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NR 324
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NR 324 ATI - TEST 4 PRACTICE ASSESSMENT
NR 324 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is planning care for a client who has a suspected myocardial infarction. Which of the following should... [Show More] the nurse administer first? C. Oxygen 2 ATI - TEST 4 PRACTICE ASSESSMENT While reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities? C. Atrial deporlarization 3 ATI - TEST 4 PRACTICE ASSESSMENT A client comes to the emergency department via ambulance to report severe radiating chest pain and SOB. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse assisting with this client client's care first? C. Initiate oxygen therapy. 4 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is preparing a client for an echocardiogram the following day. Which of the following instruction should the nurse include about this test? C. It requires lying quietly on one side. Rationale: For a Transthoracic Echocardiogram (TTE), the client lies quietly on the left side with slight head elevation. There is no reason for the client to be NPO. The test takes up to 1 hour and there is not discomfort as a transducer with conductive jelly is used on the chest. 5 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reviewing the laboratory values on a client who has HTN. Blood tests are drawn and reveal the following results. Which of the following results should the nurse identify as critical? B. Potassium 2.3 mEq/L 6 ATI - TEST 4 PRACTICE ASSESSMENT The nurse is completing a medication review of a client who has elevated cholesterol levels and takes an anticoagulant. Which of the following should the nurse report to the provider?. D. Uses garlic as a cholesterol lowering agent. Rationale: The nurse should be aware that the use of garlic to lower cholesterol may potentiate the action of anticoagulant medication and should report the finding to the provider. 7 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who enters the emergency department complaining of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction? C. Perform a 12-lead ECG 8 ATI - TEST 4 PRACTICE ASSESSMENT While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? A. A cardiac murmur Rationale: Cardiac murmurs are relatively lout, turbulent sounds the nurse can hear between usual, expected heart sounds. They create a whooshing or swishing sound. 9 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reviewing the initial laboratory values for partial thromboplastin time, and prothrombin time, and thrombin time on a client who has an acute episode of disseminated intravascular coagulation (DIC). The nurse should expect the laboratory values to be B. prolonged. Rationale: The nurse should expect the laboratory values to be prolonged because the anticoagulant pathways are impaired and consume the key clotting factors, resulting in clotting dysfunction. 10 **ATI - TEST 4 PRACTICE ASSESSMENT** A nurse is reinforcing discharge teaching for a client who has received an implantable cardioverter/defribillator (ICD). Which of the following information should the nurse include? B. The client should hold his cell phone on the side opposite the ICD. Rationale: The client should keep his cellular phone on the side opposite of the ICD, as close proximity could interfere with the ICD's function. The client should inform airport security of the device. The client does not carry the ICD is in his pocket, this is an IMPLANTABLE device. 11 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client who is postoperative following an insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.) A. Count your pulse for 1 min each morning. C. Do not wear tight clothing over the insertion area. Rationale: Avoid coming into contact with metal detectors is incorrect, there is not danger going through a metal detector, but the client should inform airport security because the pacemaker will trigger an alarm. Do not operate microwave ovens is incorrect. It is save for clients with a pacemaker to operate microwave ovens unless they are old and do not have the appropriate shielding or of they are defective. 12 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? C. The pacemaker spikes before each QRS complex. 13 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what this medication will do, which of the following is an appropriate nursing response? D. It prevents strokes in clients who have atrial fibrillation. Rationale: Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants such as warfarin help prevent thrombosis formation. 14 ATI - TEST 4 PRACTICE ASSESSMENT A client is telling the nurse in the clinic that he gets a headache after he takes sublingual nitroglycerin (Nitrostat). Which of the following should the nurse remind the client to do? C. Lie down in a cool environment and rest. Rationale: HA is a common side effect of nitroglycerin. The nurse should suggest conservative measures to manage the HA. Generally, HAs that are a side effect of nitroglycerin are transient. They usually last about 5 min an rarely longer than 20 min. 15 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client who has a new prescription for warfarin sodium (Coumadin). Which of the following should the nurse include? B. He should use an electric razor while on this medication. 16 ***ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? A. Obtain a venous duplex ultrasound. Rationale: Venous duplex utlrasonography is a noninvasive diagnostic test used to detect distal DVT. Performing Homan's sign and dislodge the clot therefore this is inappropropriate. Warm therapy is used with DVTs not cold therapy 17 **ATI - TEST 4 PRACTICE ASSESSMENT** A client complains of SOB and chest pain the first day following multiple long bone fractures. THe nurse would consider which of the following client complications when assessing the client? B. Fat emboli Rationale: The client with a compound long bone fracture is at high risk for developing a fat embolus within 24 to 96 hr. 18 ***ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is collecting data from an infant that has a coarctation of the aorta. Which of the following is a clinical manifestation? A. Increased blood pressure in the arms with decreased blood pressure in the legs Rationale: There is a narrowing next to the ductus areteriosus which results in an increased pressure proximal to the defect with a decreased distal to the obstruction. Therefore, an increase blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta. 19 ATI - TEST 4 PRACTICE ASSESSMENT When checking a client's capillary refill, the nurse finds that the color returns to usual in 10 seconds. The nurse understands that this finding indicates which of the following? A. Arterial insufficiency Rationale: To test the capillary refill, the nurses presses on the client's nail beds to produce blanching and then measures the time it takes for the color to return. With adequate arterial capillary perfusion, the color should return within 3 seconds. Taking longer than 3 seconds indicates impaired arterial blood flow to the extremity. 20 ATI - TEST 4 PRACTICE ASSESSMENT Whenever a nurse is caring for clients who are receiving heparin, which of the following [Show Less]
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NR 324 ADULT HEALTH STUDY GUIDE
NR 324 ADULT HEALTH STUDY GUIDE 1. Describe the composition of the major body fluid compartments. The major body fluid compartments contain mineral... [Show More] salts which is called electrolytes. Electrolyte that charged positively are called cations such as sodium, potassium, calcium, and magnesium. Electrolytes that are charged negatively are called anions such as chloride, and bicarbonate. These negative and positive charges are combined to make salts. 2. Describe what causes Fluid volume deficit, (a) the assessment, (b) nursing management, (c) nursing education. When sodium and water intake is less than output, it causes isotonic loss or insufficient isotonic fluid in the extracellular compartment. The major reasons for isotonic fluid deficit are abrupt decrease in oral intake of water and salt, vomiting, diarrhea, drainage from fistula, hemorrhage, burns, massive sweating without compensating with intakes. Physical assessment for fluid volume deficit will be sudden weight loss, postural hypotension, thread pulse, tachycardia, dry mucous membrane, poor skin turgor, flat neck vein when supine, dark yellow urine. If sever thirst, restlessness, confusion, hypotension, oliguria (urine output less than 30 ml/hr), and hypovolemic. Nursing management is encouraging fluid therapy (PO or IV), monitor vital sign, monitor input and output of patient fluid, monitor patient weight, assess patient lifestyle, diet habit, medication, risk factors for fluid imbalance. Client education will be educating client about the recommended diet, educate how to monitor input and output, instruct the patient to weight with the same cloth, same time, and same scale. Educate to avoid alcohol consumption because it increases of fluid loss. 3. Describe what causes Fluid volume excess, (a) the assessment, (b) nursing management, (c) nursing education. When sodium and water intake is greater than output, it causes isotonic gain or excessive isotonic fluid in the extracellular compartment. The major causes of fluid overload are excessive fluid administration of sodium containing isotonic IV or oral intake of salt and water, heart failure, renal disease, sudden weight gain, edema, fluid in lungs, and cirrhosis. Physical assessment for fluid overload will be sudden weight gain, edema, if sever, confusion, hematocrit, decrease BUN, and pulmonary edema. Nursing management will be checking the medication, client life style, dietary intake, factors for fluid imbalance. Teach clients to exercise if tolerable, watch for fluid intake and output, elevate the extremities to prevent edema and recommend dialysis in sever renal failure. Client education will be managing the fluid balance or instruct the risk factor for developing fluid imbalance. 4. Describe the laboratory normal values, clinical manifestations, assessment priorities (i.e. Neuro, Cardiac, cardiovascular, etc.) & nursing collaborative management of the following imbalances. Clinical Lab Values Clinical Manifestations Assessment priorities Nursing Management (Include diet) Nursing Education and considerations Hyponatremia & Hypernatremia Hyponatremia: - Na+ below 135 mEq/L. Body gain more water than salt. Too dilute of body fluid. Excessive ADH (SIADH). Excess IV administration of D5W. Loss of more salt than water. Hypernatremia: - N+ above 145 mEq/L. Body gain more salt than water. Excessive sodium containing IV administration or oral intake of Na+. Renal retain more Na+. Confusion, decrease LOC, poor skin turgor, cold and clammy skin, flat neck vein, lethargy, and coma. Confusion, decrease LOC, lethargy, coma, excessive thirst, seizure if too much/ fast IV administered. Instruct patient to stay away from processed foods, salty chips, and any other salty foods. Educate the patient about the risk for fluid imbalance and the effect of the fluid imbalance on the body system. Hyperkalemia & Hypokalemia Hyperkalemia: - K+ above 5.0 mEq/L. Excessive administration of IV K+. Massive amount of K+ moves out of cells. End renal stages. Hypokalemia: - K+ below 3.5 mEq/L. Low serum K+ concentration. Excessive use of K+ free IV solutions. K+ moves into the cells. Too much insulin treatment of DKA. Low K+ consumption. Constipation, dysrhythmias, muscle weakness. Dysrhythmias, bilateral muscle weakness mostly in quadriceps, and abdominal distension. Instruct the patient about the risk of K+ imbalance foods such as fruits potatoes, instant coffee, brazil nuts, and Molasses. Maintaining a good rest. Instruct the client to allow the smooth, skeletal, and cardiac muscles to have a normal muscle friction. Hypercalcemia & Hypocalcemia Hypercalcemia: - Ca+ above 10.5 mg/dL. High calcium concentration. Too much calcium consumption. Shift the Ca+ out of the bone. Decrease Ca+ output. Hypocalcemia: - Ca+ below 8.4 mg/dL. Low calcium intake. Shift of Ca+ into bones inactive form. Excessive output of Ca+, usually appear in the end stage of renal disease. Decrease LOC, Anorexia, N/V, fatigue, Constipation, lethargy, confusion, and heart problem. Muscle spasm, numbness, tingling of toe, fingers, and around mouth region. Chvostek’s sign. Seizure, dysrhythmias, and Trousseau sign. Watch for calcium balance. Dairy products, fish with bone, broccoli, orange, and vitamin D. Instruct patient about the influence on bone and nerve cells. Instruct them how it’s important for muscle contraction and bone health. Hypomagnesemia & Hypermagnesemia Hypomagnesemia: - Mg+ below 1.5 mEq/L. Low Mg+ intake. Malnutrition and chronic alcoholism, diarrhea, steatorrhea, excessive Mg+ output. Hypermagnesemia:- Mg+ above 2.5 mEq/L. High Mg+ intake. Excessive use of Mg+ contains laxative. Decrease Mg+ output occur in end-stage of renal disease. Positive Chvostek sign, hyperactive deep tender reflex, muscle cramps, and twitching, grimacing, dysphagia, tetany, and insomnia. Tychacardia, dysrhythmia, decrease rate of respiration, and cardiac arrest. Dark green leafy vegetables, whole grains, Mg2+ containing laxatives, and undigested fat. Instruct the patient how it influence their neuromuscular junction. Hyperphosphatemia & Hypophosphatemia Hyperphosphatemia: - High Phosphate intake. Decrease phosphate output. Hypophosphatemia: - Low Phosphate in extra cellular fluid. Phosphate shifts into the cell. Too much phosphate output. Renal decrese function, Oliguria decrease. Mostly in processed food. Milk. Instruct client about how it is used for the production of ATP which is the major energy source of all cellular. 5. Explain the difference between Chvostek’s sign and Trousseau sign when assessing a client with a calcium imbalance? Chvoske sign refers to an abnormal reaction to the stimulation of the facial nerve. When the facial nerve is tapped at the angle of the jaw (i.e. masseter muscle), the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia (i.e. from hypoparathyroidism, pseudo-hypoparathyroidism, hypo-vitamin D) with resultant hyper-excitability of nerves. Trousseau sign of latent tetany which also occur in low calcium level. The sign appears when the blood pressure cuff is placed in a person’s arm (brachial artery). When the cuff inflate, the blood flow will absent, and the wrist and other joints as well as the fingers will be adducted. 