ATI Capstone Post Assessment Assignment WEEKLY

​A nurse is providing care for an uncircumcised male newborn and his mother. What information should be provided during discharge regarding bathing of the penile area of the newborn male?

- To cleanse an uncircumcised penis, wash with soap and water and rinse the penis. The foreskin should not be forced back or constriction may result.

A nurse is caring for a client who is experiencing acute alcohol withdrawal. What are three (3) manifestations of alcohol withdrawal the nurse should be aware of when managing care of this client?

- Withdrawal delirium can occur 2 to 3 days after cessation of alcohol. This is considered a medical emergency. Manifestations include severe disorientation, psychotic manifestations (hallucinations), severe hypertension, cardiac dysrhythmias, and delirium. Alcohol withdrawal delirium can progress to death.

A nurse is reviewing medications while preparing to administer morning medications. List three (3) risk factors that can cause a decrease in medication effectiveness.

- increase body weight - genetics - tolerance to the medication - inadequate gastric acid - diarrhea - vascular insufficiency - prolonged gastric emptying time. - Always assess for constipation and teach to avoid foods that cause constipation

​The nurse is caring for a client with suspected bacterial meningitis. What is a priority action for the nurse to initiate?

- isolate the client and maintain droplet precautions per facility protocol.

​A nurse has provided education to a client with hypothyroidism who has a new prescription for levothyroxine. What statements by the client would indicate they understand the instructions?

- take the medication daily on an empty stomach 30 to 60 min before breakfast - will verbalize the importance of lifelong replacement (even after improvement of symptoms) and will not to discontinue the medication without checking with the provider - will check with the provider before switching to another brand of levothyroxine - will monitor and report signs of cardiac excitability (angina, chest pain, palpitations, dysrhythmias) - will have T4 and TSH levels drawn as directed by their provider.

A nurse is providing pre-procedural instructions to the client having a barium swallow. What instructions should be included in this teaching?

- NPO after midnight - No smoking after midnight - Stools will be white for 24 to 72 hours post procedure (EDUCATE)

A nurse is caring for a client with a tension pneumothorax. What is a tension pneumothorax?

- A tension pneumothorax occurs when air enters the pleural space during inspiration through a one‑way valve and is not able to exit upon expiration. The trapped air causes pressure on the heart and the lung. As a result, the increase in pressure compresses blood vessels and limits venous return, leading to a decrease in cardiac output. Death can result if not treated immediately. - As a result of a tension pneumothorax, air and pressure continue to rise in the pleural cavity, which causes a mediastinal shift.

​A nurse is caring for a client who is considering use of a hormonal intrauterine system. What information regarding the advantages of an intrauterine device (IUD) should the nurse provide?

- An IUD can maintain effectiveness for 1 to 10 years. - Contraception can be reversed. - Does not interfere with spontaneity - Safe for mothers who are breastfeeding - It is 99% effective in preventing pregnancy.

A nurse is working on a maternal newborn unit. What security measures should the nurse ensure are in place to prevent abduction?

- An identification system that identifies employees, volunteers, physicians, students, and regularly scheduled contract services staff as authorized personnel of the health care facility should be established. - Electronic security systems in high-risk areas (the maternal newborn unit to prevent infant abductions, the emergency department to prevent unauthorized entrance) - Key code access into and out of areas such as the maternal newborn unit - Wrist bands that electronically link parents and their infant - Alarms integrated with closed-circuit television cameras - Nurses should be prepared to take immediate action when breaches in security occur. Time is of the essence in preventing a breach in security.

​What may an older client complain of when experiencing decreased cardiac output and decreased contraction strength?

- An older client may complain of poor activity tolerance.

Anticholinergic medications are used to treat extrapyramidal symptoms. What is the expected pharmacological action?

- Anticholinergic medications block the muscarinic receptors, which assist in maintaining balance between dopamine and acetylcholine receptors in the brain. - Remember that this class of medication dries all of the body fluids & can be very difficult for the pt with BPH

​A client on the mental health unit is being discharge to a community base program referred to as Assertive Community Treatment (ACT). What should the nurse explain to the client about this program?

- Assertive community treatment (ACT) is considered nontraditional case management and treatment by an interprofessional team for clients who have a severe mental illness and are challenged by traditional treatment. ACT helps to reduce reoccurrences of hospitalizations and provides crisis intervention, assistance with independent living, and information regarding resources for necessary support services.

