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Bundle of HURTS exam, graded A+
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HURST Review: Renal questions and answers, graded A+
Glomerulonephritis: Acute can lead to chronic Glomerulonephritis: It is an inflammatory reaction in the glomerulus Glomerulonephritis: Anti... [Show More] bodies lodge in the ________________, causing _____________________________________ glomerulus; scarring and decreased filtering Glomerulonephritis: Main cause streptococcus (Group A beta) (attacks the valves in the heart) Glomerulonephritis: Signs/Symptoms -flank pain -oliguria -hematuria -proteinuria -periorbital edema -increased BP -FVE -increased urine specific gravity -azotemia -malaise and H/A Glomerulonephritis Signs/Symptoms: Flank pain is costovertebral angle tenderness (CVA tenderness) -tap on back to see how high the infection is in the kidney Glomerulonephritis Signs/Symptoms: Periorbital edema will progress to other areas of the body Glomerulonephritis Signs/Symptoms: Azotemia is abnormally high BUN and creatinine Glomerulonephritis Signs/Symptoms: Why does the client experience malaise and H/A? toxins Glomerulonephritis: Treatment -get rid of the strep or cause -I & O and daily weights -diuretics -monitor BP -restrict fluids -balance activity with rest -dialysis -modify dietary needs Glomerulonephritis Treatment: How is fluid replacement determined? 24 hour fluid loss + 500 mL Glomerulonephritis Treatment: How are dietary needs modified? -increased carbs -decreased sodium -decreased protein (makes BUN go up) Glomerulonephritis Client Teaching: Diuresis begins in 1 to 3 weeks after onset Glomerulonephritis Client Teaching: ____________________ may stay in the urine for _________________ Blood and urine; months Glomerulonephritis Client Teaching: Teach the signs/symptoms of renal failure Glomerulonephritis Client Teaching: Signs/Symptoms of renal failure -malaise -H/A -anorexia -nausea -vomiting -decreased output -weight gain Glomerulonephritis Client Teaching: If you notice s/s of renal failure present.... call the provider Nephrotic Syndrome: These clients lose a lot more protein than clients with glomerulonephritis Nephrotic Syndrome: Pathophysiology -it is an inflammatory response in the glomerulus -big holes form so protein starts leaking out in the urine (proteinuria) -NOW the client is hypoalbuminemic -without albumin you can't hold onto fluid in the vascular space -so the fluid goes out into the tissues -NOW the client has edema -the circulating blood volume is decreased as a result -the kidneys sense this decrease & the want to replace it -the RAS system kicks in -aldosterone is produced and retains sodium and water -but there is no protein (albumin) in the vascular space to hold it -so this fluid goes into the tissues (MORE edema) -this results in ANASARCA Nephrotic Syndrome: What is anasarca? total body edema Nephrotic Syndrome: Problems associated with protein loss -blood clots (thrombosis) -increased cholesterol -increased triglycerides Nephrotic Syndrome: Why would blood clots form as a result of protein loss? they are losing proteins that normally prevent their blood from clotting Nephrotic Syndrome: Why are levels of cholesterol and triglycerides increased with protein loss? the liver compensates by making more albumin causing an increased release of cholesterol and triglycerides Nephrotic Syndrome: Causes are idiopathic (unknown cause), but have been related to -bacteria or viral infections -NSAIDs -cancer and genetic predispositions -systemic diseases such as lupus or diabetes Nephrotic Syndrome: Signs/Symptoms -massive proteinuria -hypoalbuminemia -edema (anasarca) -hyperlipidemia Nephrotic Syndrome: Treatment includes -diuretics -ACE inhibitors -prednisone -cyclophosphamide -diet -lipid lowering drugs -anticoagulation therapy -dialysis Nephrotic Syndrome Treatment: We give ACE inhibitors to block aldosterone secretion Nephrotic Syndrome Treatment: We give prednisone for inflammation Nephrotic Syndrome Treatment: We give cyclophosphamide to decrease the body's immune response Nephrotic Syndrome Treatment: How does cyclophosphamide decrease the immune response? shrink holes so protein can't get out Nephrotic Syndrome Treatment: Patients on cyclophosphamide are immunosuppressed Nephrotic Syndrome Treatment: Major complication of nephrotic syndrome and being on cyclophosphamide infection Nephrotic Syndrome Treatment: How much protein should these clients receive? 1 to 2 grams/kg/day Nephrotic Syndrome Treatment: The client can become _______________________ fast malnourished Nephrotic Syndrome Treatment: We should decrease their ________________ intake sodium Nephrotic Syndrome Treatment: RULE limit protein with kidney problems EXCEPT with nephrotic syndrome Nephrotic Syndrome Treatment: We need to take daily weights and I & Os Nephrotic Syndrome Treatment: Measure abdominal girth or extremity size Nephrotic Syndrome Treatment: They need good skin care Acute Kidney Injury (AKI): This is a sudden episode of renal damage Acute Kidney Injury (AKI): Goal reverse it to prevent chronic renal failure Acute Kidney Injury (AKI): 3 Types 1. Pre-renal 2. Intra-renal 3. Post-renal Acute Kidney Injury (AKI): Which of the 3 types occur 60-70% of the time? pre-renal Acute Kidney Injury (AKI): Pre-renal failure is when blood can't get to the kidneys Acute Kidney Injury (AKI): Causes of pre-renal failure -hypotension -decreased HR (arrhythmia) -hypovolemia -any type of shock Acute Kidney Injury (AKI): Intra-renal failure is when damage has occurred within the kidney Acute Kidney Injury (AKI): Causes of intra-renal failure -glomerulonephritis or nephrotic syndrome -malignant hypertension (uncontrolled HTN) -diabetes mellitus -acute tubular necrosis -dyes used in test such as heart cath & CT scan -drugs (aminoglycosides - "-miacins") -NSAIDS Acute Kidney Injury (AKI): Acute tubular necrosis is damage to the filtering bodies of the kidneys Acute Kidney Injury (AKI): What causes acute tubular necrosis? -hypotension -sepsis -drugs that damage kidneys (dyes) Acute Kidney Injury (AKI): Post-renal failure is when urine can't get out of the kidneys Acute Kidney Injury (AKI): Causes of post-renal failure -enlarged prostate -kidney stone -tumors -ureteral obstruction -edematous stoma (ileal conduit) Acute Kidney Injury (AKI): 4 phases of acute kidney injury 1. initiation phase (injury occurs) 2. oliguric phase (output may be < or equal to 100 mL/24 hr) 3. diuretic phase (kidney recovering) 4. recovery phase (3-12 months) Acute Kidney Injury (AKI): Signs/Symptoms -increased BUN & creatinine -increased or fixed specific gravity -HTN -HF -anorexia, nausea, vomiting -uremic frost -retain phophorus -anemia -hyperkalemia -metabolic acidosis Acute Kidney Injury (AKI) Signs/Symptoms: Why would the urine specific gravity be fixed? because they may lose their ability concentrate and dilute urine (nothing to do with hydration) Acute Kidney Injury (AKI) Signs/Symptoms: Why would the client have HTN and/or HF? retaining fluid Acute Kidney Injury (AKI) Signs/Symptoms: Why would the client experience anorexia, nausea, and vomiting? retaining toxins Acute Kidney Injury (AKI) Signs/Symptoms: Because of uremic frost, clients need good skin care Acute Kidney Injury (AKI) Signs/Symptoms: Because clients retain phophorous, their serum calcium decreases (calcium being pulled from bones) Acute Kidney Injury (AKI) Signs/Symptoms: Why would these clients have anemia? not enough erythropoietin being made by the kidneys Acute Kidney Injury (AKI) Signs/Symptoms: Hyperkalemia can cause lethal arrhythmias Acute Kidney Injury (AKI) Signs/Symptoms: Why would these clients have metabolic acidosis? unable to filter hydrogen or bicarb Acute Kidney Injury (AKI) Treatment: Goals -prevent complications -manage s/s -eliminate the cause of the kidney injury Acute Kidney Injury (AKI) Treatment: Nursing Measures -bedrest (to decrease metabolism & caloric needs) -TCDB (turn, cough, deep breathe) -monitor I & Os -daily weights -monitor VS closely Acute Kidney Injury (AKI) Treatment: 1 kg = 1,000 mL of fluid Acute Kidney Injury (AKI) Treatment: Medications -loop diuretics or osmotic diuretics -IV glucose and insulin (hyperkalemia) -IV calcium gluconate (dysrhythmias) -polystyrene sulfonate (excrete potassium) -phosphate binding drugs (prevent hypocalcemia) Acute Kidney Injury (AKI) Treatment: Give any IV medications in the smallest volume allowed to avoid overloading the client Acute Kidney Injury (AKI) Treatment: Regarding nutrition, we need to increase carbohydrates and fats Acute Kidney Injury (AKI) Treatment: Regarding nutrition, clients need a low protein diet Acute Kidney Injury (AKI) Treatment: Regarding nutrition, clients need to avoid foods/fluids high in phosphate Acute Kidney Injury (AKI) Treatment: Regarding nutrition, clients need to avoid foods high in potassium like bananas, citrus, and coffee Acute Kidney Injury (AKI) Treatment: Prevent infection by -using aseptic technique -meticulous skin care -preventing pressure ulcers -mouth care -no catheter, if possible -protect from others who have an infectious disease Acute Kidney Injury (AKI) Treatment: What is the leading cause of death? infection Acute Kidney Injury (AKI) Treatment: What may be needed? Renal replacement therapy (RRT) Acute Kidney Injury (AKI) Treatment: The nurse needs to support the client and family Acute Kidney Injury (AKI) Treatment: The oliguric phase ends in 10-14 days Acute Kidney Injury (AKI) Treatment: Diuretic phase begins when output increases Acute Kidney Injury (AKI) Treatment: Fluid and electrolyte replacement is based on lab results Acute Kidney Injury (AKI) Treatment: During the recovery phase, client is placed on increased protein and increased calories Acute Kidney Injury (AKI) Treatment: During the recovery phase, the client is to resume activity as tolerated Renal Replacement Therapy (RRT): These therapies take over or replace the kidney function Renal Replacement Therapy (RRT): When is it started? -when BUN and creatinine levels can't be decreased -when FVE is compromising the heart and lungs -when hypercalcemia and metabolic acidosis can't be treated successfully Renal Replacement Therapy (RRT): This includes -hemodialysis -continuous renal replacement therapy -peritoneal dialysis Renal Replacement Therapy (RRT) - Hemodialysis: The machine is the glomerulus (filter) Renal Replacement Therapy (RRT) - Hemodialysis: It is done _________________________, so the client has to ____________________________ between treatments 3-4 times per week; watch what they eat and drink Renal Replacement Therapy (RRT) - Hemodialysis: The client is given ________________________ during dialysis to prevent ______________________ an anticoagulant; blood clots from forming Renal Replacement Therapy (RRT) - Hemodialysis: What anticoagulant is usually given and what must be implemented as a result? Heparin usually and bleeding precautions should be implemented Renal Replacement Therapy (RRT) - Hemodialysis: These clients can be ______________________ and can lead to ____________________ depressed; suicide (eating something they shouldn't) Renal Replacement Therapy (RRT) - Hemodialysis: Before beginning, assess fluid status Renal Replacement Therapy (RRT) - Hemodialysis: What are watched constantly during hemodialysis? electrolytes and BP Renal Replacement Therapy (RRT) - Hemodialysis: Not all clients can tolerate this. These are usually clients with an unstable cardiovascular system Renal Replacement Therapy (RRT) - Hemodialysis: This requires vascular access Renal Replacement Therapy (RRT) - Hemodialysis: Blood is being removed, cleansed, and then returned at a rate of 300 to 800 mL/min Renal Replacement Therapy (RRT) - Hemodialysis: What is a vascular access? a site where they have access to a large blood vessel because very rapid blood flow is essential for hemodialysis Renal Replacement Therapy (RRT) - Hemodialysis: What types of vascular access are there? -AVF (arteriovenous fistula) -AVG (arteriovenous graft) [Show Less]
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Hurst Readiness Exam 1, questions and answers 100% correct
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women i... [Show More] dentify which hormone as causing amenorrhea? 1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG) Rationale 1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital tract suitable for fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle in the ovary. 4. Incorrect: This is the hormone present in urine for pregnancy test The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect? 1. Mediastinal shift 2. Tension pneumothorax 3. Flail chest 4. Pulmonary contusion Rationale 3. Correct: Hallmark of flail chest is paradoxical chest wall movement. This is often described as a see-saw effect when observing the rise and fall of the chest. 1. Incorrect: A closed or open tension pneumothorax results from the lung collapsing and air entering into the pleural cavity. This results in pressure shifting toward the unaffected pleural cavity. 2. Incorrect: Tension pneumothorax occurs when there is an accumulation of air in the pleural cavity. The client may exhibit dyspnea, tachycardia, or hypotension. 4. Incorrect: A pulmonary contusion usually results from blunt trauma. Bruising of lung would be demonstrated by pain but not paradoxical chest wall movement. Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? 1. Client admitted with possible tuberculosis (TB) awaiting skin test results. 2. Client diagnosed with seizure disorder. 3. Client with a new pacemaker scheduled to be discharged in the morning. 4. Client with a history of mild heart failure prescribed one unit of packed red blood cells for anemia. Rationale 2. Correct: OB nurses would have the appropriate knowledge needed to care for a client with a seizure disorders, because they care for clients who have eclampsia (seizures). 1. Incorrect: This client might have tuberculosis (TB) and is not a good choice to move to the OB floor, because of the risk for transmission of an infectious disease. 3. Incorrect: This client is not the best one to be transferred to the OB floor, because these nurses do not routinely care for clients with a new pacemaker. The client is also likely to remain on a cardiac monitor until discharge. 4. Incorrect: This client is at risk for fluid volume overload since there is a history of heart failure and would require close monitoring while receiving a blood transfusion. The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include? 1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses. Rationale 1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time 30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to moisten the skin. Lotion will also soften calluses. A lotion that reduces dryness effectively is a mixture of lanolin and mineral oil. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary healthcare provider first. When caring for young adult clients, which developmental tasks would the nurse expect to see? 1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 3. Developing meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be given or shared in return. 5. Developing sense of fulfillment by volunteering in the community. Rationale 3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust. 1. Incorrect: Parenting is a primary task of middle adulthood. This is the middle adulthood stage of Generativity versus Stagnation, where each adult must find some way to satisfy and support the next generation. 2. Incorrect: During late adulthood, there is refection on life accomplishments. This is the maturity stage of Ego Integrity versus Despair, where there is a reflection of one's life. 5. Incorrect: During middle age, a sense of fulfillment can be found by volunteering in the community. This is part of middle age, where the adult is finding ways to support others. What symptoms does the nurse expect to see in a client with bulimia nervosa? 1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise Rationale 2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating: recurrent inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. Amenorrhea is found in anorexia nervosa. 1. Incorrect: Amenorrhea is found in anorexia nervosa. 5. Incorrect: Excessive exercise is found in bulimia nervosa as a means to compensate for the binge eating. A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? 1. Surgical cannulation of the bile duct is causing spasm and pain. 2. Carbon dioxide used intraperitoneally is irritating the phrenic nerve. 