6. Explain the common clinical manifestations, and nursing management of the following acid-base imbalances: A) Metabolic acidosis Metabolic acidosis is when there is an increase of metabolic acid. The person will experience decrease level of consciousness which is lethargy, confusion, and coma. Abdominal pain, dysrhythmias, increase rate and depth of respiration. pH is low or below 7.35, PaCO2 will be normal, or if it is uncompensated below 35. And, the HCO3- level below 22 mEq/L. B) Metabolic alkalosis Metabolic Alkalosis is when an increase of bicarbonate. It happens when there is excessive administration of sodium bicarbonate, excessive blood transfusion, and ECV. s/s are light- headedness, numbness, and tingling of fingers, toe and muscle cramps. pH will be above 7:45, PaCO2 normal if uncompensated or above 45 mm Hg if compensated, HCO3 above 26 mEq/L. C) Respiratory acidosis When there is excessive carbonic acid in our body usually caused by Alveolar Hypoventilation. Headache, light-headedness, decreased level of consciousness (confusion, lethargy, coma), dysrhythmias Laboratory findings: Arterial blood gas alterations: pH below 7.35, PaCO2 above 45 mm Hg (6 kPa), level normal if uncompensated or above 26 mEq/L (26 mmol/L) if compensated. D) Respiratory alkalosis When there is deficiency of carbonic acid which caused by alveolar hyperventilation. Hypoxemia from any cause (e.g., initial part of asthma episode, pneumonia) Acute pain Anxiety, psychological distress, sobbing Inappropriate mechanical ventilator settings Stimulation of brainstem respiratory control (e.g., meningitis, gram-negative sepsis, head injury, aspirin overdose). Physical examination: Light-headedness, numbness and tingling of fingers, toes, and circumoral region, increased rate and depth of respirations, excitement and confusion possibly followed by decreased level of consciousness, dysrhythmias Laboratory findings: Arterial blood gas alterations: pH above 7.45, PaCO2 below 35 mm Hg (4.7 kPa), level normal if short lived or uncompensated or below 22 mEq/L (22 mmol/L) if compensated 7. Describe the composition (give examples) and reasons for use of common IV fluid solutions. A) Isotonic: When we administer the same tonicity as normal blood is called isotonic. B) Hypertonic: When we administer the hypertonic solution, it means more concentrated than normal blood. C) Hypotonic: When we administer hypotonic, it means the solution is more dilute than the blood. 8. Explain how to administer IV KCL (potassium), What guidelines must the nurse follow? IV KCL should be administered with NS. It should not be administered via IV push or bolus. 9. Discuss the types and nursing management (maintenance) of commonly used central venous access devices. A) PICC Line: This is the central venous catheter inserted into a vein in the arm. The length of the line is up to 60 cm and the gauge ranges are 24 to 16. They are usually used with patients who need vascular access for 1 week to 6 months, but in place for a long period of time. PICC line has so many advantages such as lower cost, lower infection rate, fewer complication, and can be used for inpatient and outpatient. Nursing management with PICC line will be assessing the tube/line for clamping or kinking, administer anticoagulant or thrombolytic agents, and flush the syringe with 10 ml NS gently. If there is any sign of embolism, administer oxygen, place the patient on the left side with the head down, and notify the physician. If there is any sign of local infection, apply warm drainage for the infected site or remove the catheter if necessary. If the sign of the infection is systemic, check the vital sign, wash hands to prevent further infection, take blood culture, administer antibiotics therapy, or remove the catheter if necessary. B) Metaport: they are single or double subcutaneous injection port of a central catheter infusion. They are meant to use for a long-term therapy and have a low risk of infection. It feels more secured for the patient and have less maintenance problem than other central venous catheters. In order to prevent any tube clotting, sludge, and drug particles in the port, the regular flushing is required within the port. The nurse role will be assessing the catheter and the insertion site for any redness, edema, warmth, drainage, and tenderness or pain. The nurse also must perform the pain assessment and observation of the site. 10. Identify the normal laboratory diagnostic ranges for interpreting acid-base imbalances. ( Ph balance, HCO3, and PaCO2). The normal laboratory diagnoses ranges are as follows pH 7.35-7.45, PaCO2 35-45 mm Hg, PaO2 80-100 mm Hg, O2 sat 95%-100%, Anion gap 5-11 mEq/L, Osmolality 280-300 mOsm/kg H2O, Sodium 136-145 mEq/L, Potassium 3.5-5.0 mEq/L, Chloride 98-106 mEq/L, Bicarbonate 22-26 mEq/L, Calcium 8.4-10.5 mg/dL, Magnesium 1.5-2.5 mEq/L, Phosphate 2.7-4.5 mg/dL. 11. Explain metabolic acidosis and metabolic alkalosis. Metabolic acidosis occurs during the increase of metabolic acid and the decrease of metabolic base or bicarbonate in our body. When the body exert too much bicarbonate as diarrhea or other method uncontrollably, the kidney will unable to compensate or excrete enough metabolic acid which accumulate in the blood. The pH will also fall. This problem usually seen in a patient with DKA, alcoholism, sever hyperthyroidism, and end stage renal disease. Metabolic alkalosis occurs when body are not able to excrete bicarbonate which is an increase of base in our body and when the body loses too much metabolic acid. This kind of problem seen in patient with massive blood transfusion, sever vomiting and gastric suctioning (NG tube). 12. Explain respiratory acidosis and respiratory alkalosis. Respiratory acidosis occurs when the lungs are unable to excrete carbonic acid. It usually arises from alveolar hypoventilation. The body will have excess amount of carbonic acid in the blood which also will make the decrease of pH. The kidney compensates by increasing excretion of metabolic acid in the urine; however, the process takes longer time, up to 24 hours to 5 days for effective respond. This problem has been seen in a patient with COPD, bacterial pneumonia, extensive atelectasis, or a drug overdose. Respiratory alkalosis occurs when the lungs excrete too much carbonic acid and water. The PaCO2 will decrease which causes the deficit of carbonic acid in the blood, which also increase the pH level. Kidney might not compensate this problem. This problem has been seen in a patient with acute pain, anxiety, head injury, and meningitis. 13. Complete the table below: Bronchoscopy, CT scan, TB Screening test, Thoracentesis Explanation of the Procedure Pre-Procedure Consideration What are the post-procedure Complications Nursing teachings Bronchoscopy Biopsy, specimen collection, and assessment collection. Minor bleeding, tongue edema, low oxygen level, shortness of breath. Instruct patient to be on NPO until gag reflex, give sedative medication if ordered, monitor for bleeding, and recovery from sedation. CT scan Instruct patient to stay NPO, assess for vital sign, assess for allergy, if child, prepare for sedative med. Remove all metal, belt, and jewelries. If pregnant, the radiation is harmful for unborn baby. Exposure of radiation is harm. Monitor the patient for hydration. Instruct the patient about the scanner machine noise. TB screening Test Assess the patient recent travel history, Ask where patient has lived, assess for sign and symptom. Patient might Deny to take medication, Patient might not show up with in expected day to read the result. Teach the importance of taking the medication if their result is positive. Instruct the patient active TB virus can act up at any age. Thoracentesis Assess for vital sign, explain the procedure for the patient, instruct the patient that they have to sit up for the procedure. Asses for cough, respiration, chest pain, and sitting position. Explain the patient procedure, stay on your unaffected side for at least 30 min or more. 14. Describe the signs and symptoms of inadequate oxygenation? There are two types of sign and symptom of inadequate oxygenation such as early and late. Early sign and symptoms are irritability, tachycardia, dyspnea on exertion, dysrhythmia, and mild hypertensions. The late sign and symptoms of hypoxia are coma, confusion, hypotension, lethargy, cyanosis, cool, and clammy skin. 15. List common age-related changes of the respiratory system that are found upon assessment. Elderly people chest wall become stiff, barrel chest, decrease chest wall compliance, respiratory muscle strength decrease, and decrease elasticity. 16. Explain the nursing management of a client experiencing epistaxis? Start helping the patient with first aid which is by telling the patient to be quit, place the patient in a sitting position and head tilted forward, and apply direct pressure by pinching the entire nose for 10-15 min. Open mouth and breath. if this help doesn’t help, seek immediate medical help. 17. Discuss the rationale for tracheostomy insertion, and the nursing management of the patient who requires a tracheostomy (include management for accidental dislodgement). It is a sterile procedure, the procedure helps bypass an upper respiratory obstruction, and facilitate removal of secretions. Teach client to take more fluid, cough and deep breathing. If the tube is accidentally dislodged, replace the tube. 18. Identify the common clinical manifestations for a client with larynx cancer. Patient will have white/red patch in mouth, their voice will change, wound/ulcer that will not heal, difficulty swallowing, and pain. 19. Discuss the nursing management of the patient who has undergone a laryngectomy. Instruct the patient to expect some voice change or even might loss of their speech ability, the importance of good oral care, the change of smell and test ability, the importance of cleaning the tube, and teach them the NG tube feeding possible option for them. 20. Explain some communication methods used for clients who have had temporary or permanent loss of speech. It usually depends of the patient; however, if they are unable to speak, explain them that writing the thing want to say on board, expressing the feeling in non-verbal way, and use of some collaboration speech therapy are always available for them. 21. Explain the difference between these common types of pneumonia, risk factors and clinical manifestations. (Aspiration, Inhalation, and Hematogenous spread) Pneumonia is a bacterial infection of lower respiratory system. Some of the risk factors are air pollution, trauma, excessive alcohol consumption, prolog bedridden, malnutrition, IV drug use, upper respiratory tract infection, smoking, and so on. Aspiration is one of the causes of pneumonia that reaches the lung. Many of the organisms that cause pneumonia is normal inhabitation of the pharynx in healthy adult. Inhalation is the other methods of causing pneumonia that reaches the lung. Inhalation of the microbes present in the air such as fungal pneumonia. Hematogenous spread is also the other methods of causing pneumonia that reaches the lungs. It usually happens by the spread from a primary infection elsewhere in the body. 22. Explain the difference between Community-Acquired Pneumonia & Medical Care–Associated Pneumonia. Community-Acquired pneumonia is an acute infection of the lungs which occurs in patients who have not been hospitalized or in a long-term care facility within 14 days of the onset of symptoms. Medical care-associated pneumonia can be explained in three forms such as hospital-associated pneumonia which occurs within 48 hours or longer after admission and was not incubation at the time of hospitalization. Ventilator associated pneumonia which occurs more than 48 hours after endotracheal intubation. Health care-associated pneumonia is a new-onset one in a patient who are hospitalized. 23. Explain the common assessment findings for pneumonia patients, common breathing techniques used, nursing diagnosis, nursing care, including discharge instructions and client teaching. The most common assessment finding for pneumonia patient is cough, shaking chills, dyspnea, tachypnea, and pleuritic chest pain. The cough may be productive or may not. Sputum may be green, yellow, or even rust colored or bloody. The breathing/lung sound will be rhonchi and crackles. The sounds will be bronchial breath sound and increase fremitus. Diagnosis will be chest x-ray, history and physical examination, gram stain of sputum and blood culture, and pulse oximetry. 24. Define tuberculosis, and what are the risk factors? Tuberculosis (TB) is an infection disease of the lungs cause by Mycobacterium tuberculosis. The people who are at risk for TB are homeless people, people who have very limited access to health care, those who living or working in institutions such as long term facilities, and exposure with an infected person. 25. What is the priority nursing management for clients with tuberculosis, (include isolation and patient and family teaching regarding prevention methods)? If the nurse triggered the patient with TB, that patient should be placed on airborne isolation, receive a medical workup such as chest x-ray, sputum smear, and culture, and receive appropriate drug therapy. Teach the patient to cover their mouth when every time they cough, sneeze, or produce sputum. Teach the patient to take the medication appropriately. 26. Describe the risk factors, clinical manifestations, and priority nursing management of lung cancer. Smoking is the number on risk factor for lung cancer. It is approximately 80-90% of lung cancer are caused by smoking. Being able to second had smoker or exposure to tobacco smoke area could increase the chance of getting a lung cancer. 27. What is the common diagnostic tool for lung cancer, and what is the priority teaching for clients with lung cancer? The common diagnostic tool for lung cancer will be history and physical examination, chest x-ray, sputum culture, CT scan, and bronchoscopy. Client teaching will be that allow them as much control as possible for their personal care, encourage to express any concerns, and teach them the removal of lung could be one of the treatment if things getting worst. 28. Describe the purpose and nursing responsibilities related to chest tubes. Chest tube are inserted for the purpose of draining the plural space and reestablish negative pressure and promote lung expansion. The tube might also use to drain air and fluid for post-operative patients. Nurses are responsible to wash hands before and after the procedure, to keep the insertion site sterile, to assess vital sign, assess for pain, reposition patient after surgery, and so on. 29. Define Cor-Pulmonale. It is the enlargement of the right ventricle caused by a primary disorder of the respiratory system. It may be with or without overt cardiac failure and pulmonary HTN. Common symptoms include exertional dyspnea, tachypnea, cough, and fatigue. Physical signs include evidence of right ventricular hypertrophy on ECG and an increase in intensity of the second heart sound. 30. Explain thoracentesis and pleuralcentesis, what are the primary complications of these procedures? Thoracentesis is aspiration or collection of intra-pleural fluid. The patient has to sits on the edge of a bed or a chair and lean forward over a bed side table. The thoracentesis needle is inserted into the intercostal space and fluid will aspirate. Instruct the patient not to talk or cough during the procedure. Assess for breathing pattern and vital sign after the procedure. The primary complication of this procedure is infection. 31. Describe the common clinical manifestations, and triggers for clients with asthma? Common clinical manifestation of asthma is dust, cockroaches, pollens, cigarettes, sprays, molds, working environments, alcohols, stress, cold and dry air, and GERD. 32. Explain the nursing management of the patient with asthma. Always determine the baseline respiratory status, monitor chest movement, auscultate breath sounds, offer warm fluid, and administer medication as ordered. 33. Explain the priority nursing management for a client having an acute asthma attack. What role does an rescue inhaler have in acute management of asthma patients? Monitor the patient respiratory and cardiac assessment such as auscultate lung sounds, monitor ABG, check BP and RR rate, and check pulse oximetry. The rescue inhaler help the patient airway to open for a certain period of time. So, teach them how to use these machines properly. 34. Explain the common clinical signs & symptoms, diagnostic procedures, and treatment for Pulmonary Embolism. Pulmonary embolism is a life-threatening condition. Common clinical sign and symptoms are SOB, weakness, diaphoresis, tachypnea, wheezing, crackles, increase weight, and pulmonary edema. Treatment will be administering oxygen and IV as ordered. 