A nurse is caring for a client in the manic phase of bipolar disorder. Identify three (3) clinical manifestations associated with this phase of the bipolar disorder.

- Bipolar - Manic Phase: - Labile mood with euphoria - Agitation and irritability - Restlessness - Dislike of interference and intolerance of criticism - Increase in talking and activity - Flight of ideas - rapid, continuous speech with sudden and frequent topic change - Grandiose view of self and abilities (grandiosity) - Impulsivity - spending money, giving away money or possessions - Demanding and manipulative behavior - Distractibility and decreased attention span - Poor judgment - Attention-seeking behavior - flashy dress and makeup, inappropriate behavior - Impairment in social and occupational functioning - Decreased sleep - Neglect of ADLs, including nutrition and hydration - Possible presence of delusions and hallucinations - Denial of illness

Identify types of consequences associated with misbehavior by a child.

- Natural Occurrence - missing a treat or not showing up on time. - Logical - not being able to go outside or play until toys are picked up - Unrelated - having privileges taken away or being placed in time-out

Macule

- Nonpalpable, skin color change, < 1 cm. - Example: Freckle

​Identify two (2) areas of injury prevention applicable to the adolescent client. Provide one (1) example for each area identified.

- Bodily harm - Keep firearms in a locked cabinet or box. - Teach proper use of sporting equipment prior to use. - Insist on helmet use and/or pads when roller skating, skateboarding, bicycling, riding scooters, skiing, and during any other activities that increase injury risk. - Avoid trampolines. - Be aware of changes in mood and monitor for self‑harm in at‑risk adolescents. Watch for the following: Poor school performance, Lack of interest in things of previous interest, Social isolation, Disturbances in sleep or appetite, & Expression of suicidal thoughts - Burns - Drowning - Motor-vehicle injury - Substance use - Sexually transmitted infections (STIs) - Pregnancy prevention

The nurse is teaching the parents of an infant with tonsillitis caused by group A ß-hemolytic streptococci about the importance of compliance with antibiotic therapy. What teaching regarding this infection is important to share with the parents?

- Chronically infected tonsils with group A ß-hemolytic streptococci may pose a potential threat to other parts of the body. Some children who frequently have tonsillitis may develop other disease such as rheumatic fever and kidney infection. Rheumatic fever is an inflammatory disease that occurs as a reaction to Group A β-hemolytic streptococcus (GABHS) infection of the throat. Rheumatic fever usually occurs within 2 to 6 weeks following an untreated or partially treated upper respiratory infection (strep throat) with GABHS.

An adult client is suspected to abuse cocaine. What are three (3) manifestations of cocaine intoxication the nurse will assess for?

- Cocaine can be injected, smoked, or inhaled (snorted).Effects: Rush of euphoria (extreme well-being) and pleasure, increased energy - Effects of intoxication: * Mild toxicity: dizziness, irritability, tremor, blurred vision * Severe effects: hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, possible cardiovascular collapse and death - Withdrawal manifestations: * Depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation * Not life-threatening, but possible occurrence of suicidal ideation. Nursing care: - Perform a nursing self‑assessment. - Maintain a safe environment. - Implement seizure precautions. - Orient the client to time, place, and person. - Create a low‑stimulation environment. - Monitor the client's vital signs and neurologic status.

The client states that he has an upcoming trip to an area where West Nile Virus is prevalent. What recommendations regarding prevention should be reviewed with the client? ​

- Community health nurses must maintain knowledge of disease rates, modes of transmission, incubation, early manifestations, periods of communicability, and how to intervene at all levels of prevention related to communicable disease.

​A nurse is conducting discharge planning for an at-risk older adult client. Provide an example of a community resource this client may require once discharged.

- Continuity of Care: Coordinator of Care - Physical therapy, occupational therapy, wound care, home health services, respite care - Rationale: Community resources for at-risk older adult clients include physical therapy, occupational therapy, wound care, home health services, and respite care.

A nursing is preparing to administer ibuprofen to a post-partum client. What assessments should the nurse complete prior to administering this medication? ​

- Contraindications such as allergies, anticoagulant usage, evidence of GI bleeding and other bleeding disorders. The nurse should also assess pain level and location.

A nurse is caring for a client with a spinal cord injury. What are possible causes of autonomic dysreflexia that the nurse should monitor for?