3. Large abdominal retractors used in the procedure compressed a nerve. 4. Side lying position in the operating room generated pressure damage. Rationale 2. Correct: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon dioxide (CO2) is used to inflate the abdominal/chest wall during the procedure for better visualization of the internal organs. If the CO2 irritates the phrenic nerve, it radiates to the shoulder. 1. Incorrect: Surgical cannulation of the bile duct is not performed during a laparoscopic cholecystectomy. 3. Incorrect: Large abdominal retractors are not used during this procedure. This is done via a small incision to accommodate a scope. 4. Incorrect: The client is turned in several directions during the procedure to prevent damage to the abdominal viscera. A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Rationale 2. Correct: This client has a severe infection. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: Not acidosis with hyperventilation and pH of 7.53. 3. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range and is not acidosis. 4. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range. An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed? 1. "Soap and water should be used for hand washing when our hands are visibly soiled." 2. "Gloves do not have to be worn when taking a client's vital signs or passing out meal trays." 3. "Standard precautions should be used on all clients." 4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn." Rationale 4. Correct: Standard precautions are needed. If there is a risk for coming in contact with client secretions or excretions, a standard mask may be worn. Routine nursing care does not warrant the use of an N95 mask. This type mask is needed for client's who are placed on Airborne Precautions such as for tuberculosis (TB). 1. Incorrect: This is a correct statement regarding the prevention of infection. Hand washing with soap and water is part of standard precautions. 2. Incorrect: This is a correct statement. Gloves are needed when coming into contact with body fluids. 3. Incorrect: This is a correct statement. Standard precautions is part of the first line of defense against the spread of infection. The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? 1. Cottage cheese 2. Salami 3. Baked chicken 4. Potatoes Rationale 2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid foods rich in tyramine or tryptophan. These include: cured foods, those that have been aged, pickled, fermented, or smoked. These can precipitate a hypertensive crisis. 1. Incorrect: Clients taking MAOIs can eat cottage cheese in reasonable amounts. 3. Incorrect: Clients taking MAOIs can eat baked chicken. 4. Incorrect: Clients taking MAOIs can eat potatoes. Which nurse is providing cost effective care to a client? 1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves. Rationale 1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well-established interventions that are effective and also are cost-effective. Two additional preventive interventions were found to be cost-saving: childhood immunization and counseling adults on the use of low dose aspirin. 5. Incorrect. A postop surgical wound dressing change is a sterile procedure: Sterile gloves are necessary and failure to use them could lead to infection, which would then increase the cost of care to a client. A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12. What is the priority nursing intervention for this client? 1. Continue to assess every 15 minutes. 2. Stimulate the client with a sternal rub. 3. Administer acetaminophen with codeine for headache. 4. Notify the primary healthcare provider. Rationale 4. Correct: On the Glasgow coma scale, we like a number between 13 to 15. This assessment score has dropped to 12, so the client is getting worse and the headache could mean increasing intracranial pressure (ICP). This is the only intervention that can fix the problem. 1. Incorrect: Reassessing in 15 minutes is delaying treatment. When neuro changes start happening, they happen rapidly. 2. Incorrect: Stimulating the client will increase the client's ICP. 3. Incorrect: A sedative should NOT be administered. The client's level of conscious has decreased. The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment? 1. Dramatic decrease in pain after beginning medications. 2. Severe abdominal pain following medication administration. 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash. Rationale 1. Correct. The client usually experiences dramatic improvement within 24 hours after beginning NSAIDs. 2. Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain in experienced, the primary healthcare provider should be notified immediately. 3. Incorrect. NSAIDs do not reduce plasma uric acid levels. 4. Incorrect. This is not an adverse effect of NSAIDs, in fact, most NSAIDs are also antipyretics and would prevent fever. A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? 1. Use simple words. 2. Speak loudly to the client. 3. Do not speak to the client at this time. 4. Use open-ended questions to ask what is wrong. Rationale 1. Correct: Use simple words, because the client cannot comprehend anything but the most elemental communications during a panic attack. 2. Incorrect: A calm, low level of intensity to reduce anxiety is needed. Speaking loudly will increase the client's anxiety. 3. Incorrect: Calm, simple words are needed instead of silence which could be interpreted as ignoring the client. 4. Incorrect: Simple communication of reassurance needed. This is not the time for open ended questions and would increase the client's anxiety. The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor. Rationale 2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a depilatory cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 5. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought about getting a family member to help with the baby?" Rationale 3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked. 1. Incorrect: Maternity blues includes tearfulness, despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening problem. Assume the worse. Think about the safety of mom and baby. The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin. Rationale 3. Correct: All hazardous materials must have a MSDS, which includes the identity of the chemical, the physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the name of the manufacturer or distributor. 1. Incorrect: The nurse should look at the MSDS, the best source of information. Calling another department does not ensure that the nurse will get as comprehensive information as the MSDS provides. 2. Incorrect: The drug handbook is for medication, not handling of hazardous material. 4. Incorrect: The nurse can place the biopsy into a container with formalin and is within the scope of practice for the nurse. The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? 1. Confusion and disorientation. 2. Scared and lonely and grabs the nurse's hand for comfort. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse. Rationale 2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client. 1. Incorrect: There is no indication of confusion or disorientation. 3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch. 4. Incorrect: There is no indication of a desire to reminisce from the information in the question. A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider? 1. Blood pressure 136/84 2. Report of nausea 3. Anxiety 4. Urinary output at 50 mL/hour Rationale 3. Correct: Anxiety, restlessness, or a sense of apprehension is often the first sign/symptoms of acute pulmonary edema. 1. Incorrect: Blood pressure is normal. The number one concern right now is the anxiety: an early sign of pulmonary edema. 2. Incorrect: Although we would want to help the client having nausea, the anxiety is of upmost importance, as it might indicate acute pulmonary edema. 4. Incorrect: The client is dehydrated. A urinary output of 50 mL/hr, although low, is not at a critical level. Signs of pulmonary edema will take priority. The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? 1. Educating the client regarding pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques. Rationale 2., 3., 4. & 5. Correct: Assisting the client to a side lying position, providing a back massage, providing heat therapy, and using distraction techniques are all proven interventions that can raise the client's pain threshold. In other words, raise the level at which a client first perceives a stimulus as pain. All of these provide comfort, are non-invasive, and show the client that the nurse cares. 1. Incorrect: Education regarding pain control does not help the client's pain and would not be appropriate while the client is experiencing pain. The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number. Rationale 5mg x 18 kg = 90 mg/day Which client diagnosis would require the nurse to initiate droplet precaution? 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Varicella 3. Vancomycin-resistant enterococci (VRE) 4. Whooping cough Rationale 4. Correct: Droplet isolation precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). Healthcare workers should wear a surgical mask while in the room. Mask must be discarded in trash after leaving the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. 1. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room {examples: MRSA, VRE, diarrheal illnesses, open wounds, Respiratory syncytial virus (RSV)}. Healthcare workers should wear a gown and gloves while in the client's room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. 2. Incorrect: Airborne isolation precautions are used for diseases or very small germs that are spread through the air from one person to another (examples: Tuberculosis (TB), measles, varicella). Healthcare workers should ensure client is placed in an appropriate negative air pressure room (a room where the air is gently sucked outside the building) with the door shut. Wear a fit-tested NIOSH-approved N-95 or higher level respirator while in the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. Ensure the client wears a surgical mask when leaving the room. Instruct visitors to wear a mask while in the room. 3. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV). Healthcare workers should wear a gown and gloves while in the client's room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two year old taking only clear liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula. Rationale 1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate. 2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a nutritional evaluation receiving supplementation for nutritional needs. After reviewing the nutritional evaluation, the TPN will be formulated accordingly. 3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on liquids for more than 3 days, then would be at nutritional risk. After 3 days the nutritional status of the child should be evaluated due to the food restrictions of a clear liquid diet. 4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is tolerated, then the strength will be advanced; therefore, this client is not at risk. [Show Less]
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HURST Review: Neuro questions and answers with rated solutions
Neurological Assessment includes -client's current condition -Glasgow Coma Scale -pupillary changes -hand grips/leg lifts/pushing strength of feet -Ba... [Show More] binski reflex Neurological Assessment of Client's Current Condition - Onset: It's important to know when the symptoms started Neurological Assessment of Client's Current Condition - Onset: Ask them _______________________________ and what ____________________________ when was the onset; symptoms did the client have intially Neurological Assessment of Client's Current Condition - Description of Symptoms: Have them describe Neurological Assessment of Client's Current Condition - Description of Symptoms: Know the ________________, how __________________________, and how _______________ location; long the symptoms have persisted; severe Neurological Assessment of Client's Current Condition - Associated Factors: Determine if there were any __________________________________ associated with the symptoms triggers or aggravating factors Neurological Assessment of Client's Current Condition - Associated Factors: Ask them "did anything ________________________ the symptoms?" help relieve Neurological Assessment of Client's Current Condition - Overall Appearance: Note the client's general appearance and behavior Neurological Assessment of Client's Current Condition - Overall Appearance: Observe if there are any ______________________________ of a ____________________________ deficit? obvious signs; neurological (speech slur? drooping side of face?) Neurological Assessment of Client's Current Condition - Degree of Consciousness: What is the MOST important aspect of the neuro exam? assessment of the client's mental status, including LOC Neurological Assessment of Client's Current Condition - Degree of Consciousness: Mental status includes -awareness of surroundings and alertness -orientation to person, place, and time -memory: both short-term and long-term Neurological Assessment of Client's Current Condition - Degree of Consciousness: The most sensitive indicator of neuro status is LOC Neurological Assessment of Client's Current Condition - Degree of Consciousness: A change in LOC may be the first sign that there is a problem Neurological Assessment - Glasgow Coma Scale: This scale is used to assess the LOC in a client who already has altered consciousness or has the potential of altered consciousness Neurological Assessment - Glasgow Coma Scale: This scale is used primarily in the ED or ICU Neurological Assessment - Glasgow Coma Scale: The definition of this scale is a scale that measures the degree of LOC Neurological Assessment - Glasgow Coma Scale: 3 responses of this scale 1. eye opening 2. motor response 3. verbal response Neurological Assessment - Glasgow Coma Scale: RULE - we like a high number ranging from 13 to 15 Neurological Assessment - Glasgow Coma Scale: What is always #1 with neurological assessment? LOC Neurological Assessment - Glasgow Coma Scale: Eye Opening (E) scores 4 - spontaneous 3 - to verbal command 2 - to pain 1 - no response Neurological Assessment - Glasgow Coma Scale: Motor Response (M) scores 6 - to verbal command 5 - to localized pain 4 - flexed/withdraws 3 - flexes abnormally 2 - extends abnormally 1 - no response Neurological Assessment - Glasgow Coma Scale: Verbal Response (V) scores 5 - oriented/talks 4 - disoriented/talks 3 - inappropriate words 2 - incomprehensible sounds 1 - no response Neurological Assessment - Glasgow Coma Scale: The total score is determined using what formula? E + M + V Neurological Assessment - Pupillary changes: Determined using PERRLA Neurological Assessment - Pupillary changes: Normal pupil size 2-6 mm Neurological Assessment - Hand Grips/Leg Lifts/Pushing Strength of Feet: This is assessed for strength and equality and if client will follow a command Neurological Assessment - Babinski Reflex: Normal in an infant up to 1 year Neurological Assessment - Babinski Reflex: Though it is normal in an infant up to 1 year, it may be seen up to 2 years (should disappear when walking starts) Neurological Assessment - Babinski Reflex: Abnormal in an adult Neurological Assessment - Babinski Reflex: The adult or child greater than 1 year should have a normal reflex or ____________________________ when the bottom of the foot is stroked curling of the toes (Plantar Reflex) Neurological Assessment - Babinski Reflex: What does it mean if the adult has a Babinski reflex or fanning of the toes when you stroke the bottom of the foot? there is a severe problem in the CNS that is affecting an upper motor neuron Neurological Assessment - Babinski Reflex: Possible causes of a Babinski reflex in an adult -tumor or lesion on the brain or spinal cord -meningitis -multiple sclerosis -Lou Gehrig's disease Neurological Assessment - Deep Tendon Reflex Scale: 0 is no response (absent) Neurological Assessment - Deep Tendon Reflex Scale: 1+ is present, but sluggish or diminished (hypoactive) Neurological Assessment - Deep Tendon Reflex Scale: 2+ is active or expected response (normal) Neurological Assessment - Deep Tendon Reflex Scale: 3+ is more brisk than expected. slightly hyperactive, but not necessarily pathological Neurological Assessment - Deep Tendon Reflex Scale: 4+ is brisk, hyperactive, with intermittent or transient clonus Neurological Assessment - Deep Tendon Reflex Scale: An ankle clonus is a