Hesi Notebook

Antacids:

Allow 1 hour between antacid administration and the administration of other medications to minimize interactions with other medications.

A nurse preparing to assist with data collection of an adult client is reading the client's medical record. The nurse sees that the health care provider noted resonance on percussion of the client's posterior chest. What interpretation does the nurse make of this finding?

Resonance on percussion predominates in healthy adult lung tissue. Hyperresonance is noted when too much air is present, such as in emphysema or pneumothorax. A dull note on percussion indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or in the presence of a tumor.

Rhonchi

Rhonchi are coarse rattling or snoring sound caused by secretions in the bronchial airways.

Scoliosis

Scoliosis—lateral curvature of thoracic and lumbar segments of the spine, usually with some rotation of the vertebral bodies involved—is most apparent during the preadolescent growth spurt. Screening should begin at age 10 to 12. Asymmetry on the forward-bend test suggests scoliosis.

Secondary Prevention

Secondary prevention: clients who have health problems, screening and treatment of the disease at an early stage, to limit disability (e.g., Pap smears, mammograms, testicular self-exams).

The nurse teaches the client how to perform a breast self-examination (BSE). Which action should the nurse take to determine that she understands how to perform a BSE?

To best determine client's learning and understanding of how to perform a procedure, the nurse would ask the client to perform the procedure and observe the client's performance. Verbalizing how to perform the examination, reading pamphlets, and viewing computer instructions do not ensure that the client knows how to perform a BSE.

West Nile virus

West Nile virus is associated with mosquito bites

Objective Data

What the nurse observes by inspecting, palpating, percussing, and auscultating during the physical examination; also includes data from the client's health record and the results of laboratory and diagnostic studies

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis?

With diabetic ketoacidosis serum lipid levels are high because of the increased breakdown of fat. Serum lipid levels can go so high that the serum appears opalescent and creamy. With diabetic ketoacidosis the hematocrit level is increased because of dehydration. Calcium level is unrelated to diabetic ketoacidosis.

A new father tells a nurse that his sister and her family plan to visit the new baby and that his niece and nephew have just recovered from chickenpox (varicella). Their lesions are completely healed or have scabs and are no longer draining. He asks the nurse whether it is safe for them to be near the baby. What is the best response by the nurse?

"The most contagious time is before the spots appear. It'll be safe to visit.". Chickenpox (varicella) is an infectious respiratory disease spread by droplets; the contagious period occurs 1 day before the lesions appear and for 6 days after the first crop of vesicles have crusts. Chickenpox is spread primarily in respiratory droplets, not from the lesions.

A client is undergoing high-dose warfarin sodium (Coumadin) therapy. The nurse checks the client's lab results and sees that the INR is 3.5. Which determination should the nurse make on the basis of this result?

INR should be maintained at 2.0 to 3.0 in a client undergoing standard warfarin sodium (Coumadin) therapy and 3.0 to 4.5 in a client undergoing high-dose therapy. A value of 3.5 is therefore expected.

Air Embolism

If an air embolism is suspected, place the client in a left side-lying position, with the head lower than the feet (to trap air in right side of the heart); administer oxygen as prescribed; and notify the health care provider.

The Physical Assessment

Inspection Palpation Percussion Auscultation

Abdominal Assessment

Inspection Auscultation Percussion Palpation

Insulin:

Insulin lowers glucose level. Administer insulin at 45- to 90-degree and 45- to 60-degree in a thin person. Regular insulin is the only type of insulin that may be administered by IV.

Platelets range

Normal value for platelets range from 150,000 to 400,000 cells/mm3. High altitudes, long periods of cold weather, and exercise all increase the platelet count. Bleeding precautions should be instituted in the client with a low platelet count.

Palpate

Palpate the apical pulse at the fourth or fifth interspace or medial to the midclavicular line (not palpable in obese clients or clients with thick chest walls).

The nurse present with the health care provider examines Sara's breasts and informs Sara that she felt no masses. The nurse also teaches Sara about breast self-examination and tells her that, according to the American Cancer Society's (ACS's) recommendations for early detection of cancer, Sara should take which action?