35. Describe the common clinical manifestations, and diagnostic tests for patients with chronic obstructive pulmonary disease (COPD). The common clinical manifestation of COPD is barrel chest, generalized cyanosis of lips, mucous membranes, face, nail beds; dry or productive cough; hypercapnia; low O2; decreased breath sounds; coarse crackles in lung field that tend to disappear after coughing, wheezing; dyspnea, orthopnea; poor nutrition, weight loss; activity intolerance; anxiety (anger, fear of alone, fear of not able to catch breath). The diagnostic tests will be CT scan, chest x-ray, and ABG. 36. What are the common risk factors for chronic obstructive pulmonary disease (COPD)? The common risk factors for COPD are smoking, exposing to polluted and chemicals air, infection, TB, asthma, and age. 37. Identify the indications for O2 therapy, methods of delivery, and complications of O2 administration. What precautions should be taken with 02 in clients with COPD? Patient with COPD or any other associated problems such as hypoxia are treated by oxygen therapy. The complication might be if high amount of oxygen administers, the patient become dependent on it. Always precaution of smoking around oxygen in-use area. 38. Explain the nursing management of the patient with COPD. Check the respiratory and oxygen saturation frequently, advise patient not to smoke around the oxygen area, and encourage slow deep breathing, turning, and cough. Administer medication if administer, monitor ABG, chest x-ray, CT scan, and pulmonary function test. 39. Describe, the clinical manifestations, and nursing management of the patient with cystic fibrosis. Cystic fibrosis is an autosomal recessive, multisystem disease characterized by altered transport of sodium and chloride ions in and out of epithelial cells. This defect primarily affects the lungs, gastrointestinal tract (pancreas and biliary tract), and reproductive tract. Clinical manifestations: wheezing, coughing, restless, tachycardia, frequent pneumonia, weight loss, failure to thrive, steatorrhea, mucous is very thick (like glue), increase sputum, increase pulmonary function, delayed puberty, etc. Nursing management: chest physiotherapy (move mucous), postural drainage, breathing exercise, coughing techniques, IV therapy, oxygen, diet therapy, depression, discuss sexuality such as delayed development, susceptible to infections; monitor pancreas, glucose, reproductive; anti- inflammatory meds, antibiotics, bronchodilators. 40. What is the most common diagnostic test for clients suspected to have cystic fibrosis? The most common diagnostic test for cystic fibrosis is ABG, chest x-ray, genetic test, and sweat chloride test. Reference: Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment and management of clinical problems. St. Louis: Mosby. [Show Less]
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NR 324 Exam 1 Study Guide Chapters 17, 26, 27, 28, 29, and ABG interpretation
NR 324 Exam 1 Study Guide Chapters 17, 26, 27, 28, 29, and ABG interpretation. Fluid & Electrolyte 1. Potassium Chloride intravenous- care of patien... [Show More] t, how much (meq/hr) is the infusion rate?(p.316) Potassium Chloride intravenous can be administered to treat a patient with hypokalemia. Except in severe deficiencies, KCL is never given unless there is urine output of at least 0.5ml/kg of body weight per hour Safety Alert: • KCL given intravenously must always be diluted. • Never give KCL via IV push or in concentrated amounts. • IV bags containing KCL should be inverted several times to ensure even distribution in the bag. • Never add KCL to a hanging IV bag to prevent giving a bolus dose. How much (meq/hr) is the infusion rate? The preferred maximum concentration is 40 mEq/L; however, stronger concentrations may be given for severe hypokalemia (up to 80mEq/L) with continuous cardiac monitoring. The rate of IV administration of KCL should not exceed 10 to 20mEq per hour and should be administered by infusion pump to ensure correct administration rate. Because KCL is irritating to the vein, assess IV sites at least hourly for phlebitis and infiltration o Infiltration can cause necrosis and sloughing of the surrounding tissue. Central IV lines should be used when rapid correction of hypokalemia is necessary 2. ABG interpretation( do the practice questions that teacher gave& p324 & hesi 43,44) An acid-base balance must be maintained in the body because alterations can result in alkalosis or acidosis. Maintain the acid –base balance involves 3 systems • Chemical buffer o The chemical buffer act immediately to prevent major change in the body fluid pH by removing or releasing hydrogen ions. The main chemical buffer is the Bicarbonate-Carbonic acid (HCO3- H2CO30system. • Normally there are 20parts of bicarbonate to 1 part of carbonic acid. If the 20:1 ratio is altered, the pH is changed( ratio is important not absolute values) • Carbonic acid (H2CO3) is form when carbon dioxide (CO2) combines with water (H2O). • Excess CO2 in the body alters the ratio and creates an imbalance. Other buffer system involve: o Monohydrogen-dihydrogen phosphate o Intracellular and plasma protein o Hemoglobin • Respiratory system (lungs) o The respiratory system responds in minutes and reaches maximum effectiveness in hours Control CO2 content through respirations (carbonic acid content) Control, to a small extent, water balance (CO2+H2O=H2CO3) Release excess CO2 by increasing respiratory rate. Retain CO2 by decreasing respiratory rate. The rate of the CO2 is control by the respiratory center in the medulla in the brainstem. If the respiratory problem is the cause of an acid –base imbalance (e.g., respiratory failure), the respiratory system loses its ability to correct a pH alteration. • Renal system (kidney) o The renal response takes 2 to 3 days to respond maximally, but the kidneys can maintain balance indefinitely in chronic imbalance. Regulate bicarbonate levels by retaining and reabsorbing bicarbonate as needed. a very slow compensatory mechanism ( can require hour or days). Cannot help with compensation when metabolic acidosis is created by renal failure If the renal system is the cause of and acid-base imbalance (e.g., renal failure), it loses its ability to correct a pH alteration. Arterial Blood Gas (ABG) values provide valuable information about a patient’s acid-base status, the underlying cause of the imbalance, the body’s ability to regulate pH, and the patient’s overall oxygen status. (p. 324, shows the steps on how to diagnose acid disturbances and identification of compensatory processes). • Uncompensated respiratory Alkalosis with hypoxemia(Kidney clearance) • Uncompensated Respiratory Acidosis with Hypoxemia • Partially compensated Respiratory Acidosis • Partially compensated Metabollic Alkalosis(Kidney and lungs are helping each other) • Fully compensated Respiratory Alkalosis(Good prognosis) Page44 hesi Acid-base condition pH Pco2 (mm Hg) HCO3 (mEq/L) Normal 7.34-7.45 35-45 22-26 Respiratory Acidosis ↓ ↑ Normal Respiratory Alkalosis ↑ ↓ Normal Metabolic Acidosis ↓ Normal ↓ Metabolic Alkalosis ↑ Normal ↑ • Respiratory • Opposite • Metabolic • Equal A. pH 7.50, pco2 30,HC03 26 B. PH 7.30, Pco2 42,HC03 20 C. pH 7.48, Pco2 42, HCO3 32 D. pH 7.29, Pco2, 55, HCO3 26 (Refer to Hesi page 46 for Answers) 3. Fluid volume deficit- assessment findings- which is most important?(p. 309 & hesi p.39) Fluid deficit occurs when the body loses water and electrolytes isotonically, that is in the same proportion as exists in the normal body fluid Causes: • Vomiting • Diarrhea • GI suctioning • Sweating • Inadequate fluid intake • Massive Edema, as in initial stage of major burns • Ascites • Elderly forgetting to drink • Diabetic insipidus Assessment findings: • Weight loss (1 pint of fluid loss=1pound of weight loss) • Decreased skin turgor • Oliguria (concentrated Urine) • Dry and sticky mucous membranes • Postural hypotension or weak, rapid pulse Labs findings: • Elevated BUN and creatinine • Increased serum osmolarity • Elevated hemoglobin and hematocrit Treatment • Strict I&O • Replacement of fluids isotonically, preferably orally Page 309 for mor info 4. Fluid Deficit- post burn- greatest concern After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes (success p.420) 5. Low serum protein level- implications ( I think of the Edema because you won’t have enough albumin to pull that water from the interstitial space) 6. Hyponatremia- signs and symptoms, most important assessment findings and monitoring, care of patient (p. 313hesi p.40) • The normal sodium is 135-145 • Sodium is the main cation of the ECF • Play a major role in maintaining the concentration and volume of the ECF. o Therefore, sodium is the primary determinant of ECF osmolality. Sodium affects the water distribution between ECF and ICF. • Sodium is also important in the generation and transmission of nerve impulse and the regulation of acid-base balance. • The GI tract absorbs sodium from food. • Sodium leaves the body through urine, sweat, and feces. • The Kidneys are the primary regulator of sodium balance. o The kidney regulates the ECF concentration of sodium by excreting or retaining water under the influence of ADH. • Aldosterone also plays a big role in sodium regulation by promoting sodium reabsorption from the renal tubules. o Aldosterone (p.1206): is a potent mineralocorticoid that maintains extracellular fluid volume. It acts at the renal tubules to promote renal reabsorption of sodium (Na+) and excretion of potassium (K+) and hydrogen ions (H+). • Changes in the serum of sodium level may reflect a primary water imbalance, a primary sodium imbalance, or a combination of the two. Sodium imbalances are typically associated with imbalances in ECF volume. Hyponatremia • Patho: • Causes: o may result from loss of sodium-containing fluids o from water excess(dilutional hyponatremia) o or combination of both • Nursing implementation or treatment: o Restrict fluid o Hypertonic saline solution(3%NaC) can be given to restore the serum sodium level( if severe symptoms like seizures develop) o Hesi p. 40 Abnormality and common causes Signs and symptoms or assessment findings Treatment or intervention Hyponatremia(↓Na) Diuretics GI fluid loss Hypotonic tube feeding D5W or hypotonic IV fluids Diaphoresis Anorexia, nausea, vomiting Weakness Lethargy Confusion Muscle cramps, twitching Seizures Na<135mEq/L Restrict fluid(safer) If IV saline solution prescribed administer very slow. 7. Diuretic therapy- hypokalemia- interaction with what other drug?(p.315) Patient taking Digoxin, Digitalis experience increased digoxin toxicity if their serum potassium level is low. Skeletal muscle weakness and paralysis may occur with hypokalemia. *Severe hypokalemia can cause weakness and paralysis of respiratory muscles, leading to shallow respirations and respiratory arrest. 8. Hypercalcemia- plan of care(p.317) Two thirds of hypercalemia cases are caused by hyperparathyroidism and one third are caused by malignancy, especially from breast cancer, lung cancer, and multiple myeloma. Hypercalcemia is also associated with vitamin D overdose. Excess calcium leads to reduced excitability of both muscles and nerves. Plan of care for hypercalcemia: • The basic treatment of hypercalcemia is promotion of excretion of calcium in urine by administration of a loop diuretic (ex. Furosemide [Lasix]), and hydration of the patient with isotonic saline infusions. • In hypercalcemia, the patient must drink 3000 to 4000ml of fluid daily to promote the renal excretion of calcium and to decrease the possibility of kidney stone formation. • Synthetic calcitonin can also be administered to lower serum calcium levels. A diet low in calcium may be prescribed. • Mobilization with weight-bearing activity is encouraged to enhance bone mineralization. Plicamycin (Mithrancin), a cytotoxic antibiotic, inhibits bone resorption and thus lowers the serum level. In hypercalcemia related to malignancy the drug of choice is paramidronate (Aredia), which inhibits the activity of osteoclasts(cells that break down bone and result in calcium release) o Paramidronate is preferred over plimacamycin because it does not have cytotoxic side effects and it inhibits bone resorption without inhibit bone formation and mineralization. 9. PICC- D50 dextrose- Why?(p.327) Peripheral Inserted Central Catheters (PICCs) are central catheters inserted into a vein in the arm rather than a vein in the neck or chest. They are single- or multiple-lumen, nontunneled catheters that are up to 60cm in length with gauges just above the antecubital fossa (usually cephalic or basilic vein) and advanced to a position with the tip ending in the distal one third of the superior vena cava. The PICC lines are intended for patients who need vascular access for 1 week to 6 months but can be in place for longer period of time. Advantages of PICC line: • Lower infection rate • Fewer insertion-related complications • Decreased cost • Insertion at the bedside or outpatient area Complications of PICC lines include: • Catheter occlusion and phlebitis o If phlebitis occurs it usually appears within 7to 10 days fallowing insertion. o The line in which the PICC line in place should not be used for blood pressure readings or blood drawing. Solutions containing 10% dextrose or less may be administered through the peripheral IV line. Solution with concentrations greater than 10% must be administered through a central line so that there is adequate dilution to prevent shrinkage of RBCs Normal Blood sugar=70-110mg/dl Hypoglycemia(low blood sugar) 10. CVAD- plan of care(p.328-331) a. Nursing management of CVADs includes assessment, dressing change and cleansing, injection cap changes, and flushing. Catheter and insertion site assessment includes inspection of the site for redness, edema, warmth, drainage, and tenderness or pain. b. Dressing change and cleansing of the catheter insertion site using sterile technique. (For infection control –prevent sepsis). (a Dacron cuff on the catheter serves to stabilize the catheter and may decrease the incidence of infection by impeding bacteria migration along the catheter beyond the cuff). c. Injection caps must be changed at regular intervals using strict sterile technique according to institution policy or when they are damaged from excessive punctures. Teach the patient to turn the head to the opposite side of the CVAD insertion site during cap change. If the catheter can’t be clamped, instruct the patient to lie flat in bed and perform the valsalva maneuver whenever the catheter is open to air to prevent air embolism. d. Flushing is one of the most effective ways to maintain lumen patency and to prevent occlusion of the CVAD. It also keeps incompatible drugs or fluids from mixing. Use the push-pause technique, instilling 1-2 ml with each push of normal saline solution. e. Removal of CVADs- remove the sutures if present and gently withdrawing the catheter while instructing the patient to perform the Valsalva maneuver as the last 5-10 cm of the catheter is withdrawn. Pressure should be immediately applied to the site to prevent air from entering and to control bleeding. Patient should be in trendelenburg position. i. Infusion of IV solutions through a PICC line allows rapid dilation of 5% dextrose in 0.45% saline. 11. Electrolyte laboratory normal and abnormal values- interpretation(p.309, hesi p.39) Electrolyte normal lab values Sodium (Na+) 135-145 mEq/L Potassium ( K+) 3.5-5 mEq/L Calcium (Ca) Ionized 4.4-5.3 mg/dl and total 8.9-10.1 mg/dl Phosphate(PO3^4) 2.5- 4.5 mg/dl or 1.8-2.6 mEq/L Magnesium(Mg2+) 1.5-2.5 mEq/L Chloride(Cl-) 98-108mEq/L 12. NGT- low suction. Patient NPO- priority assessment to report to HCP 13. Increased Extracellular Fluid Osmolality- priority assessment(p.305 hesi39) 14. Hpo/hypercalcemia- priority of care(p.317,318) 15. Post thyroidectomy- plan of care, signs and symptoms to watch for.