ATI med-surg-study-guide_latest-fall-2020_-a-guide. (1)_removed

Removing a peripheral IV catheter- Answer: make sure the tip is intact 14. Patient has INR of 1.5 prior to surgery. What are you going to do? Answer: Prep the patient for surgery 15. Following the surgical placemen ...

Removing a peripheral IV catheter- Answer: make sure the tip is intact 14. Patient has INR of 1.5 prior to surgery. What are you going to do? Answer: Prep the patient for surgery 15. Following the surgical placement of a new ileostomy, which of the following would you teach them? Answer: chew food well Rationale: Patients with a new ostomy involving the small intestine (i.e. an ileostomy) are told post-op to avoid foods that increase flatus (green leafy vegetables, beer, carbonated beverages, dairy, and corn); avoid high-fiber foods for first 2 months; CHEW FOOD WELL; increase fluid intake; and evaluate evidence of blockage. 16. A patient is on isolation due to C difficile infection; which of the following represents correct infection protection protocol? Answer: Collect fecal sample with gloves 17. A patient (has either a list of symptoms or a new prescription for anti-coagulant) during medical history they report they have been TAKING IBUPROFEN FOR 3 YEARS. What lab would you expect to be drawn? Answer: Fecal Testing/Stool Guaiac/ Fecal Occult Blood Test (FOBT) 18. A patient has been on total parenteral nutrition for 10 full days, which of the following would be an indication that the nutrition therapy is effective? Answer: Potassium 4.0 (Pg.524) 19. Which of the following clients is MOST at risk for developing atelectasis? Answer: Post anesthesia for bowel resection o Rationale: This patient was the only patient who had abdominal surgery; patients with abdominal surgery are at the HIGHEST risk for atelectasis because the pain from incision/surgical procedure causes them to reflexively breathe in a shallow, cautious way. Positioning (guarding) also causes decreased in lung expansion. 20. The nurse is preparing a patient for paracentesis procedure, which of the following instructions would be given to the patient to decrease the risk of perforation? Answer: Instruct patient to empty their bladder prior to the procedure, this is done in order to decrease the size of a bladder and it reduces the chance of accidental bladder perforation.Pg 527 21. The nurse is providing home care for a patient receiving peritoneal dialysis, the patient has a fever of 102, and the catheter has decreased dialysate outflow. Which of the following should the nurse perform first? Answer: Reposition the patient o Rationale: Nursing Actions regarding reduced or inadequate outflow include: repositioning the client (b/c this moves the distal lumen of the catheter which may become pressed up against the abdominal wall = obstruction); milk the tubing if a visible clot is present in the catheter; check the tubing for kinks or closed clamps, determine when the patient’s last bowel movement was (constipation can also cause low outflow, pts on peritoneal dialysis are instructed to use a stool softener daily and consume a high-fiber