According to the ACS, yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. Clinical breast exams (CBEs) are recommended about every 3 years for women in their 20s and 30s and every year for women aged 40 and older. Breast self-exams (BSEs) should be performed monthly (starting at age 20 is an option), and women should know how their breasts normally look and feel and promptly report any changes to a health care provider. The ACS also recommends that some women be screened with the use of magnetic resonance imaging (MRI) in addition to mammography, because of their family history, a genetic tendency, or certain other factors.

Primary prevention

Activities are designed to prevent disease or dysfunction and include health-education programs and wellness activities that maintain or improve health: immunizations, exercise programs. Examples of primary prevention include smoking cessation, preserving good nutritional status, physical fitness, immunization, improving roads, or fluoridation of the water supply as a way to prevent dental caries.

Low Hematocrit

Activity intolerance related to loss of red blood cells. The nurse should carefully assess the patient with a low hematocrit for ability to tolerate physical activity. When the hematocrit is under 30%, the patient's pulse may be rapid with no activity. The nurse should assess the extent of the patient's weakness and fatigue on exertion when planning physical care activities. For example, the patient may have a bath followed by a rest period before ambulating.

Presbycusis:

Agee-related hearing loss. Causes include exposure to loud noise and some medications. Symptoms include a loss of ability to hear high-pitched sounds.

Abdomen Assessment Percussion

All four quadrants are percussed lightly. Next, the borders of the liver and spleen are percussed. Tympany should predominate over the abdomen, and dullness should be felt over the liver and spleen. Percussion over the kidney at the 12th ribs (costovertebral angle) should produce no pain.

Cervical and Uterine Cancer

All women should begin cervical cancer screening 3 years after they begin having vaginal intercourse and no later than 21 years old; screening should be done every year with the regular Pap test or every 2 years with the newer liquid-based Pap test.

A client with breast cancer who has undergone a mastectomy will be receiving chemotherapy. The oncologist prescribes allopurinol (Zyloprim), 100 mg orally daily, to be started before the initiation of chemotherapy. What reason does the nurse give the client for this medication?

Allopurinol is used to reduce the blood level of uric acid. The level of uric acid increases as a result of the breakdown of DNA that occurs after chemotherapy-induced cell death. Allopurinol should be administered before the start of chemotherapy.

What is an Alpha-fetoprotein (AFP) Test?

An AFP blood test is used to check a developing fetus for risk of birth defects, such as neural tube defects or Down syndrome. Correct interpretation of the concentration of AFP requires precise knowledge of gestational age. High levels after 15 weeks' gestation can indicate a neural tube defect such as spina bifida or anencephaly.

Androgens:

Androgens can cause bleeding (if the client is taking an oral anticoagulant), hepatotoxicity, and a reduced serum glucose level, thereby reducing insulin requirements in the client with diabetes mellitus.

Abdomen Assessment

Auscultation is performed before percussion and palpation, which may increase peristalsis. Hold the stethoscope lightly against the skin, and listen for bowel sounds in all four quadrants; begin in the right lower quadrant (RLQ) because bowel sounds are normally heard here. Note the character and frequency of normal bowel sounds: high-pitched gurgling sounds occurring irregularly 5 to 30 times a minute. Identify sounds as normal, hypoactive, or hyperactive (borborygmus). Auscultate for 5 minutes before concluding that sounds are absent. Auscultate over the aorta, renal arteries, iliac arteries, and femoral arteries for vascular sounds or bruits.

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client?

Because atelectasis involves collapsing of alveoli, breath sounds are diminished in the lower lobes. The client will have rapid, shallow respirations to compensate for poor gas exchange. Atelectasis results in an elevated temperature and productive cough.

Oral prednisone, 10 mg/day, has been prescribed for a hospitalized client with a history of type 1 diabetes mellitus for the treatment of an acute exacerbation of asthma. The nurse should monitor the client closely for which concern?