- Distended bladder is the most common cause (kinked or blocked urinary catheter, urinary retention, or urinary calculi) - Fecal impaction - Cold stress or drafts on lower part of the body - Tight clothing - Undiagnosed injury or illness (kidney infection or stone, lower extremity fracture)

A nurse is completeing discharge teaching for a client receiving disulfiram as a deterrent to drinking. What information will the nurse provide to the client regarding how it works and precautions to take?

- Disulfiram works by producing symptoms referred to as a disulfiram-alcohol reaction. These symptoms persist as long as alcohol is being metabolized. Disulfiram should not be administered until it has been ascertained that the client has abstained from alcohol for at least 12 hours. It is important that if Disulfiram is discontinued that sensitivity to alcohol may last for as long as 2 weeks. And consuming alcohol or alcohol-containing substances during this 2 week period could result in the disulfiram reaction. - Symptoms of disulfiram-alcohol reaction can occur within 5-10 minutes of ingestion of alcohol. Mild reactions can occur at blood alcohol levels as low as 5-10 mg/dL. Symptoms are fully developed at approximately 50 mg/dL, and may include Flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, sweating, hyperventilation, tachycardia, hypotension, weakness, blurred vision, and confusion. - Severe reactions can occur at blood alcohol levels of approximately 125 to 150 mg/dL including respiratory depression, cardiovascular collapse, arrhythmias, myocardial infarction, acute congestive heart failure, unconsciousness, convulsions and death.

The nurse assesses a client's cortisol level who has Cushing's disease. What is the expected finding the nurse should expect?

- Elevated plasma cortisol levels in the absence of acute illness or stress indicate Cushing's disease/syndrome. - Urine (24-hr urine collection) contains elevated levels of free cortisol.

Motor Vehicle Injury Education

- Encourage attendance at drivers' education courses. - Emphasize seat belt use. - Discourage use of cell phones, including texting, while driving. - Teach the dangers of combining substance use with driving.

During the admission assessment a client informs the nurse that they utilize essential oils and acupuncture as part of their health routine. What is the nurse's responsibility regarding this information?

- Ensure client practices are documented. Ensure medications and treatments are evaluated for potential interactions. Partner with client to develop the plan of care. - The nurse's role is to ensure that care is provided with continuity over time and across disciplines.

A nurse is caring for a client who is prescribed digoxin. What is the therapeutic digoxin level range? What are three (3) manifestations of digoxin toxicity?

- Therapeutic serum levels may vary, but usually range from 0.5 to 2 ng/ml. - Manifestations of digoxin toxicity include fatigue, weakness, vision changes, and GI effects.

​​A nurse has provided education to a client who has a new prescription for exenatide. What statements by the client would indicate they understand the instructions?

- Exenatide injection should be given within 60 min before the morning and evening meal. Never administer after a meal - keep the injection pen in the refrigerator and to discard after 30 days - the client will notify the provider if nausea, vomiting and diarrhea becomes intolerable - the client will notify the provider for severe and intolerable abdominal pain which can indicate pancreatitis.

​Give an example of how a nurse exhibits fidelity in client care.

- Fidelity is loyalty and faithfulness to the client and to one's duty as a nurse. Example: A client asks a nurse to be present when they talk to their guardian for the first time in a year. The nurse remains with the client during this interaction.

The client with Klebsiella in the urine is ordered the medication ciprofloxacin. Identify three (3) complications associated with this medication the client can develop with administration of this medication.

- GI discomfort - Achilles tendon rupture (assessment is critical) - Suprainfection - Phototoxicity

The nurse is caring for a client taking spironolactone. Identify the adverse effects of spironolactone and what findings should be reported to the provider.

- Hyperkalemia - Endocrine effects (impotence in males, irregular menstrual cycles in females) - drowsiness - metabolic acidosis. Client teaching to avoid these adverse effects: The use of ACE inhibitors increases the risk of hyperkalemia. Teach clients to avoid potassium containing salt substitutes

A nurse is caring for a client with hyperemesis gravidarum. What is the purpose of each of the following medications ordered for this client?

- IV Lactated Ringers will be given for hydration. - Pyridoxine (vitamin B6) should be given as tolerated and may also be given with doxylamine. - Ondansetron is an antiemetic and will be given cautiously for uncontrollable nausea and vomiting.​

Sexually Transmitted Infections (STIs) Education

- Identify risk factors through the assessment and interview process. - Provide education about prevention of STIs, and resources for treatment.

