness
o Thoracentesis nursing interventions
After thoracentesis, client should deep breathe to re-expand lungs
Place client in upright position with arms resting on an overhead table to widen
the intercostal space and spread ribs for tube insertion
Nurse should assist a client who cannot sit up into a side-lying position
with the affected side up
Client should receive local anesthetic for the procedure and will not require
NPO status after midnight
Instruct client to resume activity within 1 hour following procedure
o Arterial lines nursing interventions
Used to obtain arterial blood gases and monitor hemodynamic pressures
Most appropriate position of a client while recording values obtained from an
arterial line is supine with the head of the bed elevated up to 60 degrees
Nurse should place a pressure bag around the flush solution of 0.9% sodium
chloride because the pressure from an artery is greater than that of the line
o Patient teaching of heparin
Instruct the client to report any bleeding or bruising to provider
Instruct the client to avoid flossing
Instruct client to apply firm pressure to injection site 1-2 minutes but to
avoid massaging
Instruct the client to use an electric razor when shaving to reduce the risk of cuts
to the skin
o Patient teaching for ureterostomy
During procedure, client's bladder is removed and the ureters are brought to the skin
surface of the abdomen to form a stoma from which urine will flow into ostomy bag
Client will not have urge to void
Drink 2-3 L of fluid per day to reduce mucus formation and maintain hydration
Client should cut the opening of the skin barrier 1/8-inch wider than the stoma
to minimize irritation of the skin from exposure to urine
Client should avoid using moisturizing soaps to clean the skin around the
stoma because it will prevent the pouch from adhering to the skin
o COPD expected findings
Increase in PaCO2, because COPD retains PaCO2 due to the weakening and the
collapse of the alveolar sacs, which decreases the area in lungs for gas exchange
and causes the PaCO2 to increase above the expected reference range
pH below expected range
Increased HCO3 levels
Low oxygen level
Med-Surg Exam Concepts
o Crutches
Place body weight on crutches
Advance unaffected leg onto the stair
Shift weight from 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
,Med-Surg ATI Study Guide.
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
,Med-Surg ATI Study Guide.
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
, Med-Surg ATI Study Guide.
o Hormone replacement therapy adverse effects
Urgent effects (contact provider)
Calf pain (indicates DVT)
Numbness of the arms (indicates possible CVA)
Intense headache (indicates possible CVA)
Nonurgent effects (manifestation of menopause)
Night sweats
Vaginal dryness
o Thoracentesis nursing interventions
After thoracentesis, client should deep breathe to re-expand lungs
Place client in upright position with arms resting on an overhead table to widen
the intercostal space and spread ribs for tube insertion
Nurse should assist a client who cannot sit up into a side-lying position
with the affected side up
Client should receive local anesthetic for the procedure and will not require
NPO status after midnight
Instruct client to resume activity within 1 hour following procedure
o Arterial lines nursing interventions
Used to obtain arterial blood gases and monitor hemodynamic pressures
Most appropriate position of a client while recording values obtained from an
arterial line is supine with the head of the bed elevated up to 60 degrees
Nurse should place a pressure bag around the flush solution of 0.9% sodium
chloride because the pressure from an artery is greater than that of the line
o Patient teaching of heparin
Instruct the client to report any bleeding or bruising to provider
Instruct the client to avoid flossing
Instruct client to apply firm pressure to injection site 1-2 minutes but to
avoid massaging
Instruct the client to use an electric razor when shaving to reduce the risk of cuts
to the skin
o Patient teaching for ureterostomy
During procedure, client's bladder is removed and the ureters are brought to the skin
surface of the abdomen to form a stoma from which urine will flow into ostomy bag
Client will not have urge to void
Drink 2-3 L of fluid per day to reduce mucus formation and maintain hydration
Client should cut the opening of the skin barrier 1/8-inch wider than the stoma
to minimize irritation of the skin from exposure to urine
Client should avoid using moisturizing soaps to clean the skin around the
stoma because it will prevent the pouch from adhering to the skin
o COPD expected findings
Increase in PaCO2, because COPD retains PaCO2 due to the weakening and the
collapse of the alveolar sacs, which decreases the area in lungs for gas exchange
and causes the PaCO2 to increase above the expected reference range
pH below expected range
Increased HCO3 levels
Low oxygen level