Because of their effect on glucose production and utilization, glucocorticoids can increase the plasma glucose level, causing hyperglycemia and glycosuria. Clients with diabetes mellitus may need to increase the dosage of insulin or oral hypoglycemic medications during treatment with a glucocorticoid.

Decreased Platelet count. Teaching patients how to decrease their risk for bleeding:

Before obtaining any prescription or over-the-counter drug, inform the pharmacist about a low platelet count. Avoid contact sport or strenuous exercise that can cause injury. Use a soft bristle toothbrush. Check with the doctor before having any dental procedure. If a cut occurs, clean the area and apply firm pressure for five minutes. Prevent constipation by increasing dietary fiber and consuming adequate fluids; a stool softener may be needed. Avoid rectal suppositories or enemas for constipation and do not use a rectal thermometer. Do not take medications containing aspirin. Use an electric razor rather when the platelet count is low. Use of needles and invasive procedures should be minimized.

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Blood sugar level of 600 mg/dL. Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, is a serious condition mostly seen in older persons. HHNS can happen to people with type 1 or type 2 diabetes that is not being controlled, but it occurs more often in people with type 2. It's often triggered by illness or infection. As a result of diabetic hyperosmolar syndrome, the body tries to rid itself of the excess blood sugar by passing it in urine. Left untreated, it can lead to life-threatening dehydration. If HHNS continues, the severe dehydration will lead to seizures, coma and eventually death.

The nurse talks to the 25 yr old female about breast self-examination (BSE). The nurse should reinforce instructions that a BSE is best performed at which time?

Breast self-examination (BSE) should be performed monthly at a regular time when the breasts are not tender. In premenopausal women, the best time is 7 days after the start of menstruation. At this time, hormonal stimulation of the breasts is at its lowest point. Postmenopausal clients and clients who have undergone hysterectomy should select a specific day of the month and perform a BSE each month on that day.

Bronchodilators:

Bronchodilators are contraindicated in individuals with peptic ulcer disease, severe cardiac disease or cardiac dysrhythmias, hyperthyroidism, and uncontrolled seizure disorders. The nurse must monitor the client closely for adverse effects (e.g., restlessness, tremors, palpitations and tachycardia, dysrhythmias, anorexia, nausea, and vomiting); if effects occur, the medication is stopped, and the health care provider is notified. Instruct the client to avoid products, such as coffee, tea, cola, and chocolate, that contain caffeine. Instruct the client with diabetes to monitor the blood glucose level, because bronchodilators can increase glucose levels.

A nurse is gathering subjective data from an adult client about the client's daily food intake. Which question should the nurse ask the client first?

Can you tell me what you ate and drank over the past 24 hours?" The first question the nurse should ask the client would provide data about the client's typical daily intake. Once this has been determined, the nurse would collect data regarding who shops and prepares the food and whether the client has adequate income to purchase healthy food. The nurse might ask the client about MyPlate before teaching the client about healthy eating habits; however, the nurse would use it as a guide for teaching nutrition, regardless of whether the client has heard of it.

Guidelines for Administering Parenteral Nutrition (PN)

Check the components of the solution against the health care provider's prescription. The solution should be refrigerated and administered within 24 hours from the time it was prepared. Remove the solution from the refrigerator 30 minutes to 1 hour before use. PN must be administered through tubing with the use of an in-line filter to trap crystals in the solution

Clinical Breast Exam

Clinical breast examinations (done by the health care provider) about every 3 years are recommended for women in their 20s and 30s. Women over age 40 should have one each year.

A client is admitted for acute renal failure secondary to diabetes and hypertension. Which test should the practical nurse (PN) review to determine the best indicator of adequate glomerular filtration?

Creatinine is a chemical waste product that's produced by muscle metabolism. Healthy kidneys filter creatinine and other waste products from blood. The filtered waste products leave the body in urine. If the kidneys aren't functioning properly, an increased level of creatinine may accumulate in the blood. A serum creatinine test measures the level of creatinine in the blood and provides an estimate of how well the kidneys filter (glomerular filtration rate). For type 1 or 2 diabetes, a creatinine test is done at least once a year. Any illness that may affect the kidneys — such as high blood pressure or diabetes — or medication that may affect the kidneys, the doctor may recommend creatinine tests.