series of abnormal reflex movements of the foot, induced by sudden dorsiflexion Neurological Assessment - Deep Tendon Reflex Scale: A normal reflex response would be documented as 2+/4+ (you put the score you got over the highest number on the scale) (documented this way because different nurses use different scales) General Diagnostic Tests - Lumbar Puncture: Where is the puncture site? lumbar subarachnoid space General Diagnostic Tests - Lumbar Puncture: 3 Purposes 1. obtain CSF 2. measure pressure readings with a manometer & reduce CSF pressure 3. administer drugs intrathecally (into the spinal canal) General Diagnostic Tests - Lumbar Puncture: Why would we want to obtain CSF? to analyze for blood, infection, and even tumor cells General Diagnostic Tests - Lumbar Puncture: How is the client positioned and why? propped up over the bedside table with head down or on side in fetal position (chin to chest and knees flexed) to add a lot of arch to the back (opens up space between the vertebrae) General Diagnostic Tests - Lumbar Puncture: If the patient is tense during the LP, the results will be falsely elevated General Diagnostic Tests - Lumbar Puncture: Inspect the surrounding skin at the puncture site for any infection General Diagnostic Tests - Lumbar Puncture: CSF should be clear and colorless (looks like water) General Diagnostic Tests - Lumbar Puncture: Post-procedure the client should lie _________________ for ________________ because _____________________ flat or prone; 4-8 hours; want a seal to form General Diagnostic Tests - Lumbar Puncture: Post-procedure we want to increase fluids to replace lost CSF and reduce the risk of complications General Diagnostic Tests - Lumbar Puncture: What is the most post-procedure complication? headache General Diagnostic Tests - Lumbar Puncture: The pain of a post-procedure H/A ________________________ when the client sits up or stands up and ________________________ when they lie down increases; decreases General Diagnostic Tests - Lumbar Puncture: How is a post-procedure H/A treated? -bed rest -fluids -pain meds -blood patch General Diagnostic Tests - Lumbar Puncture: Big complications are -brain herniation -infection General Diagnostic Tests - Lumbar Puncture: With known increased ICP, a LP is contraindicated General Diagnostic Tests - Lumbar Puncture: The brain is pulled down with a LP so if you suspect brain herniation or IICP NOTIFY MD General Diagnostic Tests - Lumbar Puncture: Bacteria can get into the _____________________ and ________________ and would cause ____________________ puncture site; spinal fluid; meningitis Intracranial Pressure: Earliest sign of IICP change in LOC Intracranial Pressure: A change in LOC may be as pronounced as _________________ or as subtle as ________________________ going into a coma; a change in attention span Intracranial Pressure: Early signs/symptoms of IICP -change in LOC (earliest sign) -slurred or slowed speech -delay in response to verbal suggestion -increase in drowsiness -restlessness for no apparent reason -confusion Intracranial Pressure: Late signs/symptoms of IICP -marked change in LOC progressing to stupor, then coma -VS changes (Cushing's triad) -decerebrate and decorticate posturing Intracranial Pressure: Cushing's Triad requires immediate intervention to prevent further brain ischemia and restore perfusion Intracranial Pressure: Cushing's Triad consists of -systolic hypertension w/widening pulse pressure -slow, full, and bounding pulse -irregular respirations (look for change in pattern, like Cheyne-Stokes or ataxic respirations) Intracranial Pressure: Decerebrate and decorticate posturing indicate that the motor response centers of the brain, mid-brain, and the brain stem are compromised Intracranial Pressure: Decorticate posturing is present with arms flexed inward and bent in toward the body and the legs extended Intracranial Pressure: Decerebrate posturing is present with all 4 extremities in rigid extension Intracranial Pressure: With decerebrate and decorticate posturing, the client will be rigid, tight, and burning more calories Intracranial Pressure: Which posturing is the worst? decerebrate posturing Intracranial Pressure: Miscellaneous Signs of IICP -H/As -change in pupils and pupil response -projectile vomiting Intracranial Pressure: RULE-anytime you have a client with a head injury, if they start complaining of a H/A, assume their ICP is going up [Show Less]
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Hurst Review Questions (7) questions and answers with rated solutions
The nurse is caring for a client with body dysmorphic disorder. The client tells the nurse, "My ugly ears make everyone sick!" Which defense mechanism is t... [Show More] his client utilizing? Select all that apply 1. Sublimation 2. Somatization 3. Symbolism 4. Projection 5. Conversion 3. Symbolism 4. Projection Which client should the nurse recognize as being at greatest risk for the development of cancer? 1. Smoker for 30 plus years 2. Body builder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome 4. Older individual with acquired immunodeficiency syndrome 00:02 01:20 A client is seen at the clinic two weeks after starting amitriptyline. The client reports improved sleep patterns and appetite, but no change in feelings of sadness or depression. What comment by the nurse is most appropriate? 1. "Would you like me to ask the doctor to increase your dose?" 2. "You might need to be changed to a different medication." 3. "Tell me what type of situations make you feel depressed." 4. "Some medications take a little longer to improve moods." 4. "Some medications take a little longer to improve moods." What is the primary electrolyte that the nurse should be aware to monitor for in a client who is receiving an insulin infusion? 1. Sodium 2. Potassium 3. Calcium 4. Phosphorus 2. Potassium Calculator A nurse is providing care to a post-operative parathyroidectomy client. Which occurrence takes highest priority? 1. Psychoses 2. Renal calculi 3. Positive Trousseau's sign 4. Laryngospasm 4. Laryngospasm The unlicensed assistive personnel (UAP) reports to the nurse that a client who received morphine sulfate 4 mg IVP 30 minutes ago has a respiratory rate of 10 breaths/ minute. What is the nurse's priority intervention? 1. Administer naloxone 0.4 mg IVP. 2. Notify the primary healthcare provider of respiratory status. 3. Deliver breaths at 20 breaths/ minute via a bag-valve mask. 4. Instruct the UAP to ambulate the client. 1. Administer naloxone 0.4 mg IVP. The nurse is caring for a 5 year old client who is 12 hours post tonsillectomy. The client is pain free and has advanced to a soft diet. What is the priority nursing intervention? 1. Apply warm compresses to the throat. 2. Encourage gargling to reduce discomfort. 3. Position the child supine. 4. Monitor for frequent clearing of the throat 4. Monitor for frequent clearing of the throat A client is admitted to the Labor & Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this client? Select all that apply 1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 4. Administer propranolol for BP > 100 diastolic. 5. Initiate external fetal heart monitoring. 1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 5. Initiate external fetal heart monitoring. The nurse identifies that additional teaching about skin care is needed when an 80 year old client makes what statement? 1. "I shower 3 - 4 times per week." 2. "I apply moisturizers at least daily." 3. "I bathe in the tub at least 6 times per week." 4. "I drink 64 ounces (1.89 L) of liquid per day." 3. "I bathe in the tub at least 6 times per week." A 35 year old client asks a clinic nurse how to find out if the client is overweight or obese. The client weighs 135 pounds and is 5 feet 2 inches tall. What should the nurse educate the client about? 1. Calculating body mass index 2. Measuring abdominal circumference 3. Determining lean body mass 4. Finding the nearest hydrostatic testing location 1. Calculating body mass index An alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors? Select all that apply 1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 4. Advanced age. 5. Response to analgesic. 1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 5. Response to analgesic. The family of a client recently placed on antipsychotic medications for the treatment of schizophrenia calls the nursing hot line and reports that the client's temperature is 105.1ºF (40.6ºC), and that the client's muscles are stiff. What should the nurse tell the family? 1. Continue to monitor for signs and symptoms of infection. 2. Transport the client to the emergency room. 3. The signs and symptoms will subside within a day or so. 4. They should call the primary healthcare provider tomorrow. 2. Transport the client to the emergency room. 00:02 01:20 A client who has recurrent episodes of allergic rhinitis asks the nurse what could be done to decrease symptoms. What instruction should the nurse provide to this client? Select all that apply 1. Remove pets from interior of home. 2. Treat a stuffy nose with warm salt water. 3. Remove carpeting. 4. Stay inside when pollen count is at its lowest. 5. Wash bed linens in hot water. 1. Remove pets from interior of home. 2. Treat a stuffy nose with warm salt water. 3. Remove carpeting. 5. Wash bed linens in hot water. The nurse is preparing to hang an IV bag of Heparin after receiving a prescription from a client's primary healthcare provider: Heparin IV to infuse at 1000 U/h. What flow rate should the nurse set the IV infusion pump rate at? Round to the nearest whole number. Heparin 25,000 units (100usp units/mL) added to 0.45% NS 250mL 10 25000 / 250 NS = 1,000 units 250,000 / 25,000 = 10 A client buzzes the nurses' station to report chest pain. The nurse looks at the client's cardiac rhythm strip, then hurries into the client's room to find the client unresponsive and without a pulse. What initial action should the nurse take? Exhibit - Ventricular Tachycardia demonstrated on EKG 1. Administer Epinephrine 1mg IV push. 2. Begin cardiopulmonary resuscitation (CPR) for 2 minutes. 3. Defibrillate at 120 joules. 4. Insert supraglottic airway device. 3. Defibrillate at 120 joules The head nurse on a busy surgical unit is evaluating several fresh post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider? 1. A post transurethral resection client with cherry colored urine 2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery 3. A post ileostomy client with a beefy red stoma and mucus drainage 4. A post thyroidectomy client reporting tingling in toes and fingers 4. A post thyroidectomy client reporting tingling in toes and fingers A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. You need to sit down, because we need to start the group session now. 2. I will notify the primary healthcare provider about your headaches, after the group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start. 2. I will notify the primary healthcare provider about your headaches, after the group session. A client diagnosed with an embolic stroke has been admitted to the medical unit. Which nursing assessment would the nurse include to identify an early sign of increased intracranial pressure (ICP)? 1. Bradypnea 2. Bradycardia 3. Restlessness 4. Elevated systolic pressure 3. Restlessness A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin? Select all that apply 1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva 5. Heart rate 60/min 1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva What signs and symptoms would a nurse assess for in a client who is receiving hospice care and is close to death? Select all that apply 1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite 5. Increased blood pressure 1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite A client is being cared for on the orthopedic unit following a football game injury which resulted in a fracture of the left tibia and fibula. An open reduction of the fracture has been performed and a leg cast was applied. The client is receiving Morphine via a Patient Controlled Analgesia (PCA) pump at 2 mg/hr. The client begins reporting an increase in the pain level (9/10) that is not being relieved by the current Morphine dosing, and is experiencing a sensation that "pins are sticking" in the left foot. What action by the nurse is needed? Select all that apply 1. Increase the PCA dosing of Morphine. 2. Elevate the foot of the bed. 3. Perform neurovascular checks. 4. Apply ice around sides of cast. 5. Prepare for possible bivalving of the cast. 6. Notify primary healthcare provider. 3. Perform neurovascular checks. 5. Prepare for possible bivalving of the cast. 6. Notify primary healthcare provider. An elderly client with a recent diagnosis of atrial fibrillation (AF) caused by valvular heart disease, tells the nurse, "My daughter has AF and she only has to take one dabigatran pill a day. I have to take warfarin daily and have my blood checked every month. Why do I have to do all of this?" What education would the nurse provide to the client? 1. Your daughter's atrial fibrillation must not be caused by a heart valve problem so she can take a medication that does not require routine clotting studies. 2. Each primary healthcare provider may treat this dysrhythmia differently based on what the provider is used to prescribing. 3. When your daughter gets older, her primary healthcare provider will switch her to warfarin for the treatment of atrial fibrillation. 4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely. 4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely. The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care? 1. Offer the client frequent high calorie snacks. 2. Check the apical pulse before each dose. 3. Perform or assist with oral hygiene every shift. 4. Give the medication 30 minutes prior to meal. 3. Perform or assist with oral hygiene every shift. A client is suspected of having a pheochromocytoma. The nurse is explaining the process of a VMA (Vanillylmandelic acid) urine test to be complete at home. What statement made by the client indicates the need for further teaching? Select all that apply 1. "I need to keep the urine in the fridge during the 24 hours." 2. "I will have to stay well-hydrated to get enough urine to test." 3. "It does not matter what I eat or drink during this process." 4. "I need to throw away my first voiding when I start this test." 5. "I should void at the end of the 24 hours and keep that urine." 1. "I need to keep the urine in the fridge during the 24 hours." 2. "I will have to stay well-hydrated to get enough urine to test." 3. "It does not matter what I eat or drink during this process." A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary healthcare provider has prescribed ondansetron IV. What action should the nurse take? 1. Ask primary healthcare provider for an oral antiemetic. 2. Give ondansetron IVPB with the chemotherapy. 3. Wait until chemotherapy is complete to infuse ondansetron. 4. Stop chemotherapy temporarily and flush line to give ondansetron. 4. Stop chemotherapy temporarily and flush line to give ondansetron. The nurse's assessment of a client post-op abdominoplasty reveals tachycardia, restlessness and shallow slow breaths. The client was medicated with morphine 2 mg IVP one hour ago. The primary healthcare provider prescribes arterial blood gases (ABG). Which ABG report is consistent with this clinical picture? 1. pH 7.30, PaCO2 40, HCO3 29 2. pH 7.33, PaCO2 48, HCO3 25 3. pH 7.47, PaCO2 35, HCO3 29 4. pH 7.50, PaCO2 33, HCO3 22 2. pH 7.33, PaCO2 48, HCO3 25 Which prevention measure should the nurse include when instructing a client on avoidance of otitis externa? 1. Gently cleaning the ear canal with a cotton tipped applicator daily. 2. Use of astringent drops after bathing. 3. Taking preventative antibiotics prior to swimming in lakes or ponds 4. Routine use of nasal saline to clear the sinuses and eustachian tubes. 2. Use of astringent drops after bathing. A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take? Select all that apply 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. 4. Encourage the client to walk. 5. Apply a heating pad to the feet. 6. Massage the frozen digits. 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. In what order should the home health nurse see assigned clients? Place in priority order. a. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. b. Client diagnosed with rheumatoid arthritis who requires an occupational consult. c. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. d. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. a. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. d. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. c. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. b. Client diagnosed with rheumatoid arthritis who requires an occupational consult. A client is admitted to the hospital reporting chills, fatigue and left lower leg pain for nearly a week. During initial assessment, the nurse notes wide-spread swelling and redness of left ankle in addition to a fever of 103.5° F (39.72° C). Which admission order should the nurse implement first? 1. Perform sterile wound care to lower leg. 2. Start I.V. for administration of antibiotics. 3. Place client on bedrest with left leg elevated. 4. Draw blood for serial cultures and lab work. 3. Place client on bedrest with left leg elevated. Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5 1. C-section delivery Which finding by the nurse would need to be reported to the primary healthcare provider immediately when caring for an infant who was born with a myelomeningocele? Select all that apply 1. High pitched cry 2. Eyes fixed downward 3. Increasing head circumference 4. Decrease in a feeding by 30 mL 5. Projectile vomiting 1. High pitched cry 2. Eyes fixed downward 3. Increasing head circumference 5. Projectile vomiting [Show Less]