​A nurse is administering vancomycin to a client who develops an infusion reaction sometimes referred to as red man syndrome. What action by the nurse could have prevented this reaction?

- Infusion reactions (rashes, flushing, tachycardia, and hypotension, sometimes called "red man syndrome") is an adverse effect of vancomycin administration that could be prevented by administering vancomycin slowly over 60 min. - Typically, if the patient begins to flush, the nurse can decrease the rate and it should correct the problem.

A nurse is providing teaching to a client who has peptic ulcer disease. What information should the nurse include about diet and other measures to help manage this condition?

- Instruct clients to avoid foods that cause distress (coffee, tea, carbonated beverages). - Take medications as prescribed. - Decrease environmental stress. - Encourage adequate rest. - Encourage smoking cessation. - Avoid alcohol consumption.

The nurse is providing education to a client with phenylketonuria (PKU) who is planning her pregnancy. What foods should the nurse teach the client to consume?

- It is important for the client to resume the diet for at least 3 months prior to pregnancy and continue the diet throughout pregnancy. - The diet includes foods that are low in phenylalanine. Foods high in protein (fish, poultry, meat, eggs, nuts, dairy products) must be avoided due to high phenylalanine levels. Aspartame, which contains phenylalanine, should be avoided by pregnant clients who have this. The diet consists of: Fruit and vegetables, Low protein foods- e.g. low protein flour, bread, pasta and rice, Small amounts of cereal based foods- e.g. breakfast cereals, crackers and biscuits, shakes, powders designed for clients and fats like olive oil, butter, margarine, coconut oil, and sugar.

What points would the nurse discuss when teaching cane walking to a client for the first time?​

- Maintain two points of support on the ground at all times.· - Keep the cane on the stronger side of the body.· - Support body weight on both legs.· - Move the cane forward 15 cm (6-10 inches).· - Then move the weaker leg forward toward the cane.· - Next advance the stronger leg past the cane.

A couple is being evaluated for infertility after attempting to conceive naturally for 2 years. What are three (3) risk factors for males and three (3) risk factors for females that can affect fertility?​

- Males: Mumps infection, especially after adolescence, Substance abuse, Occupational exposure to teratogenic materials. History of sexually transmitted infections. - Females: Increased age (over 35), previous uterine or abdominal surgery that may have cause scar tissue formation, hormonal or adrenal disorders, exposure to teratogenic materials, being overweight or underweight, substance abuse, history of sexually transmitted infections or pelvic inflammatory disease.

​The nurse is caring for a school-aged child with a terminal illness. Name three (3) manifestations a child may experience who is nearing death.

- Manifestations of death are sensation of heat when the body feels cool, decreased sensation and movement of lower extremity, loss of senses (hearing last), Confusion or loss of consciousness, decrease appetite and thirst, swallowing difficulties, loss of bowel and bladder control, bradycardia, hypotension, Cheyne-stokes respirations, pooling pulmonary and pharyngeal secretions can case the "death rattle."

Substance Use Education

- Monitor at‑risk adolescents. - Teach adolescents about the dangers of smoking - Teach adolescents to say ""no"" to drugs and alcohol. - Present a no‑tolerance attitude.

A nurse is providing teaching to a school-age client with diabetes mellitus and her parents about sick-day guidelines to use when ill. Identify two (2) teaching points the nurse may share.

- Monitor blood glucose and urinary ketone levels every 3 hr. - Continue to take insulin or oral antidiabetic agents. - Encourage sugar-free, noncaffeinated liquids to prevent dehydration. - Meet carbohydrate needs by eating soft foods if possible. If not, consume liquids that are equal to the usual carbohydrate content. - Rest. - Call the provider for the following: blood glucose greater than 240 mg/dL, positive ketones in the urine, disorientation or confusion occurs, Rapid breathing is experienced, vomiting occurs more than once, or liquids cannot be tolerated

​A nurse has an order to administer mannitol to a critical care client. What should the nurse expect following mannitol administration?

- Osmotic diuretics reduce intracranial pressure and intraocular pressure by raising serum osmolality and drawing fluid back into the vascular and extravascular space. Depending on therapeutic intent, effectiveness may be evidenced by normal renal function (at least 30 mL/hr), decreased intracranial pressure, and decreased intraocular pressure. In addition, serum creatinine between 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women and BUN levels between 10 to 20 mg/dL.

​A nurse is providing community education regarding risk factors for ovarian cancer. Identify five (5) risk factors associated with the development of ovarian cancer.