(p.318)(1268,9) 16. Hypo/Hypermagnesemia- assessment findings- which is most important, diet, plan of care(p.319,320) 17. Hypovolemia- assessment Respiratory 18. Asthma- asthma guidelines, nursing interventions, signs and symptoms, patient med teachings Pg.588-608, Nclex pg. 69&169 Asthma is a chronic inflammatory disorder of the airways. The airways become edematous, the airways become congested with mucous, the smooth muscles of the bronchioles constrict, and air trapping occurs in the alveoli. Clinical Manifestations: wheezing, breathlessness, chest tightness, cough, dyspnea, particularly at night or in the early morning. Condition is reversible spontaneously or with treatment. The person with asthma tries to sit upright or slightly bent forward using the accessory muscle of respiration to try to get enough air. You may see hypoxia, increase pulse and blood pressure, pulses paradoxus, difficulty speaking, diminished breath sounds often referred to as the “silent chest” which means severe obstruction and impending respiratory failure. Life-threatening situation may require mechanical ventilation. Nursing interventions: • Monitor carefully for increasing respiratory distress • Administer rapid-acting bronchodilators and steroids for acute attacks. • Maintain hydration (oral fluids or IV)and humidification • Monitor blood gas values for signs of respiratory acidosis • Administer oxygen nebulizer therapy as prescribed. Monitor pulse oximetry Teach home care programs: (I think this is the guidelines as well) Identify precipitating factors, reduce allergens in the home, use metered-dose inhalers , monitor peak respiratory flow rate at home, do breathing exercises, monitor drug actions, dosages, and side effects, managing acute episode and when to seek emergency care. Precipitating Factors: Mucosal edema Increased work of breathing Beta-blockers Respiratory infections Allergic reactions Emotional stress Exercise Environmental or occupational exposure Reflux esophagitis (GERD) How to use metered-dose inhaler correctly: Table 29-7 When you use your inhaler the wrong way, less medicine gets into your lungs Guidelines for Pursed Lip breathing (PLB): Table 29-14 How to use your Peak Flow Meter: Table 29-15 Extra Info: *Risk Factors include: • Male gender in children (not in adults) • Obesity, genetics, environment People with asthma have what’s called the asthma triad, which you’ll most likely see nasal polyps, asthma, and sensitivity to aspirin and NSAIDS (wheezing will develop in any of these triads) - GERD can trigger asthma because reflux of stomach acid into the esophagus can be aspirated into the lungs, causing reflux vagal stimulation and broncho-constriction. (diagnose and manage asthma using a spirometer) 19. TB- precautions and care of patient 20. Pulmonary Function Test- plan of care, patient teachings 21. Tracheostomy care- cuffed or uncuffed 22. Tracheostomy dislodgement- action plan 23. Tracheotomy- check for aspiration, post op care 24. Respiratory signs and symptoms- priority of care 25. Post thoracotomy- priority plan of care 26. COPD- position, nursing diagnosis, diagnostic test, exercise recommendation, when to take bronchodilator? 27. Bronchitis-Advair Diskus – purpose of the drug, nursing diagnosis 28. Serevent administration patient teaching, evaluation of effectiveness of interventions(p.599) 29. Total laryngectomy- care post op, nursing diagnosis 30. Influenza- signs and symptoms 31. Nosebleeding- management(p.520,521) To manage epistaxis (nosebleed) the nurse would use simple first aid measures: • Keep the patient quiet • Place the patient in a sitting position • Apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes • Partially insert a gauze pad into the bleeding nostril. • Apply digital pressure if bleeding continues • Obtain medical assistant if bleeding does not stop. If first aid is not effective: Medical management involves identification of the bleeding site and application of a vasoconstrictive agent, cauterization, or anterior packing by a health care provider. Plagets (nasal tampon) impregnated with anesthetic solution and/or vasoconstrictive agents such as lidocaine or cocaine are placed into the nasal cavity. Allow patient to remain in place for 10 to 15 minutes. Silver nitrate may be used to cauterize after bleeding has stopped. If bleeding does not stop: Packing may be used, it consists of traditional Vaseline ribbon gauze, a prefabricated nasal sponge ( Merocel), or an epistaxis balloon (Rhino) • Refer to page 521 for instructions on how to insert the gauze. The nasal packing may alter the respiratory status, especially in older adults. Therefore, the nurse should close monitor the RR, HR and rhythm, O2 Sat and level of consciousness and also observe for sign of aspiration. Because of the risk of complication the patient may be admitted to a monitored unit to permit closer observation. The nasal packing predisposes patients to infection from bacteria (e.g. S. aureus) present in the nasal cavity. The patient should receive mild opioid analgesic for pain (e.g. acetaminophen with codeine) and antibiotic effective against staphylococci to protect against infection. The nasal packing may be left in place for few days. Before removal: the nurse should medicate the patient for pain (because this procedure is very uncomfortable). After Removal: cleanse the nares gently and lubricate them with water-soluble jelly 32. Pneumonia- evaluation of effectiveness of treatment(p.552) • Maintain adequate alveolar oxygen-carbon dioxide exchange • Clear lungs of fluids and exudates 33. Pneumococcal pneumonia- assessment findings, patient teachings, nursing diagnosis 34. Aspiration pneumonia- prevention measures(p. 548) Aspiration pneumonia refers to the condition that occurs from abnormal entry of secretions or substances into the lower airway. It usually fallows aspiration of material from the mouth or the stomach into the trachea and subsequently the lungs. Conditions that increase the risk of aspiration pneumonia are: • Seizure, Anesthesia, head injury, stroke or alcohol intake • Difficulty swallowing • Nasogastric intubation or tube feeding • Loss of consciousness (because the gag reflex are depressed. The aspirated material includes: • Food, water, vomitus, or oral contains Prevention measures: (Hesi 65) • Comatose and immobile person: Elevation of head of bed to feed and for 2hours after feeding; frequently turning • Aspiration pneumonia can be prevented by positioning unconscious patient with the head elevated 15 to 30 degree and turned to the side • By paying careful attention to the maintenance of enteral feeding therapy and an adequate airway. 35. Pleuritic chest pain- management, signs and symptoms, priority of care(p.576) 36. TB- multidrug therapy- what assessment findings to report to HCP, effectiveness of treatment 37. Chest tube monitoring 38. TB- skin test, history taking- most important to ask (p.555) The tuberculin Skin test (TST) AKA Mantoux test using purified protein derivative (PPD) is widely used to determine if a person is infected with Mycobacterium tuberculosis. The test is administered by injecting 0.1 ml of PDD intradermally on the on the dorsal surface of the forarm. The test is read by inspection and papation 48 to 72 hours later for the presence or absence of induration. The indurated area (if present): • Is measured and recorded in millimeters with 0 for no induration. The induration (not redness) at the injection site means • At the injection sites mean: the person has been exposed to TB and has develop antibodies. The reaction occurs 39. TB test positive- action plan 40. When to d/c airborne prec for TB patient 41. Peak flow- normal values- management of abnormals Used to check your asthma the way the blood pressure cuffs are used to check blood pressure. PFM is a device that measures how well air moves out of your lungs. Steps to use it: - move indicator to the bottom of the numbered scale – stand up – take a deep breath, filling your lungs completely – place the mouthpiece in your mouth and close your lips around it do not put your tongue inside the hole – blow out as hard and fast a you can in a single blow. Best peak flow# is the highest peak flow number u can achieved over a 2 week period when your asthma is under good control. It is recommended that patients check peak flows when asthma symptoms or attacks occur to compare the peak flow with the baseline. Increased doses of rapidly acting 2-agonists are indicated for peak flows in the red zone. Peak flows should be checked every morning before using medications. Peak flows are assessed during rapid exhalation. Peak flows of 80% or greater indicate that the asthma is well controlled. Corticosteroids are long-acting, prophylactic therapy for asthma and are not used to treat acute dyspnea. Because asthma is an acute and intermittent process, home oxygen is not used. The patient who has effective treatment should sleep throughout the night without waking up with dyspnea. It is recommended that patients check peak flows when asthma symptoms or attacks occur to compare the peak flow with the baseline. Increased doses of rapidly acting 2-agonists are indicated for peak flows in the red zone. Peak flows should be checked every morning before using medications. Peak flows are assessed during rapid exhalation. 42. Acute asthma attacks- priority interventions 43. Xolair- most important to report to HCP(p.598-600) Anti-IgE. Omalizumab (Xolair) 44. Pre-op thoracentesis care-pg. 514 • Purpose: Thoracentesis used to obtain specimen for pleural fluid for diagnosis, to remove pleural fluid, or to instill medication. Chest x-rays is always obtained after procedure to check for pneumothorax • Nursing responsibility: Explain procedure to patient and obtain signed permit before procedure, which is usually performed in patient’s room. Position the patient upright with elbows on an overbed table and feet supported. Instruct the patient not to talk or cough, and assist during procedure. Observe signs of hypoxia and pneumothorax and verify breath sounds in all fields after procedure. Encourage deep breaths to expand lungs. Send labeled specimens to lab. • Pg. 516 (Look also at the figure 26-14)- Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. The patient is positioned sitting upright with elbows on an overbed table and feet supported. The skin is cleansed and a local anesthetic (Xylocaine) is instilled subcutaneously. A chest tube may be inserted to permit further drainage of fluid. • Pg.568- Treatment of pneumothorax (hemothorax or chylothorax) depends on the severity and the nature of the underlying disease. If the patient is stable, and the amount of air and/or fluid accumulated in the intrapleural space is minimal, no treatment may be necessary as the condition may resolve spontaneously. If the amount of air or fluid is minimal, the pleural space also can be aspirated with a large-bore needle. This procedure is called a thoracentesis. The most definitive and common form of treatment of pneumothorax and hemothorax is to insert a chest tube and connect it to water-seal drainage. Repeated spontaneous pneumothorax may need to be treated surgically by a partial pleurectomy, stapling, or pleurodesis to promote adherence of the pleurae to one another. • Pg. 576- Thoracentesis is aspiration of intrapleural fluid for diagnostic and therapeutic purposes. For a thoracentesis, the patient sits on the edge of a bed and leans forward over a bedside table. Chest x-ray with determine the puncture site, and percussion of the chest will assess the maximum degree of dullness. The skin is cleansed with an antiseptic solution and the area is anesthetized. Thoracentesis needle is inserted into the intercostal space. Fluid is aspirated with a syringe, or tubing is connected to allow fluid to drain into a sterile container. After fluid is removed, the needle is withdrawn; a bandage is applied over the insertion site. Usually only 1000 to 1200ml of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema. A follow-up chest x-ray will detect a possible pneumothorax that could have been induced by perforation of the visceral pleura. During and after the procedure, monitor vital signs and pulse oximetry and observe the patient for any manifestations of respiratory distress. 45. Chest tube- bubbling- action plan • Pg. 572 Table 28-23 Drainage System- 1. Keep all tubing loosely coiled below chest level. Tubing should drop straight from bed or chair to drainage unit. Do not let it be compressed. 2. Keep all connections between chest tubes, drainage tubing, and the drainage collector tight and tape at connections 3. Observe for air fluctuations (tidaling) and bubbling in the water-seal chamber. ~If no tidaling is observed (rising with inspiration and falling with expiration 46. Post thoracentesis- assessment findings most important to report to HCP o Thoracentesis is aspiration of intrapleural fluid for diagnostic and therapeutic purposes. For a thoracentesis, the patient sits on the edge of a bed and leans forward over a bedside table. o Chest x-ray will determine the puncture site, and percussion of the chest will assess the maximum degree of dullness o The skin is cleansed with an antiseptic solution and the area is anesthetized. The thoracentesis needle is inserted into the intercostals space. Fluid is aspirated with a syringe, or tubing is connected to allow fluid to drain into a sterile container. After the fluid is removed, the needle is withdrawn, and a bandage is applied over the insertion site. o Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema. A follow up chest x-ray will detect a possible pneumothorax that could have been induced by perforation of the visceral pleura. During and after the procedure, monitor vital signs and pulse oximetry and observe the patient for any manifestations of respiratory distress 47. Rhinplasty- nursing interventions 48. Allergic Rhinitis- management of care 49. URI patient teachings 50. Post thoracostomy- position 51. Psot thoracostomy drainage- normal and abnormal amount 52. Pulmonary embolism- assessment, diagnosis, management, tests 53. Pulmary HTN- assessment, +diagnosis, management, tests 54. Metabolic acidosis- signs and symptoms 55. Assessment of Respiratory- breath sounds, tactile fremitus 56. Broncgoscopy- post op • Bronchoscopy is a test to view the airways and diagnose lung disease. It may also be used during the treatment of some lung conditions. The doctor will spray a numbing drug (anesthetic) in your mouth and throat. If the bronchoscopy is done through the nose, numbing jelly will be placed on one nostril. • Inserting the bronchoscope will make you cough at first. The coughing will stop as the numbing drug begins to work. There is a risk of choking if anything (including water) is swallowed before the numbing medicine wears off. You will not be allowed to eat or drink anything until your gag reflex has returned. 57. Delegation (UAP, LPN, NAP) 58. Prioritization of Care 59. Medication Calculation Exam 60. Foods rich in Calcium, phosphate, magnesium, potassium, sodium • Potassium: Bananas, oranges, cantaloupes, avocados, spinach, potatoes, peanut butter and fish. • Magnesium: green leafy vegetables, whole grains, tea, and fruit. • Calcium: Milk, cheese, dark green vegetables, dried figs, soy and legumes. • Phosphorus: Milk, liver, legumes, fish, soy, anchovies. • Sodium: tomato juice, canned vegetables, pickles, table salt, bacon, baking powder, soups, soy sauce, peanut butter, corned beef, cheeses. \ [Show Less]
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ATI RN Fundamentals Proctored Focus NR 324 Exam Review.