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Hurst Review Pediatrics, questions and answers latest updated
Growth is an increase in physical size Development is an increase in capability or function -development does not always follow growth and chrono... [Show More] logical age -chronological age and developmental age are two different things Cephalocaudal development is development that moves from the... head downward through the body and towards the feet Proximodistal development is development that moves from the... center of the body outward to the extremities Define play... play is the "work" of children -it is how they learn new things. socialize and learn to use coping skills -in addition to growth and developmental level, you must also think about the client's disease when choosing toys -for children with a heart defect, you would not give them something to do that will excite and increase their heart rate because that would increase the workload on the heart and we NEVER want to increase the workload on the heart of a client with heart disease You are taking care of a 5 month old baby. What toy is most appropriate for an infant? rattle- working on grasp reflex When a baby is born, they have... grasp reflex involuntary You are caring for an 11 year old boy in the hospital. What would be an appropriate activity for him? -playing video games in the room -coin collecting -watching TV -reading his favorite book When does the anterior fontanel close? 12 to 18 months When does the posterior fontanel close? 2 to 3 months Why are new foods introduced to infants one at a time? allergies, and they also have immature GI tracts Why are peanuts so dangerous when aspirated? when peanuts are wet, they will swell and crumble -dangerous for airway, hard to remove and allergy risk When giving an IM injection why is the ventrogluteal muscle contraindicated in children who have not been walking for at least a year? the ventrogluteal muscle is not developed well enough When viewing the auditory canal in the young child how is the earlobe positioned? down and back -bigger they are, harder you pull What are the most common reason for failed toilet training? they are not ready -never make toilet training punishable -takes boys longer How many cups of milk should a 15- month old toddler consume daily? 2 to 3 cups At what age does the best friend stage occur? 9 to 10 years What are the leading causes of death from accidental injury in infants up to 1 year of age? suffocation, motor vehicle related injuries, and drowning (bathtub or small amount of water) -falls are leading cause of ER visits Car seat safety: general guidelines -do not place car seat in the front passenger side of the car because of airbags -place infants <20 pounds in the middle of the back seat in the rear-facing, semi-reclined car seat; this provides the best protection for their heavy head and weak neck -in children 12 to 23 months of age, a convertible car seat for age and weight is recommended and can be positioned facing forward -car seats should be used, regardless of age, until the child weighs at least 30 pounds -never place padding under or behind an infant or child in a car seat (during car crash padding can become compressed leading to slack in the harness) -booster seats can be used for children 4 to 8 years Hyperthermia and car seat safety -can occur from being left in a vehicle in hot weather (greater than 80 degrees) -develops rapidly because infants are not able to regulate their body temperature -forgetting to get infants out of the car has been related to busy schedules, distractions such as cell phones and other mental preoccupations Between ages 6 and 12, what is the major cause of severe accidental injury? motor vehicle accidents -helmet safety Teach stranger safety... including not talking or texting to anyone they don't know on the internet, social media sites, or phone What happens to the growth rate between 6 and 12 years? decreases A school age child requires, on average, how many calories per day? 2400 calories How much earlier do girls experience the onset of adolescence than boys? about 1 to 2 years What is the first step in collecting vital signs or an assessment? always begin with observation Distraction techniques -used to make sure we are getting most accurate set of vital signs (pen lights, age appropriate toys, stickers) -don't forget to talk to the parents, even before you talk to the child. You need a trusting relationship with them Order to obtain vital signs -least invasive first -observe before touching or even talking to them -progression of obtaining vital signs: respiration, heart rate (done at same time), blood pressure, temperature -in infants and toddlers, always count RR and HR for one full minute because of irregularities due to their immature nervous system regulation -if vital signs cannot be taken without disturbing the child, then record the behavior with the measurements Rectal temperature considered the most reliable route for measurements in infants and children -do not get rectal temperatures on newborns, it is too risk to perforate the anus -contraindicated in any child who has diarrhea, rectal lesions, is receiving chemotherapy, is immuno-suppressed, or has no rectum No rectum known as? imperforated anus or anorectal malformation Axillary temperature may be done in all ages when an oral route is not possible Oral temperature start at age 5 to 6 years, child is more likely to cooperate at this age Tympanic temperature all ages, less sensitive for children less than 3 years of age Testing Tip always note when the temperature was taken DO NOT add or subtract a degree Oxygen saturation used to obtain a "picture" of the blood oxygen level through the skin -check perfusion, skin temperature, and edema to determine best location for the sensor probe; also consider the child's activity level -common sites are fingers and toes -the oxygen saturation on the oximeter display should correlate with the child's radial pulse Communication for newborns (birth to 1 month) -primary mode of communication is nonverbal -they express themselves through crying -respond to human voice and presence -touch has a positive effect -nursing strategy: encourage parent to touch infant Communication for infants (1 month to 12 months) -communication is still primarily nonverbal -begin verbal communication with vocalizations, starting with repeating consonants -communicate through crying and facial expressions -attentive to human voice and presence, but minimal comprehension of words -responds to touch through patting, rocking and stroking -nursing strategy: speak in gentle-toned voice, cuddle, pat, rub to calm, and encourage the presence of parents Communication for toddlers and preschoolers (1 to 5 years) -evolving verbal skills -use of language to express thoughts -children ages 3 to 4, form 3-4 word sentences, called telegraphic speech -concrete and literal thinking; may misinterpret phrases -vocabulary depends on development and family's use -may ask a lot of questions (preschooler); ask "why" to everything -short attention span -limited memory -cognitive development: egocentric, magical thinking, animism (thoughts of toys behaving like humans), object permanence (objects still exist when child can't see them) -nonverbal communication: express themselves through dramatic play and drawing, play is work of the child Communication of the school-age child (6 to 12 years) -cognitive development: able to use logic, begin to understand others points of view, begin to understand cause and effect, developing and understanding of body function -verbal communication: big vocabulary, receptive and expressive language is more balanced, misinterpretation of phrases is still common -nonverbal communication: can interpret nonverbal messages, expression of thoughts and feelings Communication of adolescents (13-18 years) -abstract thinking without full adult comprehension -interpretation of medical terminology is limited -strive for independence -trust and understanding build rapport -need privacy -nursing strategies: straightforward approach; talk in private area, conduct at least part of the interview without parent present Communication with children with physical or developmental disabilities -if unable to communicate, may feel helplessness, fear, or anxiety -family may experience fear and anxiety -nursing strategy: use gestures, picture boards, writing tablets, use a system of head nods, eye blinks What are observable signs of respiratory distress in children? -use of accessory muscles -nasal flaring -sternal retractions -grunting with respiration -any illness that affects the lungs ability to get oxygen in and carbon dioxide out will cause respiratory distress -illnesses that can cause respiratory distress include pneumonia, atelectasis, pneumothorax, and plural effusion -the amount of respiratory distress depends on the degree of airway disease What is laryngotracheobronchitis? -a viral infection that can result in: slight to severe dyspnea, barking or brassy cough, and elevated temperature -commonly known ans croup -viral organisms responsible for croup include: parainfluenza, adenovirus, and RSV -sound like a barking seal Treatment for LTB: -manage children at home with mild croup; at home most episodes can be treated with: ---steam from hot showers ---cool temperature therapy: cold air outside, open freezer --> helps constrict the swollen blood vessels in the trachea that are causing swelling (opens up airways) -if symptoms worsen or there is no improvement: ---nebulized epi or corticosteriods may be prescribed by the primary healthcare provider or administered in the emergency department -nebulized epi has a rapid onset; generally see improvement in 10 to 15 minutes; always watch for a relapse and return of symptoms when epi wears off What is epiglottis? -a serious obstructive inflammatory process: there is absence of a cough, presence of dysphagia, drooling, and rapid progression to severe respiratory distress -primary organism cause: H-flu -prevention: Hib vaccine -caused by infection of the epiglottis, can lead to partial or full occlusion of the airway -considered a medical emergency -look worse than they sound, the less noise they make, the worse they airway obstruction -never try to visualize the throat or tongue with a tongue depressor -help children remain comfortable What is RSV? -leading cause of lower respiratory tract illness in children less than 2 years of age, caused by an acute viral infection that affects the bronchioles -can be life threatening in infants Risk factors for RSV -prematurity -congenital disorders; like congenital heart defects -smoke, in any form -in premature infants and those with congential disorder, the focus is on prevention; this includes avoiding sick contacts and immunization with the RSV vaccine (Synagis, RespiGam) Signs and symptoms of RSV -begin with simple URI -nasal discharge -mild fever -wheezing -nonproductive paroxysmal cough -tachypnea with flaring nares -dyspnea and retractions -know the onset of signs/symptoms, because RSV will become worse at days 2 to 3 and can progress to life threatening respiratory distress HINT signs and symptoms can range from mild to severe; can progress from a simple cough and runny nose to copious amounts and mucous, to severe respiratory distress [Show Less]
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HURST Review: Respiratory questions and answers
Penetrating Chest Trauma: This can be -hemothorax -pneumothorax -tension pneumothorax -open pneumothorax (sucking chest wound) Hemothorax/Pneumo... [Show More] thorax: This is when blood or air has accumulated in the pleural space and the lung has collapsed Hemothorax/Pneumothorax: Signs/Symptoms include -SOB -increased HR -diminished breath sounds on the affected side -less movement on the affected side -chest pain -cough -subQ emphysema Hemothorax/Pneumothorax Signs/Symptoms: What will should up on the x-ray? air or blood Hemothorax/Pneumothorax Signs/Symptoms: What is subcutaneous emphysema? air trapped in the tissue (usually neck, face, and chest) RULE: NEVER _________________ a penetrating object pull out Hemothorax/Pneumothorax: Treatment includes -thoracentesis -chest tube -daily chest x-ray Tension Pneumothorax: Can be caused by -trauma -too much PEEP -clamping a chest tube -insertion of central venous lines -taping an open pneumothorax on all 4 sides without an air valve Tension Pneumothorax: This occurs when pressure has built up in the chest/pleural space and has collapsed the lung which then causes mediastinal shift Tension Pneumothorax: What is mediastinal shift? when pressure pushes everything to the opposite side Tension Pneumothorax: Signs/Symptoms include -subQ emphysema -absence of breath sounds on one side -asymmetry of thorax -respiratory distress -cyanosis -distended neck veins, or JVD Tension Pneumothorax: JVD is a medical emergency and can be fatal as accumulating pressure compresses vessels leading to decreased venous return resulting in decreased CO Tension Pneumothorax: Treatment includes -large bore needle -treating the cause (chest tube will be inserted) Tension Pneumothorax Treatment: Large bore needle is placed into the _________________________ (by the primary healthcare provider) to _______________________________ 2nd intercostal space; allow excess air to escape Open Pneumothorax: AKA sucking chest wound Open Pneumothorax: This is an opening through the chest that allows air into the pleural space Open Pneumothorax: Treatment includes -have client inhale, Valsalva or hummmmmmm -place petroleum gauze over the area -have client sit up (if possible) to expand lungs Open Pneumothorax Treatment: Having the client inhale, Valsalva or hummmmmmm is done to increase the intra-thoracic pressure so no more outside air can get into the body Open Pneumothorax Treatment: When placing a piece of petroleum gauze over the area, tape down _______ sides and the _______________ acts like a ________________ or _______________ 3; 4th side; air vent; flutter valve Open Pneumothorax Treatment: While clients are to sit up, if able, to expand their lungs, trauma clients _______________ until _____________________________ stay flat; evaluated for other injuries Thoracic (Chest) Procedures: These include -thoracentesis -chest tubes Thoracic (Chest) Procedures - Thoracentesis: This is performed to remove fluid or air from the pleural space Thoracic (Chest) Procedures - Thoracentesis: It is used for analysis of lungs fluids to determine the cause of the effusion Thoracic (Chest) Procedures - Thoracentesis: The fluid obtained may be sent for culture or cancer cells Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure we must check for informed consent Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure the client must STOP any anticoagulant medications Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure we must obtain -baseline VS -oxygen saturation -pain level Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure be sure that a ___________________ has been performed CXR Thoracic (Chest) Procedures - Thoracentesis: Pre-procedure positioning sit on the edge of bed, with feet supported, and lean over the bedside table Thoracic (Chest) Procedures - Thoracentesis: What if the client is not able to sit up pre-procedure? have