ATI Medical-Surgical CMS Review 2024/2025 (100%
verified)
Nursing Interventions: A nurse is planning care for a client who is post-op for a radical mastectomy.
- Begin exercises with the client 1 day after the procedure.
- Exercises that do not stress the incision site can promote lymphatic return and mobility.
Pre-Operative Teaching: For a client that is scheduled for a "total knee arthroplasty"
- Teach that elastic stockings worn after surgery will help prevent venous embothrobolism
Highest Risk Factor: Bladder Cancer
- Tobacco use
Pre-procedure Client Education: Cardiac Catheterization
- The client should remain flat for 2-6 hours following the procedure.
- The client will receive mild sedatives for relaxation/comfort
- The client will need to keep their leg straight following the procedure.
Priority Nursing Actions: A client is being admitted with frequent coughing and frothy pink sputum.
The client has a Hx of night sweats, anorexia, and weight-loss.
- Assign the client to a private, NEGATIVE-PRESSURE room
- Initiate AIRBORNE precautions
- Wear N95 mask when entering the client's room
Nursing Interventions to be Included in a plan of care for a client who has deep partial-thickness burns
over 40% of his body and is in the acute phase of the burn injury.
- Begin performing active/passive range of motion exercises with the client.
- Maintains mobility and prevents contractures
"RIFLE" Classification for AKI: Risk of Renal Dysfunction
- < 0.5 mL/kg/hr of urine output for 6 hours
"RIFLE" Classification for AKI: Injury to Kidney
- < 0.5 mL/kg/hr of urine output for 12 hours
"RIFLE" Classification for AKI: Failure or Loss of Kidney function
- no urine (anuria) output for 12 hours or
- < 0.3 mL/kg/hr for 24 hours
,ATI Medical-Surgical CMS Review 2024/2025 (100%
verified)
"RIFLE" Classification for AKI: Loss
- no urine output without renal replacement therapy for 4 to 12 weeks
"RIFLE" Classification for AKI: End-Stage Renal Failure
- no urine output without renal replacement therapy for more than 3 months
Assessment Finding: Acute Intravascular Hemolytic Reaction
- sudden oliguria
- this type of transfusion reaction causes acute kidney injury (AKI) resulting in sudden oliguria and
hemoglobinuria
Nursing Plan of Care: A nurse is caring for a client with SIADH with mild symptoms. What Rx will be
anticipated?
- tolvaptan (Samsca) which is a vasopressin antagonist that promotes the excretion of water and
corrects the fluid imbalance in clients who have SIADH.
Drug Name: Chlorpropamide
- an anti-diabetic agent with antidiuretic effects that is used to treat diabetes insipidus
Drug Name: Vasopressin
- exogenous form of antidiuretic hormone that is used to treat diabetes insipidus
Drug Name: Demopressin
- a synthetic form of antidiuretic hormone that is used to treat diabetes insipidus
Adverse Effect: Lasik eye surgery
- dry eyes
- blurred vision
Procedure: Lasik Eye Surgery
- A procedure that can correct (1) nearsightedness, (2) farsightedness, and (3) astigmatism
- The procedure changes the shape of the cornea to correct vision.
Nursing Actions: For a client who is 3 days post-op following a below-the-knee operation.
- rewrap the residual limb with a pressure bandage 3x daily which ensures the residual limb will shrink
and also provides an opportunity to assess the skin for redness/breakdown
Drug Assessment Finding: Theophylline Toxicity
- tremors (an early manifestation of toxicity is CNS stimulation, often seen as tremors
- seizures can occur if blood levels continue to rise
,ATI Medical-Surgical CMS Review 2024/2025 (100%
verified)
Pressure Ulcer: Stage I
- The skin is intact, with an area of persistent, non-blanchable redness and typically over a bony
prominence
Pressure Ulcer: Stage II
- Involves partial-thickness skin loss of the epidermis and dermis
- ulcer is visible and superficial and may look like an abrasion, blister, or shallow crater
Pressure Ulcer: Stage III
- Involves full thickness tissue loss with damage or necrosis of subcutaneous tissue
- The damage might extend down to, but NOT through the underlying fascia
- It looks like a deep crater
Pressure Ulcer: Stage IV
- Full thickness tissue loss
- Visible damage to muscle, bone and supporting structures
- Sinus tracts, deep pockets of infection and tunneling may occur
Condition Assessment Findings: Peripheral Vascular Disease
- ankle swelling
- skin is warm to touch
- skin appears thick/brownish
- hairloss
- ulcers appear moist/bleeding
- edges of ulcers are uneven
Lab to Monitor Prior to Procedure: Liver Biopsy
- Prothrombin time
- Major complication of liver biopsy is hemorrhage
- Clients who have liver disease have clotting factor defects and increased risk for bleeding
Expected Lab Findings: Lumbar puncture for a client who has manifestations of bacterial meningitis.
