Med-Surg ATI Practice Exam Concepts

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 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) 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 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 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 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