them lie on the unaffected side with HOB at 45 degrees Thoracic (Chest) Procedures - Thoracentesis: During procedure the client must be very still; no coughing or deep breaths Thoracic (Chest) Procedures - Thoracentesis: During the procedure the ______________________ is being removed from ______________________ fluid/blood/exudate; the pleural space Thoracic (Chest) Procedures - Thoracentesis: During the procedure, as the fluid is being removed, the lung should reinflate Thoracic (Chest) Procedures - Thoracentesis: During the procedure we should be checking ___________________________________ and compare to VS, oxygen sats, pain level; baseline Thoracic (Chest) Procedures - Thoracentesis: Post-procedure another ______________ is taken CXR Thoracic (Chest) Procedures - Thoracentesis: Post-procedure monitor VS Thoracic (Chest) Procedures - Thoracentesis: Post-procedure we must listen to ___________________ for __________________ lungs; absent or reduced breath sounds on the affected side Thoracic (Chest) Procedures - Thoracentesis: Post-procedure we must check ___________________ and _________________ for bleeding puncture site; dressing Thoracic (Chest) Procedures - Thoracentesis: Post-procedure we must monitor for -subQ emphysema -infection -tension pneumothorax Thoracic (Chest) Procedures - Thoracentesis: Post-procedure we have the client turn, cough, and deep breathe Thoracic (Chest) Procedures - Chest Tubes: What has happened that the client needs a chest tube? the lung has collapsed Thoracic (Chest) Procedures - Chest Tubes: If the chest tube is placed in the upper anterior chest (2nd intercostal space) then it is for the removal of air Thoracic (Chest) Procedures - Chest Tubes: If the chest tube is placed laterally in the lower chest (8th or 9th intercostal space) then it is for drainage Thoracic (Chest) Procedures - Chest Tubes: Why is the tube placed in the upper chest for air removal and in the lower chest for removal of drainage? because air rises and drainage settles Thoracic (Chest) Procedures - Chest Tubes: The client can have both an upper and lower chest tube and they are _______________________ and attached to a ____________________ y-connected together; closed chest drainage unit (CDU) Thoracic (Chest) Procedures - Chest Tubes: The chest tube is ____________________ and an occlusive dressing is applied ______________________________ and then the chest tube is connected to _______________________ sutured to the chest wall; around the chest tube exit site; a closed chest drainage unit Thoracic (Chest) Procedures - Chest Tubes: What is the purpose of the CDU? it is to restore the normal vacuum pressure in the pleural space Thoracic (Chest) Procedures - Chest Tubes: How does the CDU restore the normal vacuum pressure in the pleural space? by removing all air and fluid in a closed 1-way system until the problem is corrected Thoracic (Chest) Procedures - Chest Tubes: What are the 3 chambers of the CDU? 1. drainage collection chamber 2. water seal chamber 3. suction control chamber Thoracic (Chest) Procedures - Chest Tubes: The chest tube connects to a ____________________ that leads to the _____________________ 6 foot connection tube; drainage collection chamber Thoracic (Chest) Procedures - Chest Tubes: What if the drainage collection chamber fills up? get a new CDU (rarely have to change) Thoracic (Chest) Procedures - Chest Tubes: What is the purpose of the water seal chamber? to promote 1-way flow out of the pleural space which will prevent air from moving back up the system and into the pleural space Thoracic (Chest) Procedures - Chest Tubes: The drainage chamber and water seal chamber are connected by a small tube that allows the drainage to remain in the first chamber and the air to go down into the water of the water seal chamber Thoracic (Chest) Procedures - Chest Tubes: The water seal chamber contains ____________________ which acts as a ___________________. In other words, we are ______________________ 2 cm of water; one-way valve; preventing backflow Thoracic (Chest) Procedures - Chest Tubes: You may see ________________ in the water seal chamber when the client ________________________________________ (normal) bubbling; coughs, sneezes, or exhales Thoracic (Chest) Procedures - Chest Tubes: You will see a slight ____________________________ in the water seal tube as the client __________________ rise and fall; breathes Thoracic (Chest) Procedures - Chest Tubes: The slight rise and fall seen in the water seal tube as the client breathes is called ________________ and is _______________ tildaling; normal Thoracic (Chest) Procedures - Chest Tubes: If tidaling stops, it usually means that the lung has re-expanded Thoracic (Chest) Procedures - Chest Tubes: If the client needs suction to remove air and fluid, the suction control chamber does what? controls the amount of suction applied Thoracic (Chest) Procedures - Chest Tubes: Sterile water is placed in the suction control chamber up to the ___________________ which is the _____________________ 20 cm line; usual prescribed amount Thoracic (Chest) Procedures - Chest Tubes: Turn on the wall vacuum suction until you have slow, gentle, continuous bubbling Thoracic (Chest) Procedures - Chest Tubes: If a dry suction system is used, ___________________________ and therefore, water is not needed to regulate the pressure; has no bubbling Thoracic (Chest) Procedures - Chest Tubes: A _________ is used to set the negative pressure dial Thoracic (Chest) Procedures - Chest Tubes: Increasing the vacuum wall suction will NOT increase the pressure Management of Closed Chest Drainage System: Assess dressing; it must be kept tight and intact Management of Closed Chest Drainage System: Listen for breath sounds in _______________________ and monitor for ______________________ both lungs; breathing difficulty Management of Closed Chest Drainage System: Monitor ____________________ and report anything below ___________ pulse oximetry; 90% Management of Closed Chest Drainage System: Palpate chest tube insertion site for __________________ because this could indicate ________________________________ subQ emphysema; poor tube placement Management of Closed Chest Drainage System: Record chest drainage every _______________ for 24 hours and then every _____________________ hour; 8 hours Management of Closed Chest Drainage System: Notify primary healthcare provider of _____________ of drainage or greater in 1 hour 200 mL Management of Closed Chest Drainage System: Notify primary healthcare provider of ____________ or greater any hour after the 1st hour 100 mL Management of Closed Chest Drainage System: Notify primary healthcare provider of change in color, like yellow to bright red Management of Closed Chest Drainage System: Have client ______________________________ and use an __________________________ deep breathe, cough; incentive spirometer Management of Closed Chest Drainage System: Watch for ______________________________ because they could develop an __________________ at insertion site fever, increased WBCs, and drainage; infection Management of Closed Chest Drainage System: Watch daily chest x-rays for re-expansion Management of Closed Chest Drainage System: Where would you obtain a chest drainage specimen? chest tube (self-sealing) Management of Closed Chest Drainage System: Keep the system _________________ the level of the chest below [Show Less]
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HURST Review: Maternity Nursing questions and answers, graded A+
What is the name of the hormone that induces amenorrhea? progesterone Progesterone makes your temperature increase after ovulation Signs/Sy... [Show More] mptoms of Pregnancy: Presumptive signs include -amenorrhea -N/V -urinary frequency -breast tenderness Signs/Symptoms of Pregnancy - Presumptive Signs: What can be one of the first signs of pregnancy? urinary frequency amenorrhea N/V breast tenderness Signs/Symptoms of Pregnancy - Presumptive Signs: Why is breast tenderness is presumptive sign of pregnancy? because of the excess hormones in the body Probable signs of pregnancy include... -positive pregnancy test -Goodell's sign -Chadwick's sign -Hegar's sign -uterine enlargement -Braxton Hicks contractions -pigmentation changes of skin Signs/Symptoms of Pregnancy - Probable Signs: A positive pregnancy test is based on the presence of hCG levels Signs/Symptoms of Pregnancy - Probable Signs: There are other conditions that can increase hCG levels like hydatidiform (molar pregnancy) or some other medications Signs/Symptoms of Pregnancy - Probable Signs: What is hydatidiform (molar pregnancy)? benign neoplasm of grape-like vesicles that can become malignant If a hydatidiform (molar pregnancy) is not malignant a D & C is required with close follow-up for 6 months to 1 year Probable Signs: What is Goodell's sign? softening of the cervix during the second month Probable Signs: What is Chadwick's sign? bluish color of the vaginal mucosa and cervix during the 4th week d/t vasocongestion Probable Signs: What is Hegar's sign? softening of the lower uterine segment during the 2nd/3rd month Probable Signs: Braxton Hicks contractions occur when and for what purpose? they occur throughout pregnancy and move blood through the placenta Probable Signs: What skin pigmentation changes occur? -linea nigra -facial chloasma -abdomen striae -darkening of the areola Positive signs of pregnancy include -fetal hearbeat -fetal movement -ultrasound Signs/Symptoms of Pregnancy - Positive Signs: Fetal heartbeat can be heard with a doppler weeks 10 to 12 Positive Signs: Fetal heartbeat can be heard with a fetoscope weeks 17 to 20 Pregnancy Terms: Terms include -gravidity -parity -viability -TPAL Pregnancy Terms: What is gravidity? the number of times someone has been pregnant Pregnancy Terms: What is parity? the number of pregnancies in which the fetus reaches 20 weeks Pregnancy Terms: What is viability? when an infant has the ability to live outside the uterus Pregnancy Terms: The age of viability is 24 weeks; anything less is NOT considered viable Pregnancy Terms - TPAL: What does this acronym stand for? T - term P - preterm A - abortion (includes spontaneous and elective) L - living children Pregnancy Terms - TPAL: Bleeding, cramping, backache...think miscarriage Pregnancy Terms - TPAL: With an imminent miscarriage, the _________________ will begin to drop hCG level Pregnancy Terms - TPAL: Most miscarriages occur before 20 weeks Pregnancy Terms - Naegle's Rule for the EDD: Steps to calculate 1. find the first day of the LMP 2. add 7 days 3. subtract 3 months 4. add 1 year Pregnancy Terms - Naegle's Rule for the EDD: This rule is only accurate plus or minus 2 weeks Trimesters of Pregnancy - First Trimester: This trimester is weeks 1 through 13 First Trimester - Client Education/Teaching: During this trimester it is important to teach the client about -nutrition -weight gain -prenatal vitamin supplements -exercise -danger signs and potential complication of maternity -common discomforts -medications -smoking -primary healthcare provider visits -ultrasounds First Trimester - Client Education/Teaching: Increase protein intake to 60 grams per day (40-45 is normal) First Trimester - Client Education/Teaching: Regarding culture, consider nutritional influences such as -hot vs cold foods -Kosher foods -fasting First Trimester - Client Education/Teaching: The client should expect to gain ___________________ pounds in the first trimester and will also be dependent on what the _______________________ is 1 to 4; starting BMI First Trimester - Client Education/Teaching: What are the biggest complaints with iron? constipation and GI upset First Trimester - Client Education/Teaching: Always take iron with __________ and why? vitamin C because it prevents GI upset and enhances absorption First Trimester - Client Education/Teaching: Folic acid prevents neural tube defects First Trimester - Client Education/Teaching: What is the daily dose of folic acid? 400 mcg/day First Trimester - Client Education/Teaching: What are some iron-rich foods? -liver -spinach -lentils -raisins -fortified cereal -dark chocolate -dried fruit First Trimester - Client Education/Teaching: Regarding exercise, NO _____________ high impact exercise First Trimester - Client Education/Teaching: What are the best exercises to do? walking and swimming First Trimester - Client Education/Teaching: NO heavy exercise program, but can continue regular exercise program First Trimester - Client Education/Teaching: When exercising, you do NOT want your heart rate to get above 140 First Trimester - Client Education/Teaching: If the HR goes over 140 bpm there will be decreased CO and decreased uterine perfusion First Trimester - Client Education/Teaching: We do not want these patients to get ________________ so NO ______________________ because these will _____________________________ and can cause __________________ overheated; hot tubs or heating blankets; increase body temperature; birth defects First Trimester - Client Education/Teaching: What are some danger signs and potential complications of maternity? -sudden gush of vaginal fluid -bleeding -persistent vomiting -severe H/A -abdominal pain -increased temps -edema -NO fetal movement First Trimester - Client Education/Teaching: What is the most common complaint associated with poor outcomes? no fetal movement First Trimester - Client Education/Teaching: What are common discomforts during this trimester? -constipation -ankle edema -N/V -breast tenderness -urinary frequency -tender gums -fatigue -heartburn -increased vaginal secretions -nasal congestion -varicose veins -hemorrhoids -backache -leg cramps First Trimester - Client Education/Teaching: What are you going to tell the pregnant person about taking medications? NO medication First Trimester - Client Education/Teaching: What is smoking during pregnancy associated with? -small for gestational age -low birth weight babies -cleft lip or palate -placental abruption First Trimester - Client Education/Teaching: The risk for placental abruption doubles with smoking First Trimester - Client Education/Teaching: How often should a pregnant client visit the primary healthcare provider during the first 28 weeks? once a month First Trimester - Client Education/Teaching: How often should a pregnant client visit the primary healthcare provider during weeks 28-36 weeks? every 2 weeks (twice a month) First Trimester - Client Education/Teaching: How often should a pregnant client visit the primary healthcare provider after 36 weeks? weekly until delivery First Trimester - Client Education/Teaching: Before an ultrasound, what will you ask the client to do? drink water First Trimester - Client Education/Teaching: Why do you have the client drink water before an ultrasound? to distend the bladder and push the uterus up closer to the abdominal surface because it makes an easier to get a good picture First Trimester - Client Education/Teaching: With an ultrasound before a procedure what do you have the client do? void Second Trimester - Client Education/Teaching: What is the recommended calorie increase during this time? 300 calories per day Second Trimester - Client Education/Teaching: If the client is an adolescent they can increase their calories by 500 a day Second Trimester - Weight Gain: What is the expected weight gain during this trimester? in general, 1 lb Second Trimester - Weight Gain: This is variable depending on the woman's BMI pre-pregnancy Second Trimester: Should the client still be experiencing nausea and vomiting? no Second Trimester: Should the client still be experiencing breast tenderness? yes Second Trimester: Should the client still be experiencing urinary frequency? no, because the uterus rises and relieves pressure on the bladder Second Trimester: What is quickening and when does it happen? fetal movement around 16-20 weeks Second Trimester - Fetal Heart Rate: What should the fetal heart rate be during the second trimester? 110-160 Second Trimester - Fetal Heart Rate: If the fetal heart rate is less than 110 panic! Second Trimester - Kegel Exercise: The patient should do these frequently to strengthen the pubococcygeal muscles Second Trimester - Kegel Exercise: The pubococcygeal muscles help stop the urine flow Second Trimester - Kegel Exercise: The pubococcygeal muscles keep your uterus from falling out Third Trimester: This is weeks 27 through 40 Third Trimester: A pregnancy is considered term if it advances to 37 to 40 weeks Third Trimester - Assessment: What is the expected weight gain per week during this trimester? no more than a pound per week Third Trimester - Assessment: Monitor ______ and report ______________________ BP; any increases from the baseline Third Trimester - Assessment: Pre-eclampsia develops after 20 weeks gestation Third Trimester - Assessment: With the development of pre-eclampsia, the client will have -increased BP (160/110 or greater) -proteinuria -edema Third Trimester - Assessment: 2 or more pounds of weight gain in a week, watch closely and worry about possible pre-eclampsia Third Trimester - Assessment: The client with pre-eclampsia can have a seizure Third Trimester - Assessment: What is the drug of choice for severe pre-eclampsia? magnesium sulfate Third Trimester - Assessment: Magnesium sulfate is given ________, in __________________, and under _____________________ IV; hospital setting; close supervision Third Trimester - Assessment: Pre-eclampsia is defined as BP of 160/110 or greater that is documented 6 hours apart Third Trimester - Assessment: What does magnesium sulfate do? -acts like an anticonvulsant -sedates -vasodilates [Show Less]