The school health nurse is teaching a group of teachers about promoting the mental health of school-age children. Which action made by the teachers promotes a sense of industry among the children?

During the psychosocial development of school-age children, reinforcement in the form of grades, material rewards, additional privileges, and recognition provides encouragement and stimulation. A sense of accomplishment also involves the ability to cooperate, to compete with others, and to cope effectively with people. When the reward structure is based on evidence of mastery, children who are incapable of developing these skills are also at risk for feelings of inadequacy and inferiority. Comparison with one another can also cause some children to develop negative feelings towards themselves, and result in a sense of inferiority.

Following a major abdominal surgery, a client has a nasogastric tube attached to continuous low suction. The nurse caring for the client postoperatively monitors the client for what signs of hypokalemia

Dysrhythmias is a sign of Hypokalemia. Flattened and inverted T waves, prominent U waves, depressed ST segments, peaked P waves, and prolonged QT intervals. Muscle weakness is a symptom of potassium depletion in skeletal muscles; potassium facilitates the conduction of nerve impulses and muscle activity.

Sed rate, or erythrocyte sedimentation rate (ESR)

ESR is a blood test that can reveal inflammatory activity in the body. The test can detect the presence of inflammation caused by one or more conditions such as infections, tumors or autoimmune diseases; it also help diagnose and monitor specific conditions such as rheumatoid arthritis.

Erythrocyte Sedimentation Rate

ESR is the rate at which erythrocytes settle out of anticoagulated blood in 1 hour. This test is used to detect illnesses associated with acute and chronic infection, inflammation, advanced neoplasm, and tissue necrosis or infarction. Fasting is not necessary before an ESR determination, but a fatty meal may cause plasma alterations.

Hemoglobin functions:

Female: 12.0 - 15.0 g/dL. Male: 13.5 - 16.5 g/dL Hemoglobin (Hbg), an iron containing compound, is the main protein in Red Blood Cells (RBCs). It enables oxygen and carbon dioxide (CO2) to bind to RBCs for transport throughout the body.

A nurse manager is reviewing ethical principles with the nursing staff. Which example does the nurse manager provide to explain the concept of fidelity?

Fidelity is the duty to do what one has promised

Activity Level and Exercise

For an adult, recommend an exercise regimen of 30 minutes a day at least three times a week.

The PN assists an elderly client who has left-sided weakness with ambulation to the bathroom. The client walks with a cane. What is the most effective way for the PN to ensure safe ambulation for the client?

For maximum stability, the handle of the cane should be level with the client's greater trochanter. The cane should be held on the unaffected side, so the cane and the weaker leg can work together with each step. The PN should stand on the client's affected side, so the PN can be ready to support the weaker side if needed. The client should hold the cane 4 to 6 inches from the foot for maximum stability.

Glucagon

Glucagon increases blood glucose and is used to treat hypoglycemia in the client who is semiconscious or unconscious and unable to ingest liquids; the blood glucose level begins to increase within 5 to 20 minutes of administration.

A 16-year-old adolescent sustains an ankle injury while playing soccer. Crutches and no weight-bearing are prescribed by the practitioner. What must the nurse ensure when adjusting the crutches?

Having the crutches extend to 6 inches from the sides of the feet ensures the maximal base of support. The crutches should be 2 inches below the axillae. The elbows should be flexed, when the client holds the crossbars. Hunched shoulders indicate that the crutches are too short.

Hyperresonance

Hyperresonance is noted when excessive air is present, and a dull note indicates lung density.

Infection at IV site:

If signs of infection appear at the site, the IV line must be removed and restarted at a different site, the tip of the IV catheter is sent to the LAB for culture, and blood specimens for culture are obtained. Change the PN solution every 12 to 24 hours. Change the IV tubing every 24 hours.