- Over 40 years of age - Nulliparity or first pregnancy after 30 years of age - Family history of ovarian, breast, or colon cancer - History of dysmenorrhea or heavy bleeding - Endometriosis - High-fat diet (possible risk) - Hormone replacement therapy - Use of infertility medications - Older adult clients following surgery for cancer

Papule

- Palpable, circumscribed , < 0.5 cm. - Example: Elevated nevus

Nodule/Tumor

- Palpable, circumscribed, 0.5 cm or >. - Example: Wart

Wheal

- Palpable, irregular borders, edematous. - Example: Insect bite

A client has been prescribed misoprostol for the treatment of peptic ulcer disease. What is a true contraindication for this medication?

- Pregnancy, misoprostol is pregnancy risk category X. - Misoprostol is a category X medication

The nurse is assessing paternal adaptation and bonding with a newborn infant. What are three (3) ways the nurse can facilitate bonding between the newborn and father?​

- Provide education about infant care when the father is present and encourage the father to take a hands-on approach. - Encourage skin to skin contact with the newborn infant. - Assist the father in providing guidance and involving him in infant care. - Encourage both parents to verbalize concerns and expectations regarding infant care.

Pregnancy Prevention

- Provide education. - For pregnant adolescents, provide resources for supervision of pregnancy, nutrition, and psychological support.

​The nurse is developing a teaching plan for the upcoming discharge of a child who has a resolving sickle cell crisis. While developing the plan the nurse knows it is imperative to include what information?

- Provide emotional support, and refer to social services if appropriate. - Instruct in signs and symptoms of crisis and infection. - Advise the family of the importance of promoting rest and adequate nutrition for the child. - Encourage the child and family to maintain good hand hygiene and avoid individuals with colds/infection/viruses. - Give specific directions regarding fluid intake requirements, such as how many bottles or glasses of fluid should be consumed daily. - Provide information about genetic counseling. - Encourage maintenance of up-to-date immunizations. - Advise the child to wear a medical identification wristband or medical identification tags.

What teaching points should the nurse provide to the postpartum client regarding mastitis?

- Provide the client with education regarding breast hygiene to prevent mastitis. - Instruct the client to thoroughly wash her hands prior to breastfeeding. - Instruct the client to maintain cleanliness of her breasts with frequent changes of breast pads. - Tell the client to allow her nipples to air-dry. - Teach the client about proper infant positioning and latching-on techniques, including both the nipple and the areola. - The mother should release the infant's grasp on the nipple prior to removing the infant from the breast. - Instruct the client about how to completely empty her breasts during each feeding for prevention of milk stasis, which provides a medium for bacterial growth. - Encourage the client to use ice packs or warm packs on her affected breasts for discomfort. - Instruct the client to continue breastfeeding frequently (at least every 2 to 4 hr), especially on the affected side. - Instruct the client to manually express breast milk or use a breast pump if breastfeeding is too painful. - Instruct the client to begin breastfeeding from the unaffected breast first to initiate the letdown reflex in the affected breast that is distended or tender. - Encourage rest, analgesics, and a fluid intake of at least 3,000 mL per day. - Encourage the client to wear a well-fitting bra for support. - Tell the client to report redness and fever. - Administer antibiotics and teach the client the importance of completing the entire course of antibiotics as prescribed.

Pustule

- Pus-filled. - Example: Acne

​The nurse takes a telephone order for morphine 50 mg IVP every 3 hours. After hanging up the phone, the nurse feels this order is not safe. List three (3) strategies to prevent errors of miscommunication when receiving telephone orders.

- Repeat back the prescription given, making sure to include the medication name (spell if necessary), dosage, time, and route. - Use phonetic spelling to ensure comprehension is clear. - Take orders in a quiet non-distracted environment include all necessary elements of a prescription: date and time prescription was written; new client care prescription or medication including dosage, frequency, route of administration; and signature of nurse transcribing the prescription as well as the provider who verbally gave the prescription. - Follow institutional policy with regard to the time frame within which the provider must sign the prescription (usually within 24 hr). - Question any prescription that seems contraindicated due to a previous or concurrent prescription or client condition - Call prescriber back if order is still unclear after phone conversation has ended. - Also, make sure you follow the facilities policy.

A client has been diagnosed with tuberculosis and has been prescribed rifampin. What should the nurse include in teaching about this medication?