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Hurst Review Burns, questions and answers graded A+
Where do most burns occur? - In the home What are safety considerations in the home to prevent burns? - Keep electrical sockets covered and lighte... [Show More] rs out of reach - Smoke alarms - Change smoke alarm batteries every 6 to 12 months - Keep anything flammable 3 feet from heat sources - Clean the lint traps in the dryer with each use - Have and practice a safety plan - Do not let pot handles stick out while cooking - Drop in type stoves should be attached to the wall - Do not use table cloths if children are not present - Small appliances need to be kept out of reach of children - Set water heater no higher than 120 degrees Why does plasma leak out of the tissues after a burn? - Increased capillary permeability leads to leaking When does a majority of leaking from tissues occur and what should you worry about? - First 24 hours - Shock Why does the pulse increase in patient with burns? - Losing fluid volume leads to not enough fluid circulating - Heart tries to quickly circulate small amount of fluid Why does cardiac output decrease in patients with burns? - Losing fluid leads to less volume to pump out Why does urine output decrease in patients with burns? - Kidneys are trying to hold on to fluid or they aren't being perfused adequately Why is epinephrine secreted in patients with burns? - Makes you vasoconstrict so blood can be shunted to other organs Why are ADH and aldosterone secreted in patients with burns? - Retain sodium and water with aldosterone - Retain water with ADH - Both make blood volume increase What is the most common method for determining the % of the body that is burned? - Rule of Nines What degree of burns are considered partial thickness burns? - First and second degree What degree of burns are considered full thickness burns? - Third and fourth degree How does burn location help determine severity? - If the burn is located on the face, neck, or chest it can interfere with breathing - If the burn is located on the hands, feet, joints, or eyes it can interfere with a productive life Who is at risk for burns? - Anyone with heart, lung, or kidney disease - Pre-existing diabetes (cannot feel legs or feet) - Very old and very young Why are the very young and very old at risk for burns? - There skin is very thin and they have less subcutaneous fat - Burns tend to go deeper - Less BSA How do you stop the burning process? - Wrap the patient in a blanket - Cool water for no more than 10 minutes (**NEVER ICE- INHIBITS BLOOD FLOW) - Blankets keep out germs and keep in body heat - Remove jewelry because of swelling - Remove non-adhered clothing - Cover burns with clean, dry cloth What is the number one cause of death with burns? - Inhalation injury - Usually caused by carbon monoxide or hydrogen cyanide Why is carbon monoxide poisonous to the human body? - Carbon monoxide travels faster than oxygen and binds to the hemoglobin before oxygen can - Patient becomes hypoxic How do you treat carbon monoxide poisoning? - 100% oxygen - Puts more oxygen molecules in the "race" The oxygen saturation will be __________ on a patient with carbon monoxide poisoning. - Normal How do you treat hydrogen cyanide poisoning? - 100% oxygen - Antidote may be given at the hospital With cyanide poisoning, why is it important to determine whether the burn occurred in a closed or open area? - If someone is burned in a closed area, they will have inhaled more carbon monoxide and/or hydrogen cyanide so the risk for complications are increased. When you see a patient with burns to the neck, face, or chest, focus on what? - Airway What might the physician do prophylactically for a patient with burns to the face, neck, and chest? - Intubate What are indicators that a patient has an inhalation burn? - Singed nose hairs - Singed facial hair - Soot on face - Cough up secretions with dark specks - Difficulty swallowing - Wheezing - Blisters on face and oral mucosa - Hoarseness - Substernal or intercostal retractions - Stridor If a burn patient's respirations are shallow, what are they retaining? What imbalance are they at risk for? - Carbon dioxide - Respiratory acidosis What is the most important aspect of burn management? - Fluid replacement How many large bore IVs will a patient need if they are receiving large amounts of fluids? - Two What type of solutions will typically be used for fluid replacement? - Crystalloids (LR) - Colloids (albumin) Why is it important to know when the burn occurred? - So you know the rate to replace fluids How do you calculate the amount of fluid to give a patient with a burn? - (2-4 mL) X (Kg) X (% TBSA burned)= total fluid replacement for first 24 hours - Calculate the total amount of fluid needed for the first 24 hours and give half in the first 8 hours If a patient with burns is restless, what could this indicate? - Inadequate fluid replacement - Pain - Hypoxia How do you determine if a burn patient is getting adequate fluid replacement? - Urine output - 30 to 50 mL in an adult - 75 to 100 mL in electrical injuries - 1mL/kg/hr in children What is albumin? - Administered 24 hours after burn - Holds onto fluid in the vascular space - Causes vascular volume to increase, kidney perfusion increases, blood pressure increases, and cardiac volume increases What should you be cautious of when administering albumin? - You can stress the heart too much - Causes the patient to go into fluid volume excess - Cardiac output will decrease What measurement should you take hourly when administering albumin? - CVP - Make sure you are not overloading the patient When you are giving a narcotic what is the most important assessment to make? - Respiratory Why do you give IV medication over IM medications for a patient with burns? - IV medications work quickly - For IM medications to work you need perfusion to the muscles What immunizations should you give to a patient with burns? - Tetanus Toxoid - Immune globulin Why are broad spectrum antibiotics not used with patients who have burns? -Because they could lead to secondary infections or sepsis What is the exception to using broad spectrum antibiotics for a patient with burns? - Will be used until wound cultures have returned What should you monitor for when giving patients antibiotics that end in -mycin? - BUN - Creatinine -Hearing loss (ototoxicity) - Nephrotoxicity Why might a provider use silver impregnanted dressings on a patients burns? - Provide broad antimicrobial effects by delivering a uniformed amount of silver to the wound How long can dressings be left in place on a burn? - 3 to 4 days, depending on patient condition What are common topical drugs used for burns? - Mafenide acetate (Sulfamylon) - Silver nitrate - Antimicrobial ointments Why should antibiotic drugs be alternated? - Bacteria can build resistance or tolerance How do you apply topical agents to a burn? - Apply a thin layer using sterile gloves - Aseptic technique - Apply light gauze dressing to cover area What is debridement? - Enzymatic debridement agents are used to remove necrotic, dead tissues When is using debridement agents contraindicated? - Do not use on face - Do not use if pregnant - Do not use over large nerves - Do not use if area is opened to a body cavity What is most important to remember before sending a patient to hydrotherapy? - Pain management What could happen to a patient if immersion hydrotherapy is used? - Cross contamination - Could have different bacteria in different wounds What is an autograft? - Patient uses own skin - Intact skin is taken from donor site and placed over burned area If a patient is well nourished, the surgeon can re-harvest from the same donor site as soon as how many days? - 12 to 14 If the skin graft becomes blue or cool what could this mean? - Poor circulation Why might a provider use a needle to aspirate blood or exudate from under the graft? - If there is build up under the graft, then the graft cannot adhere - Can lead to partial or total loss of graft Do you think a patient with burns need more or less calories? - More What two things are needed in a burn patients diet to promote healing? - Protein - Vitamin C (boost immune system) What lab work would you check to ensure proper nutrition and a positive nitrogen balance? - Prealbumin (total protein albumin) What procedures can help relieve pressure when a patient has decreased circulation due to circumferential burn? - Escharotomy - Fasciotomy How often should you assess a burn patients intake and output? - Every hour Why might you get no urine return when inserting a catheter into a burn patient? - Kidneys are trying to hold on and retain what little fluid remains in the kidneys What drug is used to flush out the kidneys for a burn patient? - Mannitol If there is no urine output or less than 30 mL/hr, what should you worry about? - Kidney failure After 48 hours, the patient will begin to diurese because fluid is going back into the vascular space. Now what should you worry about? - Fluid volume excess Why might a patient with burns have hyperkalemia? - Potassium is found inside the cells - Cells begin to rupture or lyse - Potassium gets into the blood - Potassium levels go up Why do you think magnesium carbonate, pantoprazole, or famotidine are prescribed to a patient with burns? - Prevent stress ulcer (Curling's ulcer) Why do you think a provider wants the patient to be NPO and have an NG tube hooked up to suction? - Decreased motility can lead to paralytic ileus - Decreased motility - Decreased vascular volume - Hyperkalemia causes muscle weakness (intestines) [Show Less]
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HURST REVIEW: MANAGEMENT OF CARE, QUESTIONS AND ANSWERS WITH RATED SOLUTIONS
As a new nurse, you cannot provide safe care to your clients if you don't know how to -manage care -assign care -supervise care -prioritize care ... [Show More] The judgments you make in management situations have to be based on med-surg knowledge If you don't understand disease processes, you cannot set priorities of care or determine which staff member would be best to take care of the client You MUST know your _______________________, and then you can move on to ________________________ core content; management decisions Assignments include the routine care, activities, and procedures that are within the authorized scope of practice of the RN, LPN/LVN, or part of the routine functions of the UAP Assignment is the sharing of routine work that each staff member is responsible for during a given shift or work period The assigned tasks should be part of the course work taught in the basic educational program of the staff member Delegation is allowing a specific task to be performed that is not routinely performed and is BEYOND the traditional role of the individual to which the nursing activity skill, or procedure is delegated The key is that the staff member who is delegated the task has received additional training or education and has validated competency to perform the delegated task You can delegate the responsibility of the task, but you cannot delegate the ultimate accountability The RN is accountable for ALL aspects of nursing care that are being provided including the choices you make about who is considered competent to perform each task What are the 5 rights of delegation? 1. right person 2. right circumstances 3. right task 4. right direction/communication 5. right supervision and evaluation/feedback The Right Task: What is the traditional role of the UAP? UAP is an umbrella term that NCSBN defines as any unlicensed personnel trained to function in a supportive nursing role, regardless of the title The Right Task: What type of clients can the RN delegate to the UAP? -perform tasks on STABLE clients in uncomplicated situations -routine, simple, repetitive, common activites that do NOT require nursing judgment The Right Task: Examples of tasks that the UAP can perform? -hygiene -feeding -I&O -routine vital signs -ambulation EVERYDAY THINGS! The Right Task: Can a UAP take VS ona client receiving IV Dopamine? no, because it requires nursing judgment The Right Task: Can the UAP provide a total bed bath and dress the client? yes The Right Task: Can the UAP serve meals and assist with eating? yes The Right Task: Can the UAP obtain a urine specimen from a catheter? no, this is a sterile procedure The Right Task: Can the UAP turn the client every 2 hours and provide skin care? yes The Right Task: Can the UAP assist the client to the bathroom with a walker? yes The Right Task: Can the UAP perform a fleet enema? no, because this is a medicated procedure The Right Task: Can the UAP answer the client's call light? yes The Right Task: Can the UAP clean and sanitize the client's room? yes The Right Task: Can the UAP change the linen on a totally bedridden client? yes The Right Task: Can the UAP provide mouth care and denture cleansing? yes The Right Task: UAPs CAN'T do medications The Right Task: What tasks can the LPN perform? -data collection -NO assessment -updating client data -NO evaluation (involves assessment) -NO admission hx The Right Task: The RN NEVER delegates or assigns tasks that involve assessment The Right Task: The LPN can assist the RN in data collection, but that is NOT assessment in the NCLEX world The Right Task: After the initial assessment, the LPN updates client data The Right Task: Can the LPN evaluate the client to determine if a goal has been met? no The Right Task: The LPN cannot do any form of _____________________, because _________________________________ evaluation; evaluation involves assessment, and we NEVER assign or delegate assessment or judgment The Right Task: Who must do the admission history? the RN The Right Task: If someone else, such as an LPN, collects the admission data for you, NEVER sign off on the form until you have validated the data The Right Task: Can the LPN implement tasks on the plan of care? yes The Right Task: Can a LPN devise a teaching plan for a newly diagnosed diabetic? no, ONLY the RN can plan care The Right Task: LPNs can do teaching, but it's basic standardized teaching or reinforcing teaching The Right Task: Can the LPN data collect, monitor and observe? yes The Right Task: Can the LPN reinforce teaching from plan of care? yes The Right Task: Can the LPN administer IVPB medication? yes The Right Task: Can the LPN administer IVP pain medications? NO The Right Task: Can the LPN initiate transfusion of blood products? NO The Right Task: Can the LPN monitor transfusion of blood products? yes The Right Task: Can the LPN administer meds & nutrition via NG tube, G-tube or button, J-tube? yes The Right Task: Can the LPN insert, maintain and remove urinary catheters? yes The Right Task: Can the LPN maintain and remove peripheral IV catheters? yes The Right Task: Can the LPN calculate and monitor IV flow rate? yes The Right Task: What type of clients can the RN assign to the LPN? stable clients The Right Task: An unstable client is medically fragile and requires an increased level of care The Right Task: A client can be complex and stable at the same time The Right Task: DON'T let a complex, chronic diagnosis make you think the client is unstable and has to be seen only by the RN The Right Task: Always consider a new admit unstable The Right Task: The RN should assess the newly admitted client ____________. The new admission is your __________________________ FIRST; responsibility or priority The Right Task: Is the diabetic client with low blood sugar stable or unstable? unstable The Right Task: Is the client returning from an invasive procedure