Blood tests are performed on a female client who has been complaining of weakness and fatigue. The results indicate a hemoglobin level of 11 g/dL and a hematocrit of 32%. After conferring with the health care provider, which action should the nurse take on the basis of these results?

In a female client, the normal hemoglobin level is 12 to 15 g/dL and the normal hematocrit is 35% to 47%. A hemoglobin level of 11 g/dL and a hematocrit of 32% are lower than normal but not critically low. The client would not require a blood transfusion or IV iron. Instead, the nurse would provide instruction to the client regarding foods that contain iron.

A nurse is assisting with data collection for a client who complains of right upper quadrant pain. Which technique should the nurse use to palpate the abdomen?

In palpation of the abdomen, the nurse starts with light palpation to detect surface characteristics and accustom the client to being touched. The nurse then performs deeper palpation, first asking the client about any tender areas so that these areas may be palpated last. The nurse uses one hand to palpate except when certain organs (e.g., kidneys, uterus, adnexa) are being palpated. The nurse avoids any situation in which deep palpation might cause internal injury or pain.

Irregular pulse:

Irregular pulses should always be checked apically, and should be counted for 1 minute.

A nurse participates in a client care conference with health care providers and a medical resident. The health care provider tells the resident that the client needs an IV infusion of an isotonic solution. Which solution does the nurse expect the medical resident to prescribe?

Isotonic solution (a solution with the same osmolality as body fluids) increases the volume of extracellular fluid volume. One example of such a solution is 0.9% NS.

A nurse assisting with data collection is inspecting the posterior aspect of the client's posture as the client stands. The nurse notes an exaggeration of the posterior curvature of the client's thoracic spine and interprets this finding as which of the following?

Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. Lordosis, or swayback, is an increased lumbar curvature. A lateral spinal curvature is called scoliosis. Loss of height is frequently an early sign of osteoporosis.

Lactulose is prescribed for a client with hepatic encephalopathy. Which of the following parameters should the nurse monitor to evaluate the effectiveness of the medication?

Lactulose is a hyperosmotic laxative and ammonia detoxicant. It can enhance intestinal excretion of ammonia and decrease the blood ammonia level in a client with portal hypertension and hepatic encephalopathy. Diarrhea is an indicator of overdose, not effectiveness. Used correctly, the medication should result in the production of two or three soft stools per day. Electrolyte levels are monitored because of the risk of electrolyte disturbance.

Oral levothyroxine (Synthroid), 137 mcg/day, is prescribed for a client with hypothyroidism. While providing medication instructions to the client, the nurse should tell the client to take the medication in which manner?

Levothyroxine should be taken on an empty stomach to enhance its absorption. It should be taken in the morning, 1 hour before breakfast.

Lipids (Fat Emulsion)

Lipids, or fat emulsion, are administered to prevent or correct fatty acid deficiency. Fat emulsion may be administered into a peripheral vein. Assess the client for allergy to eggs. Examine the bottle for separation of emulsion into layers or fat globules and for the accumulation of froth. If any of these findings is noted, do not use the solution; instead, return it to the pharmacy. Do not use an IV filter to administer a lipid emulsion; particles in the fat emulsion are too large to pass through filters.

Lyme Disease

Lyme disease is associated with tick bites.

The PN is interviewing a male client diagnosed with hypertension. Which finding places the client at the greatest risk for a cerebral vascular accident?

Males with a waist larger than 40 inches and females with a waist larger than 35 inches are at greater risk of cardiac disease increasing the risk of CVA. The more abdominal fat an individual has the more the risk goes up.

A client who is hospitalized after a myocardial infarction asks the nurse why the client is receiving morphine. The nurse replies that morphine:

Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction; it also decreases apprehension and prevents cardiogenic shock

Nonmalefience

Nonmaleficence refers to the obligation to do or cause no harm to another

Oral Hypoglycemic Agents

Oral hypoglycemic agents stimulate the pancreas to produce more insulin and increase the sensitivity of peripheral receptors to insulin, thereby decreasing the serum glucose level. These medications are prescribed for clients with type 2 diabetes mellitus. Hypoglycemia may occur if an excessive dose is administered or if meals are omitted or delayed, food intake is decreased, or activity is increased. Inform the client taking an oral hypoglycemic agent that insulin may be needed during times of stress, surgery, or infection.