ATI RN Fundamentals Proctored Focus NR 324 Exam Review. Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? Click ... [Show More] card to see definition 👆 Yes. Click again to see term 👆 A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer C. Reapplying a condom catheter for a client who has urinary incontinence Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP 1/99 Terms in this set (99) Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? Yes. A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer C. Reapplying a condom catheter for a client who has urinary incontinence Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning B, C, D Upgrade to remove ads Only $3/month An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24hr postop to use an incentive spirometer B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump D. Replacing the cartridge and tubing on a PCA pump Rationale: The RN is responsible for the PCA pump A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all. A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances B, C, E A and D are rights of medication administration A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client? A. Charge nurse B. RN C. LPN D. AP B. RN A client returning from surgery requires assessment and establishment of a plan of care. RNs are responsible for this, especially if the client is potentially unstable. A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy A. Assault By threatening the client, the AP is committing assault. An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality B. False imprisonment The nurse gave the med as a chemical restraint to keep the client from leaving the facility against medical advice. The client did not consent. A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead w/the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." C. The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arrives A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all. A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form C. Explain the risks and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery A, B The rest of the choices are the surgeon's responsibility, not the nurse A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? A. Remind the nurse that safe client care is a priority on the unit B. Ask others on the team whether they have observed the same behavior C. Report observations to the nurse manager on the unit D. Conclude that her coworker's fatigue is not her problem to solve C. Any nurse who notices behavior that could possibly jeopardize client care or indicate a substance abuse problem has a duty to report the situation immediately to the nurse manager A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report? A. The client's input & output for the shift B. The client's BP from the previous day C. A bone scan that is scheduled for today D. The med routine from the med administration record C. A bone scan that is scheduled for today This is important because the nurse might have to modify the client's care to accommodate them leaving the unit A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should the nurse document this in the client's chart? A. The client fell in the shower. B. The client states he fell in the shower & was able to get himself back into his chair C. The nurse should not document this info because she did not witness the fall D. The client fell in the shower & is now resting comfortably B. By writing what the client states, the info is subjective data A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all. A. Cover errors w/correction fluid, & write in the correct info B. Put the date & time on all entries C. Document objective data, leaving out opinions D. Use as many abbreviations as possible E. Wait until the end of the shift to document B, C The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all. A. The physical therapist didn't ambulate the client today B. The skin barrier's seal stays on in bed but loosens when the client stands. C. The client seemed to welcome having a "day off" from physical therapy D. The wound care nurse will see the client later today E. The client ate all the food on her lunch tray A, B, D A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all. A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the prescriber's signature on the prescription within 24hrs D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone A, B, C A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him? A. Registered dietitian B. Occupational therapist C. Physical therapist D. Social worker D. social worker A social worker can make arrangements for a meal delivery service to provide nutritious meals daily, or recommend a congregate meal site near the client's home A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist D. An occupational therapist can assist clients who have physical challenges to use adaptive devices & strategies to help w/self-care activities A client who is postop following a knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects? Select all. A. Provider B. CNA C. Pharmacist D. RN E. Respiratory therapist A, C, D A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker B. CNA C. Occupational therapist D. Speech-language pathologist D A speech-language pathologist can initiate specific therapy for clients who have difficulty feeding due to swallowing difficulties A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? Select all. A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs A, B, C, E Determining pain level requires assessment, which is the job of the licensed personnel. A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all. A. A concave thoracic spine posteriorly B. An exaggerated lumbar curvature C. A concave lumbar spine posteriorly D. An exaggerated thoracic curvature E. Muscles slightly larger on his dominant side C, E A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items? A. A word she whispers 30cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand D. Stereognosis is tactile recognition A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink C. Fastening a bra from behind requires internal rotation of the shoulder, so this activity will illicit pain A nurse is preforming a neurosensory examination for a client. Which of the following tests should the nurse preform to test the client's balance? Select all. A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test A, B C and E test visual acuity , D tests cranial nerve XI is intact by asking the client to shrug shoulders without complication. A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all. A. Slower light touch sensation B. Some vision & hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation B, C, D A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all. A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "No smoking" sign should be placed on the front door D. Cotton bedding & clothing should be replaced w/items made from wool E. A fire extinguisher should be readily available in the home B, C, E Family members that smoke should do so outside, and wool creates static electricity so it should be avoided. A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction? A. "I will begin swimming lessons as soon as my baby can close her mouth under water." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will test the temp of the water before placing my baby in the bath." D. "Once my infant starts to push up, I will remove the mobile from over the bed." B Although the baby can hold his head above the water by sitting up, this does not make the baby safe in the tub. Parents should never leave a child unattended in a tub. A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds w/hemoglobin in the body D. Carbon monoxide is a very dangerous gas because it binds w/hemoglobin & ultimately reduces the oxygen supplied to the tissues in the body. Carbon monoxide is tasteless, has no scent, and cannot be seen. The water heaters, gas-burning furnances, and appliances should be inspected annually The lungs are not damaged in the process of inhalation A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea A. Hypotension Tachycardia, hot dry skin, and tachypnea are other manifestations of heat stroke A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all. A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw & fresh food separately to avoid cross contamination may prevent food poisoning B, C, E Most food poisoning is caused by a bacteria such as E. coli. Healthy individuals usually recover in a few days. A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all. A. Planning & evaluating control & prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks A, B, C, E Not D because endemic disease is already prevalent within a population, so reporting is not necessary A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all. A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another dept is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when preforming care that may result in contamination from secretions B, C, E Private room w/droplet precautions indicated for this client. The nurse should wear a gown when contamination from body fluids might happen A nurse is caring for a client who presents w/linear clusters of fluid-containing vesicles w/some crustings. Which of the following should the nurse suspect? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster D. Herpes zoster pink body rash=allergic reaction red circles w/white centers=ringworm red cheek rash bilaterally=lupus A nurse is caring for a client who reports severe sore throat, pain when swallowing, & swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness D. Illness specific s/s present is the illness stage A nurse educator is reviewing w/a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse & respiratory rate A, B, E Edema and pain and tenderness is localized A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I'm feeling well." C. "If I'm having any discomfort, I'll just got to an urgent care center." D. "If I am felling stressed, I will remind myself that this is something I should expect." B. [Show Less]
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NR 324 ATI - TEST 4 PRACTICE ASSESSMENT
NR 324 ATI - TEST 4 PRACTICE ASSESSMENT NR 324 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is planning care for a client who has a suspected myocardial ... [Show More] infarction. Which of the following should the nurse administer first? C. Oxygen 2 ATI - TEST 4 PRACTICE ASSESSMENT While reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities? C. Atrial deporlarization 3 ATI - TEST 4 PRACTICE ASSESSMENT A client comes to the emergency department via ambulance to report severe radiating chest pain and SOB. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse assisting with this client client's care first? C. Initiate oxygen therapy. 4 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is preparing a client for an echocardiogram the following day. Which of the following instruction should the nurse include about this test? C. It requires lying quietly on one side. Rationale: For a Transthoracic Echocardiogram (TTE), the client lies quietly on the left side with slight head elevation. There is no reason for the client to be NPO. The test takes up to 1 hour and there is not discomfort as a transducer with conductive jelly is used on the chest. 5 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reviewing the laboratory values on a client who has HTN. Blood tests are drawn and reveal the following results. Which of the following results should the nurse identify as critical? B. Potassium 2.3 mEq/L 6 ATI - TEST 4 PRACTICE ASSESSMENT The nurse is completing a medication review of a client who has elevated cholesterol levels and takes an anticoagulant. Which of the following should the nurse report to the provider?. D. Uses garlic as a cholesterol lowering agent. Rationale: The nurse should be aware that the use of garlic to lower cholesterol may potentiate the action of anticoagulant medication and should report the finding to the provider. 7 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who enters the emergency department complaining of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction? C. Perform a 12-lead ECG 8 ATI - TEST 4 PRACTICE ASSESSMENT While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? A. A cardiac murmur Rationale: Cardiac murmurs are relatively lout, turbulent sounds the nurse can hear between usual, expected heart sounds. They create a whooshing or swishing sound. 9 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reviewing the initial laboratory values for partial thromboplastin time, and prothrombin time, and thrombin time on a client who has an acute episode of disseminated intravascular coagulation (DIC). The nurse should expect the laboratory values to be B. prolonged. Rationale: The nurse should expect the laboratory values to be prolonged because the anticoagulant pathways are impaired and consume the key clotting factors, resulting in clotting dysfunction. 10 **ATI - TEST 4 PRACTICE ASSESSMENT** A nurse is reinforcing discharge teaching for a client who has received an implantable cardioverter/defribillator (ICD). Which of the following information should the nurse include? B. The client should hold his cell phone on the side opposite the ICD. Rationale: The client should keep his cellular phone on the side opposite of the ICD, as close proximity could interfere with the ICD's function. The client should inform airport security of the device. The client does not carry the ICD is in his pocket, this is an IMPLANTABLE device. 11 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client who is postoperative following an insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.) A. Count your pulse for 1 min each morning. C. Do not wear tight clothing over the insertion area. Rationale: Avoid coming into contact with metal detectors is incorrect, there is not danger going through a metal detector, but the client should inform airport security because the pacemaker will trigger an alarm. Do not operate microwave ovens is incorrect. It is save for clients with a pacemaker to operate microwave ovens unless they are old and do not have the appropriate shielding or of they are defective. 12 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? C. The pacemaker spikes before each QRS complex. 13 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what this medication will do, which of the following is an appropriate nursing response? D. It prevents strokes in clients who have atrial fibrillation. Rationale: Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants such as warfarin help prevent thrombosis formation. 14 ATI - TEST 4 PRACTICE ASSESSMENT A client is telling the nurse in the clinic that he gets a headache after he takes sublingual nitroglycerin (Nitrostat). Which of the following should the nurse remind the client to do? C. Lie down in a cool environment and rest. Rationale: HA is a common side effect of nitroglycerin. The nurse should suggest conservative measures to manage the HA. Generally, HAs that are a side effect of nitroglycerin are transient. They usually last about 5 min an rarely longer than 20 min. 15 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client who has a new prescription for warfarin sodium (Coumadin). Which of the following should the nurse include? B. He should use an electric razor while on this medication. 16 ***ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? A. Obtain a venous duplex ultrasound. Rationale: Venous duplex utlrasonography is a noninvasive diagnostic test used to detect distal DVT. Performing Homan's sign and dislodge the clot therefore this is inappropropriate. Warm therapy is used with DVTs not cold therapy 17 **ATI - TEST 4 PRACTICE ASSESSMENT** A client complains of SOB and chest pain the first day following multiple long bone fractures. THe nurse would consider which of the following client complications when assessing the client? B. Fat emboli Rationale: The client with a compound long bone fracture is at high risk for developing a fat embolus within 24 to 96 hr. 18 ***ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is collecting data from an infant that has a coarctation of the aorta. Which of the following is a clinical manifestation? A. Increased blood pressure in the arms with decreased blood pressure in the legs Rationale: There is a narrowing next to the ductus areteriosus which results in an increased pressure proximal to the defect with a decreased distal to the obstruction. Therefore, an increase blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta. 19 ATI - TEST 4 PRACTICE ASSESSMENT When checking a client's capillary refill, the nurse finds that the color returns to usual in 10 seconds. The nurse understands that this finding indicates which of the following? A. Arterial insufficiency Rationale: To test the capillary refill, the nurses presses on the client's nail beds to produce blanching and then measures the time it takes for the color to return. With adequate arterial capillary perfusion, the color should return within 3 seconds. Taking longer than 3 seconds indicates impaired arterial blood flow to the extremity. 