- Rifampin and other antituberculin medications must be taken for 6-12 months. - Rifampin can cause hepatotoxicity. - Client should report swelling of joints, loss of appetite, jaundice, or malaise. - Rifampin can also turn the urine orange and can interfere with the efficacy of oral contraceptives.

​List three (3) seizure precautions to implement for a client who is at risk due to substance use.

- Seizure precautions include padding the side rails, having IV access, O2 and suction equipment available at the bedside.

Vesicle

- Serous fluid-filled, < 1 cm. - Example: Blister

​A nurse is caring for a 4-year-old client with a closed head injury. What clinical manifestations would suggest deterioration in this client's condition?

- Signs of increased intracranial pressure - Retinal hemorrhage - Papilledema - Alterations in pupil size and reactivity - Extraocular palsies (especially cranial nerve VI) - Hemiparesis or quadriplegia - Elevated temperature - Unsteady gait - Bradycardia - Altered level of consciousness - Coma - Cheyne-stokes respirations

What manifestations should the nurse expect?

- Signs of respiratory distress (tachypnea, tachycardia, hypoxia, cyanosis, dyspnea, and use of accessory muscles) - Tracheal deviation to the unaffected side (tension pneumothorax)Reduced or absent breath sounds on the affected side - Asymmetrical chest wall movement

The nurse enters the room of a client that insists that they need to smoke a cigarette immediately. Explain how the nurse can use the technique of collaboration to resolve this conflict.

- Strategy: Collaborating - Both parties set aside their original individual goals work together to achieve a new common goal. Requires mutual respect, positive communication, and shared decision‑making between parties. This is a win‑win solution.

Burns Education

- Teach fire safety. - Promote sunscreen use.

Drowning Education

- Teach swimming skills and safety.

An older adult client is suspected to abuse alcohol. What questions can the nurse ask using the CAGE questionnaire?

- The CAGE questionnaire is popular for screening in the primary care setting because it is short, simple, easy to remember, and because it has been proven effective for detecting a range of alcohol problems - C Have you ever felt you should cut down on your drinking? - A Have people annoyed you by criticizing your drinking? - G Have you ever felt bad or guilty about your drinking? - E Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? - A nurse using the CAGE screening questionnaire can identify alcohol problems over the lifetime. Two positive responses are considered a positive test and indicate further assessment is warranted.

Functional Incontinence

- The inability to get to the bathroom to urinate due to physical, cognitive, or social impairment.

Stress Incontinence

- The loss of small amounts of urine when laughing, sneezing, or lifting primarily due to weak pelvic muscles, urethra, or surrounding tissues.

The nurse is caring for a client in the transition stage of labor. What are common maternal characteristics the nurse might observe in this client?​

- The nurse might observe the client feeling tired, restless and irritable. Clients often feel out of control and feelings of being unable to continue. The client may experience nausea/vomiting. The client may feel the urge to push, an increase in rectal fullness or the need to have a bowel movement.

The nurse is caring for a client with epidural anesthesia in place. What are two (2) adverse effects of this type of analgesia the nurse should monitor for? ​

- The nurse should monitor for nausea and vomiting associated with decrease gastric emptying, bradycardia or tachycardia, hypotension, respiratory depression, allergic reaction/pruritic, inhibition of bowel and bladder elimination sensations, elevated temperature.

​A pregnant client is admitted to the unit for preeclampsia. What lab values would be of concern to the nurse to report to the provider?

- The nurse will report these lab values to the health care provider: - Elevated liver enzymes (LDH, AST), - Increased creatinine, - Increased plasma uric acid, - Thrombocytopenia, - Hgb (increased in preeclampsia), - Hyperbilirubinemia

A nurse is reviewing complications of pregnancy with a client who is 31-weeks pregnant. Identify three (3) complications to discuss with the client that should be reported.

- The pregnant client should report these to the health care provider immediately as they may indicate a potentially dangerous situation: Gush of fluid from the vagina prior to 37 weeks of gestation, vaginal bleeding, abdominal pain, changes in fetal activity such as decreased fetal movement, persistent vomiting, severe headache. elevated temperature, dysuria, blurred vision, edema of face and hands, epigastric pain, concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, increased thirst and urination, and headache, and concurrent occurrence of clammy pale skin, weakness, tremors, irritability, and lightheadedness

A mother delivered a large for gestational age newborn 15 minutes ago and the perineal pad is fully saturated. The fundus is midline, at the level of the umbilicus, and boggy. What would be the priority nursing action?

