Medical surgical ATI proctored exam COMPLETE SOLUTIONS

What would you do for wound Evisceration ( removal of internal organs) , Emergency management? - ANSWER Saline cover wound What would you do for an ASTHMA emergency management of a bee sting allergies? - ANSWER Epi Pen Seizures and Epilepsy: Seizure precautions - ANSWER During a seizure: 1) Position client on the floor 2)Provide a patent airway 3) Turn client to side 4) Loosen restrictive clothing Cancer treatment options: Protective Isolation - ANSWER If WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions. - Have client remain in his room unless he needs to leave for a diagnostic procedure, in that case transport patient and place a mask on him. - Protect from possible sources of infection (plants, change water in equipment daily) - Have client, staff and visitors perform frequent hand hygiene, restrict ill visitors - Avoid invasive procedures (rectal temps, injections) - Administer (neupogen, neulasta) to stimulate WBC production Infection control: Appropriate room assignment - ANSWER Standard Precautions: 1. applies to all patients 2. Hand washing a. alcohol based preferred unless hands visually soiled ( then soap and water ) 3. Gloves - when touching anything that has the potential to contaminate. 4. Masks, eye protection & face shields when care may cause splashing or spraying of body fluids Droplet: 1. private room or with someone with same illness 2. masks Airborne: 1. private room 2. masks or respiratory protection devices a. use an N95 respirator for tuberculosis 3. Negative pressure airflow 4. full face protection if splashing or spraying is possible Contact: 1. private room or room with same illness 2. gloves & gowns 3. disposal of infections dressing materials into a single, nonporous bag without touching the outside of the bag TB: Priority action for a client in the emergency department - ANSWER -Wear an N95 or HEPA respirator -Place client in negative airflow room and implement airborne precautions -use barrier protection when the risk of hand or clothing contamination exists Immunizations: Recommended vaccinations for older adult clients - ANSWER Adults age 50 or older: - Pneumococcal Vaccine (PPSV) - Influenza vaccine - Herpes Zoster Vaccine - Hepatitis A - Hepatitis B - Meningococcal Vaccine Pulmonary Embolism: Risk factors for DVT - ANSWER - Long term immobility - Oral contraceptives - Pregnancy - Tobacco use - Hypercoagulabilty - Obesity - Surgery - Heart failure or chronic A-Fib - Autoimmune hemolytic anemia (sickle cell) - Long bone fractures - Advanced age Disorders of the male reproductive system: Complications of continuous irrigation following Trans-urethral Resection - ANSWER - Urethral trauma - Urinary retention - Bleeding - Infection Non-modifiable risk factors ( Page 3 ATI ) - ANSWER 1) Age 2) Gender 3) Genetics 4) Developmental level Modifiable risk factors ( Page 3 ATI ) - ANSWER 1) Smoking 2) Exercise 3) Health education and awareness 4) Nutrition 5) Sex practices Emergency nursing - Triage - ANSWER BASED ON ACUITY 1) Emergent- Life threatening situation going on. 2) Urgent - Need to be treated soon but not life threatening. 3) Non urgent- The patient can wait for an extended period of time , without big issues. Mass casualty event - ANSWER Class 1 - RED TAG - Immediate threat to life Examples: 1) Breathing issues 2) Chest pain 3) Heart attack coming on 4) Airway problem Class II - YELLOW TAG - Major injuries that require immediate treatment but not life threatening. Examples: 1) Major fracture Class III - GREEN TAG - Minor injury that does not require immediate attention.