20 ATI - TEST 4 PRACTICE ASSESSMENT Whenever a nurse is caring for clients who are receiving heparin, which of the following medications should the nruse have on hand in the event of an overdose? C. Protamine 21 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who takes nitroglycerin (Nitrostat) tablet at the onset of anginal pain. AFter taking the pill, the client states that his chest pain is relieved, but then he develops a sudden pounding headache. The nurse understands that the headache is D. A common adverse reaction. 22 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is collecting data from a client who has HTN and has a prescription for propranolol (Inderal). A history of which of the following conditions should be reported to the provider? D. Heart failure Rationale: Propanolol is used with caution in clients who have heart failure to to the depressive effect on the myocardial contractility; therefore, the nurse should report this finding to the provider. 23 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who is admitted with a DVT of the left leg. Which of the following interventions should the nurse include in the client's plan of care? B. Strict bedrest Rationale: Bedrest is considered supportive therapy for DVT and should be included in the plan of care. 24 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is administering monitoring medications and realizes the nifedipine (Procardia) was administered to the wrong client. Which of the following is the priority nursing action? A. Check the client's vital signs. Rationale: Nifedipine is an antihypertensive medication. The nurse should immediately check the client's vital signs for any significant alterations an then notify the provider. 25 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who is admitted to the hospital with CHF who has been taking digoxin (Lanoxin) 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse perform first? C. Check the client's vital signs. Rationale: Nausea is a symptom of digoxin toxicity. The nurse should take the client's vital signs to determine if the client is experiencing bradycardia. The nurse should withhold the drug and call the provider if the client has bradycardia. 26 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching regarding diet to a client after a myocardial infarction. The nurse evaluates the reinforcement as effective if the client selects which of the following options? B. Baked turkey, mashed potatoes, squash and salad. Rationale: Low sodium, low fat diet is usual cardiac diet. 27 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is contributing to the care plan for a client who has developed DVT. Which of the following interventions should the nurse include? C. Elevate the affected extremity when the client is resting. Rationale: Supportive treatment for DVT includes elevation of the extremity when the client is in bed or in a chair. 28 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is helping with the admission of a client from the emergency department. The client is prescribed clopidogrel bisulfate (Plavix). Which of the following precautions should the nurse anticipate? A. Bleeding Rationale: Plavix is an antithrombotic and antiplatelet aggregate used to lessen the chance of a heart attack or stroke. Bleeding precautions are implemented to limit client exposure to injury-causing events that may lead to internal or external bleeding. 29 ***ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is caring for an infant who has a congenital heart defect. Which of the following is associated with increased pulmonary blood flow? B. Patent ductus arteriosus Rationale: With patent ductus arteriosus, the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the patent ductus arteriousus and back to the pulmonary artery and lungs. 30 ATI - TEST 4 PRACTICE ASSESSMENT A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse? B. Irregular pulsations Rationale: PVCs are early ventricular depolarization that cause a pause immediately afterwards. The pause in the usual heart rhythm results in an irregular apical pulse. PVCs have a wide variety of causes, and the client typically perceives them as "palpitations." PVCs = feelings of heart skipping a beat! 31 ***ATI - TEST 4 PRACTICE ASSESSMENT*** In preparation for the discharge of a client with peripheral arterial disease PAD, the nurse should reinforce which of the following instructions? B. Adjust the thermostat so that the environment is warm. Rationale: Clients who have PAD should not wear any constrictive clothing. 32 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is talking with a client who is about to start using transdermal nitroglycerin (Nitro-Dur) to treat angina pectoris. Which of the following is an appropriate instruction for this medication therapy? B. Apply the transdermal patch in the morning. Rationale: The client should apply the patch every morning after showering and leave it in place for a minimum of 12 hours. 33 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client on a medical surgical unit with a DVT who has been on IV heparin for 5 days. The provider prescribes oral warfarin (Coumadin) without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following is an appropriate response by the nurse? D. "Heparin will be continued until the warfarin reaches a therapeutic level." Rationale: Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, they work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which usually occurs within 1 to 5 days. When PT and INR are within therapeutic range, the heparin can be discontinued. 34 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who just had a cardiac catheterization. The post procedure nursing care plan for this client should include which of the following nursing interventions? A. Have the client rest in bed for 2 to 6 hr. Rationale: Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest. 35 [Show Less]
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NR 324 ADULT HEALTH STUDY GUIDE
NR 324 ADULT HEALTH STUDY GUIDE NR 324 ADULT HEALTH STUDY GUIDE 1. Describe the composition of the major body fluid compartments. The major body f... [Show More] luid compartments contain mineral salts which is called electrolytes. Electrolyte that charged positively are called cations such as sodium, potassium, calcium, and magnesium. Electrolytes that are charged negatively are called anions such as chloride, and bicarbonate. These negative and positive charges are combined to make salts. 2. Describe what causes Fluid volume deficit, (a) the assessment, (b) nursing management, (c) nursing education. When sodium and water intake is less than output, it causes isotonic loss or insufficient isotonic fluid in the extracellular compartment. The major reasons for isotonic fluid deficit are abrupt decrease in oral intake of water and salt, vomiting, diarrhea, drainage from fistula, hemorrhage, burns, massive sweating without compensating with intakes. Physical assessment for fluid volume deficit will be sudden weight loss, postural hypotension, thread pulse, tachycardia, dry mucous membrane, poor skin turgor, flat neck vein when supine, dark yellow urine. If sever thirst, restlessness, confusion, hypotension, oliguria (urine output less than 30 ml/hr), and hypovolemic. Nursing management is encouraging fluid therapy (PO or IV), monitor vital sign, monitor input and output of patient fluid, monitor patient weight, assess patient lifestyle, diet habit, medication, risk factors for fluid imbalance. Client education will be educating client about the recommended diet, educate how to monitor input and output, instruct the patient to weight with the same cloth, same time, and same scale. Educate to avoid alcohol consumption because it increases of fluid loss. 3. Describe what causes Fluid volume excess, (a) the assessment, (b) nursing management, (c) nursing education. When sodium and water intake is greater than output, it causes isotonic gain or excessive isotonic fluid in the extracellular compartment. The major causes of fluid overload are excessive fluid administration of sodium containing isotonic IV or oral intake of salt and water, heart failure, renal disease, sudden weight gain, edema, fluid in lungs, and cirrhosis. Physical assessment for fluid overload will be sudden weight gain, edema, if sever, confusion, hematocrit, decrease BUN, and pulmonary edema. Nursing management will be checking the medication, client life style, dietary intake, factors for fluid imbalance. Teach clients to exercise if tolerable, watch for fluid intake and output, elevate the extremities to prevent edema and recommend dialysis in sever renal failure. Client education will be managing the fluid balance or instruct the risk factor for developing fluid imbalance. 4. Describe the laboratory normal values, clinical manifestations, assessment priorities (i.e. Neuro, Cardiac, cardiovascular, etc.) & nursing collaborative management of the following imbalances. Clinical Lab Values Clinical Manifestations Assessment priorities Nursing Management (Include diet) Nursing Education and considerations Hyponatremia & Hypernatremia Hyponatremia: - Na+ below 135 mEq/L. Body gain more water than salt. Too dilute of body fluid. Excessive ADH (SIADH). Excess IV administration of D5W. Loss of more salt than water. Hypernatremia: - N+ above 145 mEq/L. Body gain more salt than water. Excessive sodium containing IV administration or oral intake of Na+. Renal retain more Na+. Confusion, decrease LOC, poor skin turgor, cold and clammy skin, flat neck vein, lethargy, and coma. Confusion, decrease LOC, lethargy, coma, excessive thirst, seizure if too much/ fast IV administered. Instruct patient to stay away from processed foods, salty chips, and any other salty foods. Educate the patient about the risk for fluid imbalance and the effect of the fluid imbalance on the body system. Hyperkalemia & Hypokalemia Hyperkalemia: - K+ above 5.0 mEq/L. Excessive administration of IV K+. Massive amount of K+ moves out of cells. End renal stages. Hypokalemia: - K+ below 3.5 mEq/L. Low serum K+ concentration. Excessive use of K+ free IV solutions. K+ moves into the cells. Too much insulin treatment of DKA. Low K+ consumption. Constipation, dysrhythmias, muscle weakness. Dysrhythmias, bilateral muscle weakness mostly in quadriceps, and abdominal distension. Instruct the patient about the risk of K+ imbalance foods such as fruits potatoes, instant coffee, brazil nuts, and Molasses. Maintaining a good rest. Instruct the client to allow the smooth, skeletal, and cardiac muscles to have a normal muscle friction. Hypercalcemia & Hypocalcemia Hypercalcemia: - Ca+ above 10.5 mg/dL. High calcium concentration. Too much calcium consumption. Shift the Ca+ out of the bone. Decrease Ca+ output. Hypocalcemia: - Ca+ below 8.4 mg/dL. Low calcium intake. Shift of Ca+ into bones inactive form. Excessive output of Ca+, usually appear in the end stage of renal disease. Decrease LOC, Anorexia, N/V, fatigue, Constipation, lethargy, confusion, and heart problem. Muscle spasm, numbness, tingling of toe, fingers, and around mouth region. Chvostek’s sign. Seizure, dysrhythmias, and Trousseau sign. Watch for calcium balance. Dairy products, fish with bone, broccoli, orange, and vitamin D. Instruct patient about the influence on bone and nerve cells. Instruct them how it’s important for muscle contraction and bone health. Hypomagnesemia & Hypermagnesemia Hypomagnesemia: - Mg+ below 1.5 mEq/L. Low Mg+ intake. Malnutrition and chronic alcoholism, diarrhea, steatorrhea, excessive Mg+ output. Hypermagnesemia:- Mg+ above 2.5 mEq/L. High Mg+ intake. Excessive use of Mg+ contains laxative. Decrease Mg+ output occur in end-stage of renal disease. Positive Chvostek sign, hyperactive deep tender reflex, muscle cramps, and twitching, grimacing, dysphagia, tetany, and insomnia. Tychacardia, dysrhythmia, decrease rate of respiration, and cardiac arrest. Dark green leafy vegetables, whole grains, Mg2+ containing laxatives, and undigested fat. Instruct the patient how it influence their neuromuscular junction. Hyperphosphatemia & Hypophosphatemia Hyperphosphatemia: - High Phosphate intake. Decrease phosphate output. Hypophosphatemia: - Low Phosphate in extra cellular fluid. Phosphate shifts into the cell. Too much phosphate output. Renal decrese function, Oliguria decrease. Mostly in processed food. Milk. Instruct client about how it is used for the production of ATP which is the major energy source of all cellular. 5. Explain the difference between Chvostek’s sign and Trousseau sign when assessing a client with a calcium imbalance? Chvoske sign refers to an abnormal reaction to the stimulation of the facial nerve. When the facial nerve is tapped at the angle of the jaw (i.e. masseter muscle), the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia (i.e. from hypoparathyroidism, pseudo-hypoparathyroidism, hypo-vitamin D) with resultant hyper-excitability of nerves. Trousseau sign of latent tetany which also occur in low calcium level. The sign appears when the blood pressure cuff is placed in a person’s arm (brachial artery). When the cuff inflate, the blood flow will absent, and the wrist and other joints as well as the fingers will be adducted. 6. Explain the common clinical manifestations, and nursing management of the following acid-base imbalances: A) Metabolic acidosis Metabolic acidosis is when there is an increase of metabolic acid. The person will experience decrease level of consciousness which is lethargy, confusion, and coma. Abdominal pain, dysrhythmias, increase rate and depth of respiration. pH is low or below 7.35, PaCO2 will be normal, or if it is uncompensated below 35. And, the HCO3- level below 22 mEq/L. B) Metabolic alkalosis Metabolic Alkalosis is when an increase of bicarbonate. It happens when there is excessive administration of sodium bicarbonate, excessive blood transfusion, and ECV. s/s are light- headedness, numbness, and tingling of fingers, toe and muscle cramps. pH will be above 7:45, PaCO2 normal if uncompensated or above 45 mm Hg if compensated, HCO3 above 26 mEq/L. C) Respiratory acidosis When there is excessive carbonic acid in our body usually caused by Alveolar Hypoventilation. Headache, light-headedness, decreased level of consciousness (confusion, lethargy, coma), dysrhythmias Laboratory findings: Arterial blood gas alterations: pH below 7.35, PaCO2 above 45 mm Hg (6 kPa), level normal if uncompensated or above 26 mEq/L (26 mmol/L) if compensated. D) Respiratory alkalosis When there is deficiency of carbonic acid which caused by alveolar hyperventilation. Hypoxemia from any cause (e.g., initial part of asthma episode, pneumonia) Acute pain Anxiety, psychological distress, sobbing Inappropriate mechanical ventilator settings Stimulation of brainstem respiratory control (e.g., meningitis, gram-negative sepsis, head injury, aspirin overdose). Physical examination: Light-headedness, numbness and tingling of fingers, toes, and circumoral region, increased rate and depth of respirations, excitement and confusion possibly followed by decreased level of consciousness, dysrhythmias Laboratory findings: Arterial blood gas alterations: pH above 7.45, PaCO2 below 35 mm Hg (4.7 kPa), level normal if short lived or uncompensated or below 22 mEq/L (22 mmol/L) if compensated 7. Describe the composition (give examples) and reasons for use of common IV fluid solutions. A) Isotonic: When we administer the same tonicity as normal blood is called isotonic. B) Hypertonic: When we administer the hypertonic solution, it means more concentrated than normal blood. C) Hypotonic: When we administer hypotonic, it means the solution is more dilute than the blood. 8. Explain how to administer IV KCL (potassium), What guidelines must the nurse follow? IV KCL should be administered with NS. It should not be administered via IV push or bolus. 