The nurse checks the patient's oxygen saturation with the use of a pulse oximeter and obtains a reading of 93%. What does the nurse do first?

Oxygen saturation normally ranges from 95% to 100%. On seeing a reading of 93%, the nurse would initially reposition the sensor probe and reassess the oxygen saturation. If the reading remained at 93% after reassessment, the nurse would encourage the client to take deep breaths and place the client in a semi-Fowler or high Fowler position. If the client's oxygen saturation did not improve after implementation of these measures, the nurse would contact the health care provider and prepare to initiate or adjust the level of delivered oxygen as prescribed.

The PN assesses pain in a client diagnosed with acute pancreatitis. Which symptom would be expected during the assessment?

Pain associated with acute pancreatitis is usually severe and constant and located in the mid-epigastric region, radiating to the back.

Pancreatic Enzymes:

Pancreatic enzyme replacements should be taken with meals and snacks; side effects include abdominal cramps, pain, nausea, and diarrhea.

Respiratory Alkalosis Nursing Consideration

Partial rebreathing mask Monitor the client for signs of respiratory distress. Provide emotional support and reassurance to the client. Encourage an appropriate breathing pattern. Assist the client in using breathing techniques and breathing aids as prescribed, such as voluntary breath-holding, rebreather mask, and CO2 breathing (i.e., rebreathing into a paper bag. Monitor electrolyte values, particularly potassium and calcium. Prepare to administer calcium gluconate as prescribed to help prevent tetany.

Decreased Neutrophil count:

Patients with a neutrophil count of less than 2,000 are at high risk of developing serious infections and those with agranulocytosis (a neutrophil count less than 500) are at a life-threatening risk of developing a fatal sepsis. The nurse should carefully monitor the white blood cell count to watch for downward trends and the patient should be carefully assessed for any signs of infection. Promote oral care. The mouth is a place that can get infected easily, especially if a patient is on antibiotics, which destroys some of the good bacteria there. Prevent ulcers and breakdown. Promote nutrition and ensure food is prepared and stored appropriately.

Elevated RBC Count. Risk for injury related to potential formation of venous thrombi.

Patients with polycythemia has an increased risk of venous thrombosis, as the blood is more viscous. Priority is adequate hydration. Keeping a patient with a high RBC count dehydrated, such as being NPO for an extended time, increases risk of venous thrombosis.

Breast Self Exam

Perform self-examination 7 days after the start of menstruation, when the breasts are least likely to contain hormonally influenced lumps. Clients who have undergone hysterectomy should select a specific day and perform examination on the same day of each month.

A nurse checks the laboratory test results of a client who is undergoing chemotherapy and notes that the client's platelet count is 90,000 cells/mm3. In light of this result, which action by the nurse is appropriate?

Platelets are produced by the bone marrow to function in hemostasis. Normal platelet count ranges from 150,000 to 400,000 cells/mm3. A decrease in the number of platelets puts the client at risk for bleeding. Therefore the nurse would institute bleeding precautions for the client

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the PN that her feet have begun to swell. Which information should the PN provide that will aid in the prevention of pooling of blood in the lower extremities?

Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins and increase venous return.

The nurse plans primary prevention activities for a client. Which measures are primary prevention activities?

Primary prevention activities are those that prevent disease or dysfunction, including health-education programs and wellness activities that maintain or improve health. Examples of primary prevention include smoking cessation, preserving good nutritional status, physical fitness, immunization, or fluoridation of the water to prevent dental caries.

A nurse is performing a focused assessment on a client who had major surgery five days ago. Which data collection finding would be the best indication of a wound infection?

