Questions and Answers
Which of the following actions should the nurse plan to take before performing ocular irrigation?
What is the setting in drops per minute for administering lactated ringer's at 200 ml/hr with a drop factor of 10 drops/ml?
33 gtt/min
Which client statement indicates an understanding of discharge teaching for sublingual nitroglycerin?
Which instruction should the nurse include in the discharge teaching for a client following a left total hip arthroplasty?
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Which action should the nurse take for a client following a cardiac catheterization?
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Which statement by a client indicates adaptation to using crutches?
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Which assessment finding indicates a client is experiencing dehydration?
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For a client with a contusion of the brainstem and high urinary output, which IV medication should the nurse anticipate?
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What should the nurse advise a client who has a nagging dry cough after starting an ACE inhibitor?
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Which finding should the nurse identify as a potential trigger for exacerbations of Raynaud's disease?
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What should the nurse take first when a client with a central venous access device experiences dyspnea and tachycardia?
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For a client with reddened areas over bony prominences, which intervention should the nurse include in the care plan?
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What is the priority action for a home health nurse visiting a client with multiple sclerosis?
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Which action should the nurse take first when assessing a client in the emergency department?
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For a client at increased risk for colorectal cancer, what finding should the nurse identify?
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What should the nurse say to a client unsure about having a mastectomy?
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Identify the sequence of steps a nurse should follow when preparing to administer a unit of packed RBCs.
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Which instruction should the nurse include for a client with mucositis related to chemotherapy?
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What Glasgow Coma Scale score should the nurse assign to a client with a severe head injury who doesn't respond to painful stimuli?
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Which statement indicates understanding of sodium intake restrictions for a client with heart failure?
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What is the first action the nurse should take when preparing for ocular irrigation after a chemical splash to the eye?
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Which of the following findings should the nurse intervene immediately after extubation?
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Which laboratory finding should the nurse expect for a client with acute pancreatitis?
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What finding should a nurse expect in a client with diabetes insipidus?
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Study Notes
Ocular Irrigation and Eye Care
- Perform ocular irrigation with sterile water to flush out chemicals or irritants.
- Assess visual acuity prior to irrigation.
- Hold irrigator syringe approximately 1.5 inches above the eye.
IV Infusion Calculations
- Continuous IV infusion of lactated Ringer's at 200 ml/hr requires a rate of 33 gtt/min using tubing with a drop factor of 10 drops/ml.
Sublingual Nitroglycerin
- Advise to lie down when taking sublingual nitroglycerin.
- Replace medication every 6 months; do not stop if headaches occur without consulting a provider.
- Up to five tablets may be taken within 15 minutes before seeking emergency care.
Post-Hip Arthroplasty Care
- Recommend installing a raised toilet seat for ease of use after hip arthroplasty.
- Crossed legs should be avoided to prevent dislocation.
Cardiac Catheterization Recovery
- Maintain the affected extremity in extension and keep patient on bed rest for the prescribed duration.
Role Change Adaptation
- Acknowledge the necessity for a partner to assist with household tasks after acquiring crutches.
Gastroenteritis and Dehydration
- Decreased blood pressure is a key sign of dehydration in gastroenteritis patients.
Brainstem Injury Care
- Anticipate a prescription for desmopressin in cases of excessive urinary output in clients with brainstem injury.
ACE Inhibitor Side Effects
- A nagging dry cough often arises from ACE inhibitors, possibly necessitating a change in medication.
Raynaud's Disease Triggers
- Using nicotine transdermal patches may exacerbate symptoms of Raynaud's disease.
Central Venous Access Care
- In the case of disconnection leading to dyspnea, first action: clamp the catheter to prevent air embolism.
Skin Integrity in Older Adults
- For intact skin with reddened areas over bony prominences, support with pillows; do not massage.
Multiple Sclerosis Home Care
- Prioritize discussing eating and swallowing recommendations to enhance safety and nutrition.
Emergency Department Protocols
- In assessing a client, initiate airborne precautions to prevent the spread of infection.
Colorectal Cancer Risk Factors
- A history of Crohn's disease classifies as a significant risk factor for colorectal cancer.
Mastectomy Patient Education
- Provide comprehensive information about the mastectomy procedure to alleviate concerns.
Blood Transfusion Protocol
- Follow a specific sequence for administering packed RBCs, including obtaining venous access and verifying compatibility.
Mucositis Management
- Flossing teeth after meals is crucial in patients with mucositis to maintain oral hygiene without irritation.
Glasgow Coma Scale Assessment
- A score of 5 indicates severe impairment with non-responsiveness to stimuli, decerebrate posturing, and incomprehensible sounds.
Sodium Intake in Heart Failure
- Heart failure patients should adhere to a 2 g sodium limit; healthy alternatives include frozen fruit juice for dessert.
Emergency Ocular Care
- Collect information about the irritant causing eye injury as the first action before irrigation.
Post-Extubation Monitoring
- Stridor indicates a potential airway obstruction and requires immediate intervention post-extubation.
Acute Pancreatitis Laboratory Expectations
- Elevated blood glucose levels are common in cases of acute pancreatitis, signaling metabolic distress.
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Test your knowledge with these flashcards focused on the Med Surg ATI proctored exam. Each card presents a scenario relevant to ocular irrigation and emergency procedures. Enhance your nursing skills and preparation for clinical situations by reviewing these important concepts.