9. Discuss the types and nursing management (maintenance) of commonly used central venous access devices. A) PICC Line: This is the central venous catheter inserted into a vein in the arm. The length of the line is up to 60 cm and the gauge ranges are 24 to 16. They are usually used with patients who need vascular access for 1 week to 6 months, but in place for a long period of time. PICC line has so many advantages such as lower cost, lower infection rate, fewer complication, and can be used for inpatient and outpatient. Nursing management with PICC line will be assessing the tube/line for clamping or kinking, administer anticoagulant or thrombolytic agents, and flush the syringe with 10 ml NS gently. If there is any sign of embolism, administer oxygen, place the patient on the left side with the head down, and notify the physician. If there is any sign of local infection, apply warm drainage for the infected site or remove the catheter if necessary. If the sign of the infection is systemic, check the vital sign, wash hands to prevent further infection, take blood culture, administer antibiotics therapy, or remove the catheter if necessary. B) Metaport: they are single or double subcutaneous injection port of a central catheter infusion. They are meant to use for a long-term therapy and have a low risk of infection. It feels more secured for the patient and have less maintenance problem than other central venous catheters. In order to prevent any tube clotting, sludge, and drug particles in the port, the regular flushing is required within the port. The nurse role will be assessing the catheter and the insertion site for any redness, edema, warmth, drainage, and tenderness or pain. The nurse also must perform the pain assessment and observation of the site. 10. Identify the normal laboratory diagnostic ranges for interpreting acid-base imbalances. ( Ph balance, HCO3, and PaCO2). The normal laboratory diagnoses ranges are as follows pH 7.35-7.45, PaCO2 35-45 mm Hg, PaO2 80-100 mm Hg, O2 sat 95%-100%, Anion gap 5-11 mEq/L, Osmolality 280-300 mOsm/kg H2O, Sodium 136-145 mEq/L, Potassium 3.5-5.0 mEq/L, Chloride 98-106 mEq/L, Bicarbonate 22-26 mEq/L, Calcium 8.4-10.5 mg/dL, Magnesium 1.5-2.5 mEq/L, Phosphate 2.7-4.5 mg/dL. 11. Explain metabolic acidosis and metabolic alkalosis. Metabolic acidosis occurs during the increase of metabolic acid and the decrease of metabolic base or bicarbonate in our body. When the body exert too much bicarbonate as diarrhea or other method uncontrollably, the kidney will unable to compensate or excrete enough metabolic acid which accumulate in the blood. The pH will also fall. This problem usually seen in a patient with DKA, alcoholism, sever hyperthyroidism, and end stage renal disease. Metabolic alkalosis occurs when body are not able to excrete bicarbonate which is an increase of base in our body and when the body loses too much metabolic acid. This kind of problem seen in patient with massive blood transfusion, sever vomiting and gastric suctioning (NG tube). 12. Explain respiratory acidosis and respiratory alkalosis. Respiratory acidosis occurs when the lungs are unable to excrete carbonic acid. It usually arises from alveolar hypoventilation. The body will have excess amount of carbonic acid in the blood which also will make the decrease of pH. The kidney compensates by increasing excretion of metabolic acid in the urine; however, the process takes longer time, up to 24 hours to 5 days for effective respond. This problem has been seen in a patient with COPD, bacterial pneumonia, extensive atelectasis, or a drug overdose. Respiratory alkalosis occurs when the lungs excrete too much carbonic acid and water. The PaCO2 will decrease which causes the deficit of carbonic acid in the blood, which also increase the pH level. Kidney might not compensate this problem. This problem has been seen in a patient with acute pain, anxiety, head injury, and meningitis. 13. Complete the table below: Bronchoscopy, CT scan, TB Screening test, Thoracentesis Explanation of the Procedure Pre-Procedure Consideration What are the post-procedure Complications Nursing teachings Bronchoscopy Biopsy, specimen collection, and assessment collection. Minor bleeding, tongue edema, low oxygen level, shortness of breath. Instruct patient to be on NPO until gag reflex, give sedative medication if ordered, monitor for bleeding, and recovery from sedation. CT scan Instruct patient to stay NPO, assess for vital sign, assess for allergy, if child, prepare for sedative med. Remove all metal, belt, and jewelries. If pregnant, the radiation is harmful for unborn baby. Exposure of radiation is harm. Monitor the patient for hydration. Instruct the patient about the scanner machine noise. TB screening Test Assess the patient recent travel history, Ask where patient has lived, assess for sign and symptom. Patient might Deny to take medication, Patient might not show up with in expected day to read the result. Teach the importance of taking the medication if their result is positive. Instruct the patient active TB virus can act up at any age. Thoracentesis Assess for vital sign, explain the procedure for the patient, instruct the patient that they have to sit up for the procedure. Asses for cough, respiration, chest pain, and sitting position. Explain the patient procedure, stay on your unaffected side for at least 30 min or more. 14. Describe the signs and symptoms of inadequate oxygenation? There are two types of sign and symptom of inadequate oxygenation such as early and late. Early sign and symptoms are irritability, tachycardia, dyspnea on exertion, dysrhythmia, and mild hypertensions. The late sign and symptoms of hypoxia are coma, confusion, hypotension, lethargy, cyanosis, cool, and clammy skin. 15. List common age-related changes of the respiratory system that are found upon assessment. Elderly people chest wall become stiff, barrel chest, decrease chest wall compliance, respiratory muscle strength decrease, and decrease elasticity. 16. Explain the nursing management of a client experiencing epistaxis? Start helping the patient with first aid which is by telling the patient to be quit, place the patient in a sitting position and head tilted forward, and apply direct pressure by pinching the entire nose for 10-15 min. Open mouth and breath. if this help doesn’t help, seek immediate medical help. 17. Discuss the rationale for tracheostomy insertion, and the nursing management of the patient who requires a tracheostomy (include management for accidental dislodgement). It is a sterile procedure, the procedure helps bypass an upper respiratory obstruction, and facilitate removal of secretions. Teach client to take more fluid, cough and deep breathing. If the tube is accidentally dislodged, replace the tube. 18. Identify the common clinical manifestations for a client with larynx cancer. Patient will have white/red patch in mouth, their voice will change, wound/ulcer that will not heal, difficulty swallowing, and pain. 19. Discuss the nursing management of the patient who has undergone a laryngectomy. Instruct the patient to expect some voice change or even might loss of their speech ability, the importance of good oral care, the change of smell and test ability, the importance of cleaning the tube, and teach them the NG tube feeding possible option for them. 20. Explain some communication methods used for clients who have had temporary or permanent loss of speech. It usually depends of the patient; however, if they are unable to speak, explain them that writing the thing want to say on board, expressing the feeling in non-verbal way, and use of some collaboration speech therapy are always available for them. 21. Explain the difference between these common types of pneumonia, risk factors and clinical manifestations. (Aspiration, Inhalation, and Hematogenous spread) Pneumonia is a bacterial infection of lower respiratory system. Some of the risk factors are air pollution, trauma, excessive alcohol consumption, prolog bedridden, malnutrition, IV drug use, upper respiratory tract infection, smoking, and so on. Aspiration is one of the causes of pneumonia that reaches the lung. Many of the organisms that cause pneumonia is normal inhabitation of the pharynx in healthy adult. Inhalation is the other methods of causing pneumonia that reaches the lung. Inhalation of the microbes present in the air such as fungal pneumonia. Hematogenous spread is also the other methods of causing pneumonia that reaches the lungs. It usually happens by the spread from a primary infection elsewhere in the body. 22. Explain the difference between Community-Acquired Pneumonia & Medical Care–Associated Pneumonia. Community-Acquired pneumonia is an acute infection of the lungs which occurs in patients who have not been hospitalized or in a long-term care facility within 14 days of the onset of symptoms. Medical care-associated pneumonia can be explained in three forms such as hospital-associated pneumonia which occurs within 48 hours or longer after admission and was not incubation at the time of hospitalization. Ventilator associated pneumonia which occurs more than 48 hours after endotracheal intubation. Health care-associated pneumonia is a new-onset one in a patient who are hospitalized. 23. Explain the common assessment findings for pneumonia patients, common breathing techniques used, nursing diagnosis, nursing care, including discharge instructions and client teaching. The most common assessment finding for pneumonia patient is cough, shaking chills, dyspnea, tachypnea, and pleuritic chest pain. The cough may be productive or may not. Sputum may be green, yellow, or even rust colored or bloody. The breathing/lung sound will be rhonchi and crackles. The sounds will be bronchial breath sound and increase fremitus. Diagnosis will be chest x-ray, history and physical examination, gram stain of sputum and blood culture, and pulse oximetry. 24. Define tuberculosis, and what are the risk factors? Tuberculosis (TB) is an infection disease of the lungs cause by Mycobacterium tuberculosis. The people who are at risk for TB are homeless people, people who have very limited access to health care, those who living or working in institutions such as long term facilities, and exposure with an infected person. 25. What is the priority nursing management for clients with tuberculosis, (include isolation and patient and family teaching regarding prevention methods)? If the nurse triggered the patient with TB, that patient should be placed on airborne isolation, receive a medical workup such as chest x-ray, sputum smear, and culture, and receive appropriate drug therapy. Teach the patient to cover their mouth when every time they cough, sneeze, or produce sputum. Teach the patient to take the medication appropriately. 26. Describe the risk factors, clinical manifestations, and priority nursing management of lung cancer. Smoking is the number on risk factor for lung cancer. It is approximately 80-90% of lung cancer are caused by smoking. Being able to second had smoker or exposure to tobacco smoke area could increase the chance of getting a lung cancer. 27. What is the common diagnostic tool for lung cancer, and what is the priority teaching for clients with lung cancer? The common diagnostic tool for lung cancer will be history and physical examination, chest x-ray, sputum culture, CT scan, and bronchoscopy. Client teaching will be that allow them as much control as possible for their personal care, encourage to express any concerns, and teach them the removal of lung could be one of the treatment if things getting worst. 28. Describe the purpose and nursing responsibilities related to chest tubes. Chest tube are inserted for the purpose of draining the plural space and reestablish negative pressure and promote lung expansion. The tube might also use to drain air and fluid for post-operative patients. Nurses are responsible to wash hands before and after the procedure, to keep the insertion site sterile, to assess vital sign, assess for pain, reposition patient after surgery, and so on. 29. Define Cor-Pulmonale. It is the enlargement of the right ventricle caused by a primary disorder of the respiratory system. It may be with or without overt cardiac failure and pulmonary HTN. Common symptoms include exertional dyspnea, tachypnea, cough, and fatigue. Physical signs include evidence of right ventricular hypertrophy on ECG and an increase in intensity of the second heart sound. 30. Explain thoracentesis and pleuralcentesis, what are the primary complications of these procedures? Thoracentesis is aspiration or collection of intra-pleural fluid. The patient has to sits on the edge of a bed or a chair and lean forward over a bed side table. The thoracentesis needle is inserted into the intercostal space and fluid will aspirate. Instruct the patient not to talk or cough during the procedure. Assess for breathing pattern and vital sign after the procedure. The primary complication of this procedure is infection. 31. Describe the common clinical manifestations, and triggers for clients with asthma? Common clinical manifestation of asthma is dust, cockroaches, pollens, cigarettes, sprays, molds, working environments, alcohols, stress, cold and dry air, and GERD. 32. Explain the nursing management of the patient with asthma. Always determine the baseline respiratory status, monitor chest movement, auscultate breath sounds, offer warm fluid, and administer medication as ordered. 33. Explain the priority nursing management for a client having an acute asthma attack. What role does an rescue inhaler have in acute management of asthma patients? Monitor the patient respiratory and cardiac assessment such as auscultate lung sounds, monitor ABG, check BP and RR rate, and check pulse oximetry. The rescue inhaler help the patient airway to open for a certain period of time. So, teach them how to use these machines properly. 34. Explain the common clinical signs & symptoms, diagnostic procedures, and treatment for Pulmonary Embolism. Pulmonary embolism is a life-threatening condition. Common clinical sign and symptoms are SOB, weakness, diaphoresis, tachypnea, wheezing, crackles, increase weight, and pulmonary edema. Treatment will be administering oxygen and IV as ordered. 35. Describe the common clinical manifestations, and diagnostic tests for patients with chronic obstructive pulmonary disease (COPD). The common clinical manifestation of COPD is barrel chest, generalized cyanosis of lips, mucous membranes, face, nail beds; dry or productive cough; hypercapnia; low O2; decreased breath sounds; coarse crackles in lung field that tend to disappear after coughing, wheezing; dyspnea, orthopnea; poor nutrition, weight loss; activity intolerance; anxiety (anger, fear of alone, fear of not able to catch breath). The diagnostic tests will be CT scan, chest x-ray, and ABG. 36. What are the common risk factors for chronic obstructive pulmonary disease (COPD)? The common risk factors for COPD are smoking, exposing to polluted and chemicals air, infection, TB, asthma, and age. 37. Identify the indications for O2 therapy, methods of delivery, and complications of O2 administration. What precautions should be taken with 02 in clients with COPD? Patient with COPD or any other associated problems such as hypoxia are treated by oxygen therapy. The complication might be if high amount of oxygen administers, the patient become dependent on it. Always precaution of smoking around oxygen in-use area. 38. Explain the nursing management of the patient with COPD. Check the respiratory and oxygen saturation frequently, advise patient not to smoke around the oxygen area, and encourage slow deep breathing, turning, and cough. Administer medication if administer, monitor ABG, chest x-ray, CT scan, and pulmonary function test. 39. Describe, the clinical manifestations, and nursing management of the patient with cystic fibrosis. Cystic fibrosis is an autosomal recessive, multisystem disease characterized by altered transport of sodium and chloride ions in and out of epithelial cells. This defect primarily affects the lungs, gastrointestinal tract (pancreas and biliary tract), and reproductive tract. Clinical manifestations: wheezing, coughing, restless, tachycardia, frequent pneumonia, weight loss, failure to thrive, steatorrhea, mucous is very thick (like glue), increase sputum, increase pulmonary function, delayed puberty, etc. Nursing management: chest physiotherapy (move mucous), postural drainage, breathing exercise, coughing techniques, IV therapy, oxygen, diet therapy, depression, discuss sexuality such as delayed development, susceptible to infections; monitor pancreas, glucose, reproductive; anti- inflammatory meds, antibiotics, bronchodilators. 40. What is the most common diagnostic test for clients suspected to have cystic fibrosis? The most common diagnostic test for cystic fibrosis is ABG, chest x-ray, genetic test, and sweat chloride test. Reference: Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment and management of clinical problems. St. Louis: Mosby. [Show Less]
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NR 324 Exam 1 Study Guide Chapters 17, 26, 27, 28, 29, and ABG interpretation.