- elevated protein
- elevated WBC
- decreased glucose
, ATI Medical-Surgical CMS Review 2024/2025 (100%
verified)
- elevated CSF pressure
- cloudy CSF
Adverse Effects: What should a nurse anticipate for a client who is receiving chemotherapy?
- pancytopenia (deficiency of WBCs, RBCs, and platelets) is an expected adverse effect of chemotherapy
Heterograft Dressings are obtained from where...
- heterografts are obtained from an animal, typically a pig
Client understanding: What statement would indicate a client understands pre-procedure education
for arthroscopy?
- "The doctor will be able to see if I have signs of rheumatoid arthritis"
- (arthroscopy helps with diagnosing musculoskeletal disorders such as rheumatoid arthritis,
osteoarthritis, and internal joint injuries)
Expected Assessment Findings: A nurse is assessing for disseminated intravascular coagulation (DIC) in
a client with septic shock, secondary to an untreated foot wound. What can they expect to find?
- bleeding at the venipuncture site
- petechiae on chest and arms
- abdominal distension (due to internal bleeding)
Drug Interaction: What interacts with the drug Probenecid
- aspirin decreases the effectiveness of probenecid
Anticipated orders/prescriptions: A nurse is admitting a client who has a diagnosis of cirrhosis. What
orders should the nurse anticipate?
- obtain the client's PT/INR
- administers lactulose 30 mL 4x/day
- obtain daily weight and abdominal girth measurement
- administer a daily vitamin
- high protein diet (vegetable proteins produce less ammonia)
Frostbite: 1st Degree
- skin of the affected area is reddened and looks waxy
Frostbite: 2nd Degree
- The skin of the affected area has large fluid-filled blisters
Frostbite: 3rd Degree
- the skin of the affected area has small blisters that are blood-filled
- the skin does not blanch
verified)
Nursing Interventions: A nurse is planning care for a client who is post-op for a radical mastectomy.
- Begin exercises with the client 1 day after the procedure.
- Exercises that do not stress the incision site can promote lymphatic return and mobility.
Pre-Operative Teaching: For a client that is scheduled for a "total knee arthroplasty"
- Teach that elastic stockings worn after surgery will help prevent venous embothrobolism
Highest Risk Factor: Bladder Cancer
- Tobacco use
Pre-procedure Client Education: Cardiac Catheterization
- The client should remain flat for 2-6 hours following the procedure.
- The client will receive mild sedatives for relaxation/comfort
- The client will need to keep their leg straight following the procedure.
Priority Nursing Actions: A client is being admitted with frequent coughing and frothy pink sputum.
The client has a Hx of night sweats, anorexia, and weight-loss.
- Assign the client to a private, NEGATIVE-PRESSURE room
- Initiate AIRBORNE precautions
- Wear N95 mask when entering the client's room
Nursing Interventions to be Included in a plan of care for a client who has deep partial-thickness burns
over 40% of his body and is in the acute phase of the burn injury.
- Begin performing active/passive range of motion exercises with the client.
- Maintains mobility and prevents contractures
"RIFLE" Classification for AKI: Risk of Renal Dysfunction
- < 0.5 mL/kg/hr of urine output for 6 hours
"RIFLE" Classification for AKI: Injury to Kidney
- < 0.5 mL/kg/hr of urine output for 12 hours
"RIFLE" Classification for AKI: Failure or Loss of Kidney function
- no urine (anuria) output for 12 hours or
- < 0.3 mL/kg/hr for 24 hours
,ATI Medical-Surgical CMS Review 2024/2025 (100%
verified)
"RIFLE" Classification for AKI: Loss
- no urine output without renal replacement therapy for 4 to 12 weeks
"RIFLE" Classification for AKI: End-Stage Renal Failure
- no urine output without renal replacement therapy for more than 3 months
Assessment Finding: Acute Intravascular Hemolytic Reaction
- sudden oliguria
- this type of transfusion reaction causes acute kidney injury (AKI) resulting in sudden oliguria and
hemoglobinuria
Nursing Plan of Care: A nurse is caring for a client with SIADH with mild symptoms. What Rx will be
anticipated?