stable or unstable? unstable The Right Task: Is the client with neurological problems, stable VS, no change in LOC/neuro checks stable or unstable? stable The Right Task: Is the client with acid-base imbalance and respiratory distress with unstable VS stable or unstable? unstable The Right Task: Is the client with chronic HTN, hx of angina controlled with meds and living alone stable or unstable? stable The Right Task: Is the client with HIV+, medication compliance and working full time stable or unstable? stable The Right Task: Acid-base imbalance makes a client unstable 99% of the time The Right Task: Can the LPN perform any tasks in an unstable situation? yes! they can help the RN by taking BP, getting a crash cart, etc The Right Circumstance: First, the right circumstance could be influenced by the work setting The Right Circumstance: LPNs and RNs function in different roles depending on the work place The Right Circumstance: Another factor that influences the right circumstance is a change in the client status from stable to unstable The Right Circumstance: Client conditions can change and the LPN or UAP must report this to the RN (RN should reassess right away) The Right Circumstance: If you're unsure if the UAP can perform a procedure, go with them yourself and make sure no harm is done The Right Circumstance: When staff members are pulled to a new floor, you should pretend they are a brand new nurse all over again The Right Circumstance: Do not give a nurse from another floor any clients requiring specialized care The Right Circumstance: Routine task assignments can change based on the circumstance The Right Circumstance: The same activity may differ in each situation The Right Circumstance: We know that feeding a healthy client who has 2 broken arms is different than feeding a client who has dysphagia The Right Circumstance: Bathing a weak client is not the same as bathing a client who is severely burned The Right Circumstance: If there is ever a degree of potential harm, the RN must retain the task, no matter how routine it is The Right Person: Know the scope of practice as defined by your state (read the Nurse Practice Act) The Right Person: Know the job descriptions of the staff that work with you The Right Person: Don't assume someone is competent to do something just because of their job description The Right Person: It is the RN's responsibility to figure out the staff's _______________________. Know their ______________________________ strength and weaknesses; knowledge level and skills The Right Person: What should you do about a hospice or grieving client? send your most compassionate nurse The Right Person: What should you do about the child who needs an IV started? choose the most experienced IV nurse and send the new RN with them to be mentored Right Direction and Communication: The RN is responsible for providing clear, concise, correct, and complete communication to nursing staff at the time of delegation, as well as providing continued direction on an ongoing basis Right Direction and Communication: You must communicate a __________________ and the ______________________ time frame; priority of the task Right Direction and Communication: Tell what you want done ___________, and what you want done in a __________________________ first; particular time frame Right Direction and Communication: Provide specific directions and expectations of how you want the task to be performed and describe the findings you want to be reported Right Supervision and Evaluation or Feedback: You must _____________, ____________, and ____________________ the carrying out of any delegated task guide; supervise; evaluate Right Supervision and Evaluation or Feedback: You must follow up to see that the nursing tasks that you delegated are done properly Right Supervision and Evaluation or Feedback: We need to ask these 3 questions after a delegated task is completed 1. was the task done properly & in a safe manner? 2. was the task done in the proper time frame? 3. were the client's needs met? Right Supervision and Evaluation or Feedback: When a task is performed and you identify a weakness, you are supposed to teach, teach, teach Transferring Care Between RNs: RN to RN transfer of care is called a handoff and transfers BOTH responsibility and accountability Priorities of Care: Priority questions are considered management of care Priorities of Care: You will go see all of the clients, but you have to set priorities and go see the one who has the most life-threatening condition first Privacy: We are responsible for keeping all client information confidential Privacy: You CANNOT post pictures of your client on social media Privacy: Social media posts violate the clients' right to privacy Privacy: Violations infringe on ____________________________ and could lead to _______________________________________ federal privacy laws; job loss, action by the board of nursing, or even the loss of your license Privacy: You are the client ________________ and are responsible for _________________________________________ advocate; making sure that client privacy and confidentiality are maintained Privacy: Confidentiality and privacy should be maintained with conversations, electronic records, or any sources of client information Privacy: You can NOT access a client's record that you are not responsible for providing care to Organ Donation: Organ donation decision made by a minor can be refused by the family, regardless of presence of documentation of organ donation wishes by the client Organ Donation: Laws impacting the rights of the family to overturn documented wishes for organ donation in non-minors can vary from state to state [Show Less]
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*HURST REVIEW Qbank/Customize Quiz - Adult Health, questions and answers
The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best a... [Show More] ction at this time? 1. Warm the room. 2. Submerge the hand in warm water. 3. Order a K pad and apply to hand. 4. Have the client exercise the fingers to increase blood flow. 1. Correct: When caring for clients with skin grafts, we want good circulation, so warm that room up. 2. Incorrect: This will not improve circulation and can lead to infection. 3. Incorrect: This will not improve circulation. Someone who has a skin graft doesn't have good sensation so there is risk of another burn to the graft with this. 4. Incorrect: Working those stiff, cold fingers will further imbalance the oxygen supply. This will not help, particularly if the environment remains cool. A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? Select all that apply 1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client in recumbent position. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min. 1., 2., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring, watching for dysrhythmias, monitor I&O hourly to make sure kidneys are perfused. Limit activity to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output. 3. Incorrect: Position upright to promote optimal ventilation by reducing venous return and lessen pulmonary edema. The nurse is supervising the care of a client on bedrest with a skull fracture from head trauma. Which action, when performed by an unlicensed assistive personnel (UAP), should the nurse interrupt? 1. Assisting with turn, cough, and deep breathing (TCDB) 2. Elevating the head of the bed to 30 degrees. 3. Measuring urinary output every hour. 4. Turning off room lights. 1. Correct: The nurse should interrupt the UAP assisting with TCDB because this may increase intracranial pressure (ICP). TCDB increases intrathoracic pressure which then increases ICP. 2. Incorrect: Maintain client with head trauma in the head up position. This position promotes drainage from the head and decreases vascular congestion. 3. Incorrect: This is an acceptable action and one the UAP can do. 4. Incorrect: You want to decrease stimulation and turning off room lights will provide restful environment in an effort to decrease ICP. The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings. 1. Correct: With restlessness, think hypoxia so the nurse should start assessment with airway first. Check for patency of the ET tube. If this is patent, then the other options would be next. 2. Incorrect: This is the next best answer, but hypoxia and airway comes first. 3. Incorrect: This is the third step. Rule out the other two before checking tubing for kinks or obstructions. 4. Incorrect: Start with the client first. Then move toward the ventilator. Always assess the client first. After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough. 2. Correct: This is an oxygen therapy safety precaution that the nurse should implement after applying oxygen. It is also the only correct and safe option in the question. 1. Incorrect: The bi-nasal prongs would mean that the oxygen is going in through the nose. Breathing deeply through the mouth and out through the nose would not increase oxygenation for a client having chest pain and would disrupt the flow of oxygen through the nose. 3. Incorrect: The nurse should avoid using petroleum products where oxygen is in use because they are flammable. 4. Incorrect: These client actions have nothing to do with oxygen administration and would cause more distress to the client with chest pain. A client with a history of myasthenia gravis (MG) has been discharged from the hospital following a thymectomy. When teaching the client how to prevent complications, the home care nurse emphasizes what daily actions are most important? Select all that apply 1. Include daily weight lifting exercises. 2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals. 5. Eat three large meals daily. 2., 3. & 4. Correct: Myasthenia gravis is a chronic autoimmune disorder characterized by progressive muscle weakening and chronic fatigue. Clients become weaker throughout the day, contributing to the potential for complications. Stress reduction techniques are important since stress can contribute to a myasthenic crisis, a severe respiratory emergency. Daily tasks, including ADL's, should be completed early in the day when the client has the most energy. Medications for MG, including neostigmine and pyridostigmine, must be taken on time and prior to meals. 1. Incorrect: Clients with myasthenia gravis are instructed to include gentle daily exercise combined with periods of rest throughout the day. Weight lifting would be too strenuous and would quickly tire this client, possibly leading to a myasthenia crisis. 5. Incorrect: Because of the difficulty in chewing or swallowing, multiple small meals throughout the day are safer and more beneficial to a client with myasthenia gravis. Medications are timed in relation to meals, so consistent but smaller meals would be more beneficial for the client. A nurse is participating in a cancer risk screening program. Which signs/symptoms would indicate to the nurse that a client needs further investigation? Select all that apply 1. Unexplained weight gain of 10 pounds 2. Leukoplakia 3. Prolonged hoarseness 4. Hematuria 5. Persistent abdominal bloating 2., 3., 4., & 5. Correct: White patches inside the mouth or white spots on the tongue may be leukoplakia, which is a precancerous area that is caused by frequent irritation. It is often caused by smoking or other tobacco use. People who smoke pipes or use oral or spit tobacco are at high risk for leukoplakia. If untreated, it can become mouth cancer. A cough that does not go away and prolonged hoarseness may be a sign of cancer. Hematuria may be a sign of bladder or kidney cancer and needs further investigation. Although women may experience bloating with changes in the menstrual cycle, constant bloating should be investigated to rule out ovarian cancer. 1. Incorrect: Unexplained loss of weight or loss of appetite may indicate some types of cancer. Weight gain is not typically associated with cancer. What room assignment by the charge nurse is most appropriate for a client who is being admitted with poor appetite, malaise, and temperature of 101.5ºF (38.6ºC)? 1. Private room. 2. Room with a client who has biliary colic. 3. Room with a client who is 3 days post operative hip replacement. 4. Room with a client who is in skeletal traction due to broken femur. 1. Correct: In this particular situation, a private room is best due to the elevated temperature. This could mean the client has an infection and is contagious. All of the often clients do not need to be exposed to this client with fever of unknown cause. 2. Incorrect: Does not need to be exposed to infection. Biliary colic is pain due to a gallstone blocking the bile duct. The client may need surgery and definitely should not be exposed to infection. 3. Incorrect: Post op client already at risk for infection. This is not the most appropriate client to room with the new admit. 4. Incorrect: Does not need to be exposed to infection. The client is already at risk for infection due to the skeletal traction. Complications of skeletal traction include risk for bone infection due to a screw being placed in a bone. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what? 1. Remove air from the pleural space 2. Create access for irrigating the chest cavity 3. Evacuate secretions from the bronchioles and alveoli 4. Drain blood and fluid from the pleural space 1. Correct: A chest tube placed in the upper chest is to remove air from the pleural space. Remember air rises and fluid settles down low. 2. Incorrect: Chest tubes are placed in the pleural space to get rid of air, blood, fluid, or exudate so that the lung can re-expand. The purpose is not to create an access for irrigating the chest cavity. 3. Incorrect: The chest tube is inserted into the pleural space because the lung has collapsed due to air, blood, fluid, or exudate. The chest tube does not go into the lung so secretions can not be removed from the bronchioles and alveoli by way of the chest tube. 4. Incorrect: You have to know the purpose of the upper chest tube. Fluid drains down, so the lower one is for fluid. What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? Select all that apply 1. Smokeless tobacco increases risk for lung cancer. 2. Inspect mouth frequently for lesions. 3. White patches in mouth should be reported to healthcare provider. 4. Risk for stomach cancer can be decreased by not swallowing smokeless tobacco juice. 5. Report decreased saliva to primary healthcare provider. 6. Smoking cessation. 2., 3., & 6. Correct: The mouth should be inspected frequently for painless lesions that do not heal. This may be a sign of oral cancer and should be reported to the primary health care provider. White patches (leukoplakia) is a sign of potential oral cancer as well. Nicotine is addictive and is found in smokeless tobacco. Clients using smokeless tobacco can benefit from smoking cessation information/classes. 1. Incorrect: Use of smokeless tobacco increases the risk developing of esophageal cancer, cancers of the mouth, throat, cheek, gums, lips, tongue, pancreatic cancer, stomach cancer, kidney cancer. 4. Incorrect: This is an incorrect statement. Some amount of tobacco juice will be swallowed and can lead to esophagus and stomach cancer. 5. Incorrect: Decreased saliva is not associated with oral cancer. A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? Exhibit: Lab Values: Na+ 147 mEq/L (147 mmol/L) Specific gravity 1.030 Hct 55% 1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output 2. Correct: We already know that the question is about what life threatening complication? A pulmonary embolism. And these lab values say that the client is what? Dehydrated! So the only thing that is going to fix that is....... Increasing fluids. 1. Incorrect: This will not prevent pulmonary embolism. The problem is dehydration. Do something to fix the problem. Foods high in iron will not fix the problem. 3. Incorrect: This will not prevent pulmonary embolism. How will obtaining a urine sample for culture fix dehydration? It won't. This client needs to increase fluid intake. 4. Incorrect: We do want to monitor intake and output to see how the client is doing, however, this will not fix the problem. Hydrating the client will help the problem. A client rescued from a house fire is being treated for burns to both arms and suspected inhalation injury. What data collected by the nurse has the highest priority? 