Purulent wound drainage is most indicative of a wound infection. Drainage is typically sero-sanguineous. Although the elevated temperature, pain at the incision site, and uneven wound edges may accompany an infected wound, they aren't as specific as the drainage and could be related to other problems.

Resonance

Resonance is heard in healthy lung tissue

Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol (Stadol). Which phase of labor is the safest time for the nurse to administer this medication?

Respiratory depression of the newborn will not occur if the medication is given during the active phase; it should not be given when birth is expected to occur within 2 hours. The level of pain during the early phase can be managed with breathing techniques or diversion; giving an opioid early in labor may slow the progress of labor. Giving the medication when birth is imminent is contraindicated because it may cause respiratory depression in the newborn; the mother's level of consciousness will be altered as well, making it difficult for her to cooperate with requests to push.

Rh

Rh incompatibility occurs when the Rh-negative mother has an Rh-positive baby. To prevent the sensitization in the mother, Rh immune globulin is administered within 72 hours of the birth.

The practical nurse (PN) is caring for a client who is 2 days postpartum. The client reports that she has a bright red vaginal discharge. What action should the PN take first?

Rubra lochia, which is red, blood-tinged vaginal flow, lasts 2 to 4 days after the birth of the baby.

Tuberculosis Health Screen

Screening programs involving tuberculin skin testing in high-risk groups can detect individuals with tuberculosis, or TB. Individuals at risk include the homeless, residents of inner-city neighborhoods, the foreign-born, older adults, people in institutions such as long-term care facilities and prisons, injecting drug users, the socioeconomically disadvantaged, the medically underserved, the immunosuppressed, and health care workers with exposure to TB.

Minimizing Local Reactions

Select a needle of adequate length (1 inch, for infants) to deposit the vaccine deep into the muscle mass. Inject into the vastus lateralis muscle or the ventrogluteal muscle; the deltoid may be used in children ages 18 months and older. Use an air bubble to clear the needle after injecting the vaccine

What is the nursing priority that the practical nurse (PN) should identify for a client who is admitted for a possible kidney stone?

Straining all urine is the most important nursing action to take. Straining urine will enable the health care provider to determine when the kidney stone has been passed and may prevent surgery.

Tertiary Prevention

Tertiary prevention is focused on rehabilitation to minimize the effects of a long-term disease and to assist clients in achieving the highest possible level of function.

Testicular Self Exam

Testicular self-examination should be performed monthly, on the same day of each month, after a warm bath or shower, and the same technique should be used each time. Also inspect and palpate the penis.

A nurse is teaching a young adult male client about testicular self-examination. Which instruction should the nurse give him?

Testicular self-examination should be performed monthly, starting during puberty. Men are at greatest risk for testicular cancer between ages 18 and 38 years. Men should be taught to hold the scrotum in one hand and examine each testicle and spermatic cord separately by gently rolling the testicle between the thumb and fingers of the other hand. The client is taught to perform the examination on the same day of each month. Examination is performed after a warm bath or shower.

Prostate Cancer

Testing is usually started at age 50. In African American men and men whose father or brother was found to have prostate cancer before age 65, testing may be started at age 45. Testing may include the prostate-specific antigen (PSA) blood test with or without a rectal exam; frequency of testing may depend on the PSA level.

The female client tells the nurse that she has several moles and is worried about skin cancer. She states that her father has had "several skin cancers" removed. Which lesions would need to be examined more closely for skin cancer?

The ABCD guide can be used to assess a skin lesion for characteristics associated with cancer. In this guide, A stands for asymmetry shape, B represents border irregularity, C stands for color variation within one lesion, and D denotes diameter greater than 6 mm. Every suspicious skin lesion should be examined carefully, and a person who has a lesion with one or more of the ABCD characteristics should be evaluated by a surgeon or dermatologist. An overgrowth of skin over a scar is a keloid, which is benign. Skin lesions that are irregularly shaped or have changed in color, elevation, or size may be cancerous or precancerous. A firm, nodular lesion that is covered with a dry or rough scale may be actinic keratosis, which is a premalignant lesion. A firm, movable flesh-colored nodule that contains liquid is a cyst, which is benign.