- tolvaptan (Samsca) which is a vasopressin antagonist that promotes the excretion of water and
corrects the fluid imbalance in clients who have SIADH.
Drug Name: Chlorpropamide
- an anti-diabetic agent with antidiuretic effects that is used to treat diabetes insipidus
Drug Name: Vasopressin
- exogenous form of antidiuretic hormone that is used to treat diabetes insipidus
Drug Name: Demopressin
- a synthetic form of antidiuretic hormone that is used to treat diabetes insipidus
Adverse Effect: Lasik eye surgery
- dry eyes
- blurred vision
Procedure: Lasik Eye Surgery
- A procedure that can correct (1) nearsightedness, (2) farsightedness, and (3) astigmatism
- The procedure changes the shape of the cornea to correct vision.
Nursing Actions: For a client who is 3 days post-op following a below-the-knee operation.
- rewrap the residual limb with a pressure bandage 3x daily which ensures the residual limb will shrink
and also provides an opportunity to assess the skin for redness/breakdown
Drug Assessment Finding: Theophylline Toxicity
- tremors (an early manifestation of toxicity is CNS stimulation, often seen as tremors
- seizures can occur if blood levels continue to rise
,ATI Medical-Surgical CMS Review 2024/2025 (100%
verified)
Pressure Ulcer: Stage I
- The skin is intact, with an area of persistent, non-blanchable redness and typically over a bony
prominence
Pressure Ulcer: Stage II
- Involves partial-thickness skin loss of the epidermis and dermis
- ulcer is visible and superficial and may look like an abrasion, blister, or shallow crater
Pressure Ulcer: Stage III
- Involves full thickness tissue loss with damage or necrosis of subcutaneous tissue
- The damage might extend down to, but NOT through the underlying fascia
- It looks like a deep crater
Pressure Ulcer: Stage IV
- Full thickness tissue loss
- Visible damage to muscle, bone and supporting structures
- Sinus tracts, deep pockets of infection and tunneling may occur
Condition Assessment Findings: Peripheral Vascular Disease
- ankle swelling
- skin is warm to touch
- skin appears thick/brownish
- hairloss
- ulcers appear moist/bleeding
- edges of ulcers are uneven
Lab to Monitor Prior to Procedure: Liver Biopsy
- Prothrombin time
- Major complication of liver biopsy is hemorrhage
- Clients who have liver disease have clotting factor defects and increased risk for bleeding
Expected Lab Findings: Lumbar puncture for a client who has manifestations of bacterial meningitis.
- elevated protein
- elevated WBC
- decreased glucose
, ATI Medical-Surgical CMS Review 2024/2025 (100%
verified)
- elevated CSF pressure
- cloudy CSF
Adverse Effects: What should a nurse anticipate for a client who is receiving chemotherapy?
- pancytopenia (deficiency of WBCs, RBCs, and platelets) is an expected adverse effect of chemotherapy
Heterograft Dressings are obtained from where...
- heterografts are obtained from an animal, typically a pig
Client understanding: What statement would indicate a client understands pre-procedure education
for arthroscopy?
- "The doctor will be able to see if I have signs of rheumatoid arthritis"
- (arthroscopy helps with diagnosing musculoskeletal disorders such as rheumatoid arthritis,
osteoarthritis, and internal joint injuries)
Expected Assessment Findings: A nurse is assessing for disseminated intravascular coagulation (DIC) in
a client with septic shock, secondary to an untreated foot wound. What can they expect to find?
- bleeding at the venipuncture site
- petechiae on chest and arms
- abdominal distension (due to internal bleeding)
Drug Interaction: What interacts with the drug Probenecid
- aspirin decreases the effectiveness of probenecid
Anticipated orders/prescriptions: A nurse is admitting a client who has a diagnosis of cirrhosis. What
orders should the nurse anticipate?
- obtain the client's PT/INR
- administers lactulose 30 mL 4x/day
- obtain daily weight and abdominal girth measurement
- administer a daily vitamin
- high protein diet (vegetable proteins produce less ammonia)
Frostbite: 1st Degree
- skin of the affected area is reddened and looks waxy
Frostbite: 2nd Degree
- The skin of the affected area has large fluid-filled blisters
Frostbite: 3rd Degree
- the skin of the affected area has small blisters that are blood-filled
- the skin does not blanch