1. Estimation of total surface burn area 2. Characteristics of cough and sputum 3. Calculation of client weight and age 4. Extent of edema to arms 2. CORRECT: A client rescued from a burning house is presumed to have inhaled superheated air during that process. Though calculating fluid replacement is vital to the client's survival, the ABCs dictate the highest priority is airway. Noting any cough or sputum can help determine whether prophylactic intubation may be necessary. 1. INCORRECT: The total amount of body surface burned is crucial information needed to determine fluid replacement using the Parkland Formula. However, though IV fluids are necessary, calculating the burn percentage is not the highest priority. 3. INCORRECT: The client's age is not an immediate priority, although a complete health history will be essential to the final outcome. The client's weight will be used to calculate fluid replacement; however, there is a higher initial priority. 4. INCORRECT:. A burn causes cellular damage that leads to edema. Depending on the location and extent of that edema, circulation could be greatly impaired. However, when monitoring a burned client, the ABCs place circulation third on the priority list. A client is awake in the recovery room following a cardiac catheterization performed through the left radial artery. During the assessment, the nurse notes severe swelling of the left upper arm with a diminished left radial pulse, indicating an internal arterial hemorrhage. The cardiologist states the client will require immediate surgery to repair the leaking artery. The nurse understands what fact about the current consent form? 1. Can be assumed since it's an emergent situation. 2. Should be signed by client who is currently awake. 3. Is not needed since client consented to catheterization. 4. Must be approved by family or a spouse. 4. Correct: An additional procedure requires a new consent form which describes specifically what the cardiologist plans to do. Even though the client is awake, residual sedation from the catheterization makes it necessary for a family member or spouse to sign the consent form. 1. Incorrect: Emergent situations are those in which the client's life or limb is threatened. That type of consent is called "implied" consent; however, despite the seriousness of the situation, implied consent is not valid in this case. 2. Incorrect: Though awake following the catheterization, the client is considered impaired because of the sedation used during the catheterization. Even if the client understands what is occurring, a signature by the client is not considered legal at this time. 3. Incorrect: Once the surgery and potential risks are explained to the client, a consent form is completed specifically describing the procedure to be performed by the cardiologist. That form does not cover any additional procedures, even if directly connected to the original surgery. An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?" 4. CORRECT: The nurse needs to focus on the client's psychological as well as physical needs. An open-ended question or statement encourages the client to elaborate and share concerns that the nurse needs to address. It would be inappropriate to force the client to participate in an activity that causes extreme fear and distress. 1. INCORRECT: The nurse is dismissing the client's right to experience a specific emotion, rather than actively seeking the reason behind those feelings. The nurse is not utilizing appropriate communication techniques. 2. INCORRECT: This tactless response focuses on the orders provided by the primary healthcare provider, rather than the client's expressed concerns. Such a comment by the nurse is non-therapeutic because it ignores the client's psychological needs. 3. INCORRECT: Although the nurse offers a solution to the client, there is no chance for the client to verbalize feelings and concerns. It is more important to present the client with the therapeutic opportunity to discuss fears. The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary? Select all that apply 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Pursed-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr 1., 4. & 5. Correct: These three findings would indicate that further treatment is needed. 3+ pedal edema, and pursed-lip breathing is seen when client is still short of breath. Pale conjunctiva, nail beds, buccal mucosa are signs of impaired gas exchange. 2. Incorrect: Normal CVP is 2-6 mm Hg. This CVP is within normal range so treatment is effective. 3. Incorrect: Weight loss indicates that fluid is being removed. 6. Incorrect: A urine output of 50 mL/hour indicates that renal perfusion is adequate. What would be the best way for the nurse to evaluate the effectiveness of fluid resuscitation during the emergent phase of burn management? 1. Weight increases by 2 pounds in 24 hours 2. Urinary output is greater than fluid intake 3. Blood pressure is 90/60 mmHg 4. Urine output greater than 35 mL/hour 4. Correct: Urine output of 30 to 50 mL/hour indicates adequate fluid replacement. 1. Incorrect: May indicate fluid retention. 2. Incorrect: Does not indicate fluid balance. 3. Incorrect: Blood pressure alone does not indicate adequate fluid balance. The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? Select all that apply 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking 1., 2., 4., 5., & 6. Correct: These are all modifiable risk factors that can be managed through lifestyle changes or medical treatment. 3. Incorrect: Hispanics, African Americans, Native Americans, and Asian Americans have a higher incidence of strokes than whites. You cannot change your race or ethnicity so this is a non-modifiable risk factor for stroke. A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? Select all that apply 1. Elevate HOB 30 degrees 2. Pad side rails 3. Provide sponge bath if temperature greater than 101°F (38.3°C) 4. Initiate airborne isolation precautions 5. Darken room 1., 2., 3. & 5. Correct: An acute onset of fever, headache, stiff neck, n/v, and mental status changes are consistent with bacterial meningitis. Elevate the head of the bed to promote comfort and decrease intracranial pressure. The client is at an increased risk for seizures, and the nurse should implement seizure precautions which include padding the side rails. A sponge bath is an independent nursing intervention appropriate for a fever greater than 101°F (38.3°C). Darkening the room is also a comfort measure as this client will have photophobia. 4. Incorrect: Droplet precautions should be initiated for the first 24 hours of antimicrobial therapy. A client has been admitted with a diagnosis of portosystemic encephalopathy secondary to Laennec's cirrhosis. The primary healthcare provider writes prescriptions based on the lab values. The nurse would monitor the effectiveness of medications by observing for what specific neurologic changes in the client? Exhibit: Lab Results: Sodium: 129 meq/dl Potassium: 3.0 meq/dl Albumin: 2.0 gm/dl Ammonia: 80 mcg/dl Bilirubin: 2.0 gm/dl BUN: 32 mg/dl Creatinine: 2.0 mg/dl BP: 100/60 Pulse: 110 Resp: 28 Medication: Furosemide (Lasix) 60 mg IV every 12 hours Lactulose 30 mg by mouth every 4 hours K-Dur 40 meq by mouth twice daily Albumin 25% 100 mL IV twice daily 1. Increased urination and improved memory. 2. Increased blood pressure and lower pulse. 3. Frequent diarrhea with orientation x three. 4. Clear speech and +2 pitting edema to BLE. 3. Correct: Neurologic deterioration in clients with cirrhosis is secondary to increased ammonia levels in the body and brain, resulting in development of encephalopathy. Frequent diarrhea, secondary to the use of lactulose, helps rid the body of ammonia, allowing the client's orientation to improve to normal. 1. Incorrect: Although increased urination is expected because of the furosemide, this medication would not impact the client's memory. Additionally, there is no indication whether the improvement reflects changes in long-term or short-term memory. 2. Incorrect: As the client slowly improves, vital signs should begin to stabilize, with the blood pressure increasing and the pulse decreasing toward the normal range of 60-100. However, neither of these changes would relate to specific changes in the neurologic status. 4. Incorrect: Though the client's speech is now clear, this does not indicate improvements in either orientation or alertness. The client's speech could be clear even with disorientation. The +2 edema in BLE is decreasing but does not indicate neurologic improvement. A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates. 2. Correct: Normally, protein is broken down into ammonia, which the liver converts into urea, and the kidneys then easily excrete. However, in a diseased liver, this conversion is not possible, and ammonia continues to build up in the body, ultimately affecting the brain. The nurse would be aware that additional protein would be harmful for this client. 1. Incorrect: Increasing meat at mealtimes would be detrimental to the client's health. When protein is taken into the body, a healthy liver will convert this into urea that is then excreted by the kidneys. However, this client's impaired liver is not able to make that conversion; therefore, the ammonia levels would continue to increase. The nurse can discuss with the client other foods that might safely be added to meals. 3. Incorrect: While it is true this client is dehydrated, the issue is that the client wants to increase the amount of meat at mealtimes. This response does not address the client's request nor does it provide any teaching that would help the client once discharged. 4. Incorrect: Although this response indicates that the nurse is focusing on the client's issue with food, this reply does not address the request for more meat with meals. This would be the appropriate opportunity to educate the client on the need to limit daily protein in the diet. A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? 1. Monitor blood sugar around 2am. 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin. 1. Correct: Morning hyperglycemia may be the result of dawn's phenomenon or the Somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect Somogyi effect. 2. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of morning hyperglycemia in order to treat the condition appropriately. 3. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of hyperglycemia in order to treat the condition appropriately. An appropriate intervention for a client with Somogyi effect would be to decrease the evening dose of intermediate acting insulin, however, the nurse must first determine that the client is in fact experiencing the Somogyi effect. 4. Incorrect: This is an intervention; assessment should come first. Increasing the intermediate acting insulin would not be appropriate action for a client experiencing Somogyi effect. A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions. 3. CORRECT: Rheumatoid arthritis is an autoimmune disease that affects not only body joints but also organs of the body. Receiving methylprednisolone as treatment further suppresses the immune system, making the client even more at risk of infection. Restricting visitors with colds, respiratory problems and other infectious processes is the best method to protect the client. 1. INCORRECT: The question states the diagnosis is rheumatoid arthritis, but there is no indication the client is unsteady or needs to be on "Fall Precautions". Although the client is fatigued and has brittle bones, there is no evidence the client needs assistance ambulating. A sign is not necessary. 2. INCORRECT: Most facilities have policies to change an IV site at specific intervals, usually every three days. Changing the site daily exposes the client to an increased chance of infection from the invasive procedure. Steroids do not irritate veins and do not require frequent site changes. 4. INCORRECT: There is no rationale for contact precautions since the client's disease process is not contagious. The main concern is to protect the client from other individuals. A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? Exhibit: Select all that apply 1. Have client ambulate back to bed. 2. Initiate 100% oxygen per non rebreather mask. 3. Obtain client's blood pressure. 4. Prepare for cardioversion. 5. Auscultate lung sounds. 6. Administer nitroglycerin 1 tab SL. 3. & 5. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds. 1. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall. 2. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100%. Start with the least amount of oxygen that could relieve symptoms. 4. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs. 6. Incorrect: Nitroglycerin would be given if the client is experiencing chest pain or is suspected of having an MI. Get the client back in bed and provide the client with oxygen at 2 L/NC first. A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful? 1. Cup of almonds 2. Cheese and crackers 3. Popcorn 4. Sweet potato fries 3. Correct: Hypothyroidism clients tend to have constipation due to decreased motility of the GI tract and need increased fiber and fluid intake. Popcorn is high in fiber. 1. Incorrect: People with hypothyroidism have a slow metabolism and do not need high protein but a well balanced diet. Almonds are high in protein. 2. Incorrect: Cheese and crackers are high in sodium. This client is at risk for CAD, so sodium should be limited. 4. Incorrect: This client does not need high potassium, which fried sweet potatoes have. The high potassium dietary approaches to stop hypertension (DASH) diet is only for healthy clients with hypertension. The nurse is preparing to administer a dose of potassium iodide 300 mg by mouth to a client diagnosed with hyperthyroidism. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to hold the potassium iodide dose and notify the primary healthcare provider? Exhibit: Client Information: Medical diagnosis: Hyperthyroidism Current vital signs: BP 142/88, HR 102, R 20 Medical history: Hypertension Physical examination: Alert/oriented. PERRLA. Skin warm/dry. Lungs sounds clear bilaterally. Normal S1/S2 without murmurs, clicks, rubs. Lab test results: Glucose- 98 mg/dl (5.4 mmol/L), Sodium- 139 mEq/L (139 mmol/L), Potassium- 5.5 mEq/L (5.5 mmol/L), Creatinine - 0.9 mg/dL (79.5 µmol/L), Creatinine Clearance 110 mL/min Current medications: Losartan 50 mg one by mouth daily, Methimazole 10 mg by mouth daily Drug Reference: Medication: Potassium iodide Classification: Antithyroid agent Indications: Adjunct with other antithyroid drugs in preparation for thyroidectomy. Treatment in thyrotoxic crisis. Radiation protectant following radiation emergencies or administration of radioactive iodine. Contraindications/Precautions: Hypersensitivity; hyperkalemia; pulmonary edema; impaired renal function. Use cautiously in tuberculosis; bronchitis; cardiovascular disease. Adverse reactions/Side effects: Confusion, weakness, GI BLEEDING, diarrhea, nausea, vomiting, hyperkalemia, tingling, joint pain. Interactions: Use with lithium may cause increased hypothyroidism. Increases the antithyroid effects of methimazole and propylthiouracil. Increased hyperkalemia may result from combined use with potassium-sparing diuretics, Ace inhibitors, angiotensin II receptor antagonists or potassium supplements. Route/Dose: 300-500 mg three times a day by mouth Select all that apply 1. Creatinine - 0.9 mg/dL (79.5 µmol/L) 2. Potassium- 5.5 mEq/L (5.5 mmol/L) 3. Glucose- 98 mg/dl (5.4 mmol/L) 4. Taking losartan 50 mg one by mouth daily. 5. Currently taking methimazole 10 mg by mouth daily. 6. Creatinine Clearance 110 mL/min 2., 4., & 5. Correct: The medication is potassium iodide, which can lead to hyperkalemia when administered, so it is contraindicated if the client already has hyperkalemia. This client's potassium level is 5.5 mEq/L (5.5 mmol/L), which would support the nurse holding the medication and contacting the primary healthcare provider. Additionally, the drug guides states that potassium iodide increases the antithyroid effect of methimazole and propylthiouracil. Increased hyperkalemia may result from combined use with potassium-sparing diuretics, Ace inhibitors, angiotensin II receptor antagonists or potassium supplements. This client is currently on both losartan, an ARB, and methimazole. 1. Incorrect: This is a normal creatinine level. Normal range is 0.8 - 1.4 mg/dL (70-124 µmol/L) in males and 0.56-1.0 mg/dL (50-88 µmol/L) in females. 3. Incorrect: Potassium iodide does not affect glucose and this is a normal glucose level. 6. Incorrect: The normal creatinine clearance is 75-125 mL/min. Therefore, 110 mL/min is within normal limits and would not require withholding the potassium iodide. [Show Less]
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