NR 324 Exam 1 Study Guide Chapters 17, 26, 27, 28, 29, and ABG interpretation. NR 324 Exam 1 Study Guide Chapters 17, 26, 27, 28, 29, and ABG interpret... [Show More] ation. Fluid & Electrolyte 1. Potassium Chloride intravenous- care of patient, how much (meq/hr) is the infusion rate?(p.316) Potassium Chloride intravenous can be administered to treat a patient with hypokalemia. Except in severe deficiencies, KCL is never given unless there is urine output of at least 0.5ml/kg of body weight per hour Safety Alert: • KCL given intravenously must always be diluted. • Never give KCL via IV push or in concentrated amounts. • IV bags containing KCL should be inverted several times to ensure even distribution in the bag. • Never add KCL to a hanging IV bag to prevent giving a bolus dose. How much (meq/hr) is the infusion rate? The preferred maximum concentration is 40 mEq/L; however, stronger concentrations may be given for severe hypokalemia (up to 80mEq/L) with continuous cardiac monitoring. The rate of IV administration of KCL should not exceed 10 to 20mEq per hour and should be administered by infusion pump to ensure correct administration rate. Because KCL is irritating to the vein, assess IV sites at least hourly for phlebitis and infiltration o Infiltration can cause necrosis and sloughing of the surrounding tissue. Central IV lines should be used when rapid correction of hypokalemia is necessary 2. ABG interpretation( do the practice questions that teacher gave& p324 & hesi 43,44) An acid-base balance must be maintained in the body because alterations can result in alkalosis or acidosis. Maintain the acid –base balance involves 3 systems • Chemical buffer o The chemical buffer act immediately to prevent major change in the body fluid pH by removing or releasing hydrogen ions. The main chemical buffer is the Bicarbonate-Carbonic acid (HCO3- H2CO30system. • Normally there are 20parts of bicarbonate to 1 part of carbonic acid. If the 20:1 ratio is altered, the pH is changed( ratio is important not absolute values) • Carbonic acid (H2CO3) is form when carbon dioxide (CO2) combines with water (H2O). • Excess CO2 in the body alters the ratio and creates an imbalance. Other buffer system involve: o Monohydrogen-dihydrogen phosphate o Intracellular and plasma protein o Hemoglobin • Respiratory system (lungs) o The respiratory system responds in minutes and reaches maximum effectiveness in hours Control CO2 content through respirations (carbonic acid content) Control, to a small extent, water balance (CO2+H2O=H2CO3) Release excess CO2 by increasing respiratory rate. Retain CO2 by decreasing respiratory rate. The rate of the CO2 is control by the respiratory center in the medulla in the brainstem. If the respiratory problem is the cause of an acid –base imbalance (e.g., respiratory failure), the respiratory system loses its ability to correct a pH alteration. • Renal system (kidney) o The renal response takes 2 to 3 days to respond maximally, but the kidneys can maintain balance indefinitely in chronic imbalance. Regulate bicarbonate levels by retaining and reabsorbing bicarbonate as needed. a very slow compensatory mechanism ( can require hour or days). Cannot help with compensation when metabolic acidosis is created by renal failure If the renal system is the cause of and acid-base imbalance (e.g., renal failure), it loses its ability to correct a pH alteration. Arterial Blood Gas (ABG) values provide valuable information about a patient’s acid-base status, the underlying cause of the imbalance, the body’s ability to regulate pH, and the patient’s overall oxygen status. (p. 324, shows the steps on how to diagnose acid disturbances and identification of compensatory processes). • Uncompensated respiratory Alkalosis with hypoxemia(Kidney clearance) • Uncompensated Respiratory Acidosis with Hypoxemia • Partially compensated Respiratory Acidosis • Partially compensated Metabollic Alkalosis(Kidney and lungs are helping each other) • Fully compensated Respiratory Alkalosis(Good prognosis) Page44 hesi Acid-base condition pH Pco2 (mm Hg) HCO3 (mEq/L) Normal 7.34-7.45 35-45 22-26 Respiratory Acidosis ↓ ↑ Normal Respiratory Alkalosis ↑ ↓ Normal Metabolic Acidosis ↓ Normal ↓ Metabolic Alkalosis ↑ Normal ↑ • Respiratory • Opposite • Metabolic • Equal A. pH 7.50, pco2 30,HC03 26 B. PH 7.30, Pco2 42,HC03 20 C. pH 7.48, Pco2 42, HCO3 32 D. pH 7.29, Pco2, 55, HCO3 26 (Refer to Hesi page 46 for Answers) 3. Fluid volume deficit- assessment findings- which is most important?(p. 309 & hesi p.39) Fluid deficit occurs when the body loses water and electrolytes isotonically, that is in the same proportion as exists in the normal body fluid Causes: • Vomiting • Diarrhea • GI suctioning • Sweating • Inadequate fluid intake • Massive Edema, as in initial stage of major burns • Ascites • Elderly forgetting to drink • Diabetic insipidus Assessment findings: • Weight loss (1 pint of fluid loss=1pound of weight loss) • Decreased skin turgor • Oliguria (concentrated Urine) • Dry and sticky mucous membranes • Postural hypotension or weak, rapid pulse Labs findings: • Elevated BUN and creatinine • Increased serum osmolarity • Elevated hemoglobin and hematocrit Treatment • Strict I&O • Replacement of fluids isotonically, preferably orally Page 309 for mor info 4. Fluid Deficit- post burn- greatest concern After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes (success p.420) 5. Low serum protein level- implications ( I think of the Edema because you won’t have enough albumin to pull that water from the interstitial space) 6. Hyponatremia- signs and symptoms, most important assessment findings and monitoring, care of patient (p. 313hesi p.40) • The normal sodium is 135-145 • Sodium is the main cation of the ECF • Play a major role in maintaining the concentration and volume of the ECF. o Therefore, sodium is the primary determinant of ECF osmolality. Sodium affects the water distribution between ECF and ICF. • Sodium is also important in the generation and transmission of nerve impulse and the regulation of acid-base balance. • The GI tract absorbs sodium from food. • Sodium leaves the body through urine, sweat, and feces. • The Kidneys are the primary regulator of sodium balance. o The kidney regulates the ECF concentration of sodium by excreting or retaining water under the influence of ADH. • Aldosterone also plays a big role in sodium regulation by promoting sodium reabsorption from the renal tubules. o Aldosterone (p.1206): is a potent mineralocorticoid that maintains extracellular fluid volume. It acts at the renal tubules to promote renal reabsorption of sodium (Na+) and excretion of potassium (K+) and hydrogen ions (H+). • Changes in the serum of sodium level may reflect a primary water imbalance, a primary sodium imbalance, or a combination of the two. Sodium imbalances are typically associated with imbalances in ECF volume. Hyponatremia • Patho: • Causes: o may result from loss of sodium-containing fluids o from water excess(dilutional hyponatremia) o or combination of both • Nursing implementation or treatment: o Restrict fluid o Hypertonic saline solution(3%NaC) can be given to restore the serum sodium level( if severe symptoms like seizures develop) o Hesi p. 40 Abnormality and common causes Signs and symptoms or assessment findings Treatment or intervention Hyponatremia(↓Na) Diuretics GI fluid loss Hypotonic tube feeding D5W or hypotonic IV fluids Diaphoresis Anorexia, nausea, vomiting Weakness Lethargy Confusion Muscle cramps, twitching Seizures Na<135mEq/L Restrict fluid(safer) If IV saline solution prescribed administer very slow. 7. Diuretic therapy- hypokalemia- interaction with what other drug?(p.315) Patient taking Digoxin, Digitalis experience increased digoxin toxicity if their serum potassium level is low. Skeletal muscle weakness and paralysis may occur with hypokalemia. *Severe hypokalemia can cause weakness and paralysis of respiratory muscles, leading to shallow respirations and respiratory arrest. 8. Hypercalcemia- plan of care(p.317) Two thirds of hypercalemia cases are caused by hyperparathyroidism and one third are caused by malignancy, especially from breast cancer, lung cancer, and multiple myeloma. Hypercalcemia is also associated with vitamin D overdose. Excess calcium leads to reduced excitability of both muscles and nerves. Plan of care for hypercalcemia: • The basic treatment of hypercalcemia is promotion of excretion of calcium in urine by administration of a loop diuretic (ex. Furosemide [Lasix]), and hydration of the patient with isotonic saline infusions. • In hypercalcemia, the patient must drink 3000 to 4000ml of fluid daily to promote the renal excretion of calcium and to decrease the possibility of kidney stone formation. • Synthetic calcitonin can also be administered to lower serum calcium levels. A diet low in calcium may be prescribed. • Mobilization with weight-bearing activity is encouraged to enhance bone mineralization. Plicamycin (Mithrancin), a cytotoxic antibiotic, inhibits bone resorption and thus lowers the serum level. In hypercalcemia related to malignancy the drug of choice is paramidronate (Aredia), which inhibits the activity of osteoclasts(cells that break down bone and result in calcium release) o Paramidronate is preferred over plimacamycin because it does not have cytotoxic side effects and it inhibits bone resorption without inhibit bone formation and mineralization. [Show Less]
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ATI RN Fundamentals Proctored Focus NR 324 Exam Review.
ATI RN Fundamentals Proctored Focus NR 324 Exam Review. ATI RN Fundamentals Proctored Focus NR 324 Exam Review. Can an RN delegate to the LPN to p... [Show More] rovide tracheostomy care to a client with pneumonia? Click card to see definition 👆 Yes. Click again to see term 👆 A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer C. Reapplying a condom catheter for a client who has urinary incontinence Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP 1/99 Terms in this set (99) Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? Yes. A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer C. Reapplying a condom catheter for a client who has urinary incontinence Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning B, C, D Upgrade to remove ads Only $3/month An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24hr postop to use an incentive spirometer B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump D. Replacing the cartridge and tubing on a PCA pump Rationale: The RN is responsible for the PCA pump A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all. A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances B, C, E A and D are rights of medication administration A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client? A. Charge nurse B. RN C. LPN D. AP B. RN A client returning from surgery requires assessment and establishment of a plan of care. RNs are responsible for this, especially if the client is potentially unstable. A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy A. Assault By threatening the client, the AP is committing assault. An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality B. False imprisonment The nurse gave the med as a chemical restraint to keep the client from leaving the facility against medical advice. The client did not consent. A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead w/the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." C. The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arrives A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all. A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form C. Explain the risks and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery A, B The rest of the choices are the surgeon's responsibility, not the nurse A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? A. Remind the nurse that safe client care is a priority on the unit B. Ask others on the team whether they have observed the same behavior C. Report observations to the nurse manager on the unit D. Conclude that her coworker's fatigue is not her problem to solve C. Any nurse who notices behavior that could possibly jeopardize client care or indicate a substance abuse problem has a duty to report the situation immediately to the nurse manager A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report? A. The client's input & output for the shift B. The client's BP from the previous day C. A bone scan that is scheduled for today D. The med routine from the med administration record C. A bone scan that is scheduled for today This is important because the nurse might have to modify the client's care to accommodate them leaving the unit A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should the nurse document this in the client's chart? A. The client fell in the shower. B. The client states he fell in the shower & was able to get himself back into his chair C. The nurse should not document this info because she did not witness the fall D. The client fell in the shower & is now resting comfortably B. By writing what the client states, the info is subjective data A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all. A. Cover errors w/correction fluid, & write in the correct info B. Put the date & time on all entries C. Document objective data, leaving out opinions D. Use as many abbreviations as possible E. Wait until the end of the shift to document B, C The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all. A. The physical therapist didn't ambulate the client today B. The skin barrier's seal stays on in bed but loosens when the client stands. C. The client seemed to welcome having a "day off" from physical therapy D. The wound care nurse will see the client later today E. The client ate all the food on her lunch tray A, B, D A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all. A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the prescriber's signature on the prescription within 24hrs D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone A, B, C A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him? A. Registered dietitian B. Occupational therapist C. Physical therapist D. Social worker D. social worker A social worker can make arrangements for a meal delivery service to provide nutritious meals daily, or recommend a congregate meal site near the client's home A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist D. An occupational therapist can assist clients who have physical challenges to use adaptive devices & strategies to help w/self-care activities A client who is postop following a knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects? Select all. A. Provider B. CNA C. Pharmacist D. RN E. Respiratory therapist A, C, D A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker B. CNA C. Occupational therapist D. Speech-language pathologist D A speech-language pathologist can initiate specific therapy for clients who have difficulty feeding due to swallowing difficulties A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? Select all. A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs A, B, C, E Determining pain level requires assessment, which is the job of the licensed personnel. A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all. A. A concave thoracic spine posteriorly B. An exaggerated lumbar curvature C. A concave lumbar spine posteriorly D. An exaggerated thoracic curvature E. Muscles slightly larger on his dominant side C, E A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items? A. A word she whispers 30cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand D. Stereognosis is tactile recognition A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink C. Fastening a bra from behind requires internal rotation of the shoulder, so this activity will illicit pain A nurse is preforming a neurosensory examination for a client. Which of the following tests should the nurse preform to test the client's balance? Select all. A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test A, B C and E test visual acuity , D tests cranial nerve XI is intact by asking the client to shrug shoulders without complication. A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all. A. Slower light touch sensation B. Some vision & hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation B, C, D A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all. A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "No smoking" sign should be placed on the front door D. Cotton bedding & clothing should be replaced w/items made from wool E. A fire extinguisher should be readily available in the home B, C, E Family members that smoke should do so outside, and wool creates static electricity so it should be avoided. A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction? A. "I will begin swimming lessons as soon as my baby can close her mouth under water." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will test the temp of the water before placing my baby in the bath." D. "Once my infant starts to push up, I will remove the mobile from over the bed." B Although the baby can hold his head above the water by sitting up, this does not make the baby safe in the tub. Parents should never leave a child unattended in a tub. A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds w/hemoglobin in the body D. Carbon monoxide is a very dangerous gas because it binds w/hemoglobin & ultimately reduces the oxygen supplied to the tissues in the body. Carbon monoxide is tasteless, has no scent, and cannot be seen. The water heaters, gas-burning furnances, and appliances should be inspected annually The lungs are not damaged in the process of inhalation A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea A. Hypotension Tachycardia, hot dry skin, and tachypnea are other manifestations of heat stroke A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all. A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw & fresh food separately to avoid cross contamination may prevent food poisoning B, C, E Most food poisoning is caused by a bacteria such as E. coli. Healthy individuals usually recover in a few days. A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all. A. Planning & evaluating control & prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks A, B, C, E Not D because endemic disease is already prevalent within a population, so reporting is not necessary A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all. A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another dept is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when preforming care that may result in contamination from secretions B, C, E Private room w/droplet precautions indicated for this client. The nurse should wear a gown when contamination from body fluids might happen A nurse is caring for a client who presents w/linear clusters of fluid-containing vesicles w/some crustings. Which of the following should the nurse suspect? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster D. Herpes zoster pink body rash=allergic reaction red circles w/white centers=ringworm red cheek rash bilaterally=lupus A nurse is caring for a client who reports severe sore throat, pain when swallowing, & swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness D. Illness specific s/s present is the illness stage A nurse educator is reviewing w/a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse & respiratory rate A, B, E Edema and pain and tenderness is localized A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I'm feeling well." C. "If I'm having any discomfort, I'll just got to an urgent care center." D. "If I am felling stressed, I will remind myself that this is something I should expect." B. routine health screenings are important at any age A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between & being responsible for 2 generations C. Exploring and establishing career options & establishing oneself is important developmental task in a young adult A nurse is counseling a young adult who describes having difficulty dealing w/several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, & now I'm supposed to know what to do." D. "My girlfriend is pregnant, & I don't think I have what it takes to be a good father." C. Applying Erikson stages of development, knowing oneself is done in adolescence, and this requires the most urgent help A nurse is reviewing safety precautions w/a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all. A. Install bath rails & grab bars in bathrooms B. Wear a helmet while skiing C. Install a carbon monoxide detector D. Secure firearms in a safe location E. Remove throw rugs from the home B, C, D A is recommended for older adults and E as well for risk of falls A nurse is reviewing the CDC's immunization recommendations w/a young adult client. Which of the following recommendations should the nurse include in this discussion? Select all. A. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenzae type b E. Polio A, B, C D is not for after 18 months of age and polio is also given as a child and not usually beyond 18 yrs old A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101 F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all. A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake C. Encourage the client to limit activity & rest D. Allow the client to shiver to dispel excess heat E. Assist the client w/oral hygiene frequently A, C, E The nurse should prevent shivering & encourage the client to increase fluids. Why E-Oral hygiene helps prevent cracking of dry mucous membranes of the mouth & lips. A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemo. Which of the following is the nurse's priority instruction for measuring vital signs for this client? A. "Don't measure the client's temp rectally." B. "Count the client's radial pulse for 30 sec & multiply by 2." C. "Don't let the client know you are counting her respirations." D. "Let the client rest for 5 mins before you measure her BP." A. "Don't measure the client's temp rectally." The greatest risk to a client w/a low platelet count is injury that results in bleeding, obtaining a temp this way increases the risk for bleeding. A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe 1 full respiratory cycle before counting the rate D. Count the rate for 1 min if it is regular E. Count & report any signs the client demonstrates A, B, C For D, this is if the rate is irregular after initial count, for E, sighs are expected & don't need to be reported [Show Less]
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