- The priority nursing action would be to massage the fundus to increase muscle contraction.

A committee of nurses have been tasked with reviewing an increase in central line infections on their unit. Explain the process that they should follow.​

- The quality improvement process begins with identification of standards and outcome indicators based on evidence. Outcome (clinical) indicators reflect desired client outcomes related to the standard under review. Structure indicators reflect the setting in which care is provided and the available human and material resources. Process indicators reflect how client care is provided and are established by policies and procedures (clinical practice guidelines). Benchmarks are goals that are set to determine at what level the outcome indicators should be met.

What client teaching will the nurse provide prior to electroconvulsive therapy (ECT) regarding the steps of the procedure?

- The typical course of ECT treatment is two to three times a week for a total of six to twelve treatments. - The provider obtains informed consent. - Thirty minutes prior to the beginning of the procedure, an IM injection of atropine sulfate or glycopyrrolate is administered to decrease secretions and possibility of bradycardia. - At the time of the procedure, an anesthesia provider administers a short-acting anesthetic. A muscle relaxant is then administered to paralyze the client's muscles during the seizure activity, which decreases the risk for injury. - The nurse monitors vital signs and mental status before and after the ECT procedure. - Electrodes are applied to the scalp for electroencephalogram (EEG) monitoring. - The client receives 100% oxygen during and after ECT until the return of spontaneous respirations. - Clients are expected to become alert about 15 minutes following ECT.

Total Incontinence

- The unpredictable, involuntary loss of urine that does not generally respond to treatment.

List two (2) examples of a primary skin lesion including description and example of each. Provide an example of appropriate documentation of the integumentary system.

1. Macule 2. Papule 3. Nodule/tumor 4. Vesicle 5. Pustule 6. Wheal - EXAMPLE: Skin is pink, warm, and dry. Turgor is brisk and skin is elastic. Rough, thickened skin over heels, elbows, and knees; otherwise, skin is smooth. A 0.5 cm brown papule on right forearm and a 2.5 cm scar on left knee that is healed. Capillary refill is < 3 seconds. No edema is noted.

A client has been prescribed oxybutynin for treatment of overactive bladder and has been experiencing anticholinergic side effects. List two (2) actions the client will take to prevent adverse effects of the medication therapy.

Adverse Effects of oxybutynin: - Constipation - dry mouth - blurred vision - photophobia - dry eyes - CNS effects (hallucinations, confusion, insomnia and nervousness) Client Actions: - Increase dietary fiber - Consume 2 to 3 L/day of fluid from beverage - Avoid hazardous activities if my vision is impaired

Provide 2 examples of gross motor skills and 2 examples of fine motor skill development for a 15-month-old.

Gross Motor Skills: - Walks without help. - Creeps up stairs. - Assumes standing position Fine Motor Skills: - Uses cup well. - Builds tower of two blocks.

​The nurse has received a total bilirubin laboratory report of 7mg/dl on a newborn who is 24 hours old. What action, if any should the nurse take?

Report the total bilirubin level of 7mg/dl to the provider.Normal bilirubin levels include the following: - 24 hr: 2 to 6mg/dl - 48 hr: 6 to 7 mg/dl - 3 to 5 days: 4 to 6 mg/dl MUST NOTIFY THE PROVIDER

A client is receiving home oxygen. What teaching points should the nurse provide the client and the caregiver regarding home oxygen safety?

Since oxygen is combustible, the following nursing actions are important for the nurse to implement: - Post ""No Smoking"" or ""Oxygen in Use"" signs to alert others of the fire hazard. - Know where to find the closest fire extinguisher. - Educate about the fire hazard of smoking with oxygen use. - Have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity. - Ensure that all electric devices (razors, hearing aids, radios) are working well. - Make sure all electric machinery (monitors, suction machines) is grounded. - Do not use volatile, flammable materials (alcohol, acetone) near clients receiving oxygen

According to Piaget, what is the cognitive developmental stage for infants? What are three (3) important tasks accomplished in this stage?

The Piaget cognitive stage is sensorimotor. Infants progress from reflexive to simple repetitive to imitative activities: - Separation, object permanence, and mental representation are the three important tasks accomplished in this stage. - Separation: Infants learn to separate themselves from other objects in the environment. - Object permanence: The process by which infants learn that an object still exists when it is out of view. This occurs at approximately 9 to 10 months of age. - Mental representation: The ability to recognize and use symbols.