The nurse helps the health care provider perform a Papanicolaou (Pap) test on a 25 yr female client. After the test has been completed, the nurse provides information to the Clint about follow-up testing. The nurse should explain to the client that the Pap test should be repeated how frequently?

The American Cancer Society (ACS) recommends that all women who are or have been sexually active or who are 18 years of age or older should have an annual Papanicolaou (Pap) test and pelvic examination.

The practical nurse (PN) is reinforcing the information about a Milwaukee brace with an adolescent girl with scoliosis. Which information should the PN reinforce?

The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed for a total of 1 hour a day for hygiene. The brace is put on over a T-shirt to protect the skin. The brace will not cure the spinal curvature but slow the progression of the scoliosis curve.

A nurse is using a Snellen chart to assist with data collection on a client's visual acuity. The client stands 20 feet from the chart, and each eye is tested separately. The client is able to read the line comprising the letters P, E, C, F, and D with each eye. The nurse encourages the client to read the next smallest line with each eye, but the client is unable to do so. How does the nurse document the client's vision?

The Snellen chart is placed in a well-lit spot, and the client stands 20 feet away, with the chart at eye level. Each eye is tested separately (one eye is covered), and the client is asked to read through the chart to the smallest line of letters possible. The client is also encouraged to read the next smallest line. Findings are recorded as a comparison between what the client can read at 20 feet and the distance at which a person with normal vision can read the same line. A reading of 20/40 means that the client is able to see at 20 feet from the chart what a healthy eye can see at 40 feet

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which approach by the practical nurse (PN) is accurate and most likely to alleviate her anxiety?

The anterior fontanel or "large soft spot" has a strong epidermal membrane. The anterior fontanel closes at 12 to 18 months and the posterior closes at 8 to 12 weeks of age.

Which clinical findings support a conclusion of overdose?

The central nervous system (CNS) depressant effect of morphine causes lethargy, bradycardia, bradypnea. Morphine decrease urine output and causes constriction of pupils.

The practical nurse (PN) is caring for a hospitalized client with depression. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by the time of discharge?

The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client REPORTS feeling better and less depressed.

The nurse determines that the client has demonstrated an effective response to PN if she shows which response?

The expected outcome for a client receiving PN is maintenance of ideal body weight or a gain of 1 to 2 lb each week. Weight gain more than 3 lb per week may indicate excessive fluid intake and should be reported to the health care provider.

A nurse is monitoring a client receiving PN for signs of hyperglycemia. Which of the following observations are signs of hyperglycemia?

The high concentration of glucose in PN puts the client at risk for hyperglycemia. Signs of hyperglycemia: excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul respirations, diuresis, and in severe cases, coma.

A client is diagnosed as having kidney failure. During the oliguric phase the nurse should assess the client for:

The kidneys retain potassium & calcium during the oliguric phase of kidney failure; an elevated potassium level is one of the main indicators of the need for dialysis.

A 62-year-old female who lives alone tripped on a rug in her home and fractured her hip at the proximal end of the femur. Which predisposing factor should the practical nurse (PN) identify that most likely contributed to the fracture?

The most common cause of a fractured hip in elderly females is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years.

The nurse teaches the female put about measures to help prevent skin cancer. Which ofthe put statements leads the nurse to conclude that she understands these measures correctly?

The most effective means of preventing skin cancer is reducing exposure of the skin to sunlight. Secondary prevention through early detection is also essential. Avoiding sun exposure between the hours of 11 a.m. and 3 p.m., using sunscreen, and wearing protective clothing are all important measures for preventing sunburn. It is important to be aware of one's skin markings and to examine spots, scars, and lesions, including moles, monthly. Assistance with skin inspection should be obtained as needed. Any changes should be reported to the health care provider right away.

A nurse is monitoring a client with emphysema in whom respiratory acidosis has developed. Which clinical manifestation of this acid-base imbalance would the nurse expect to note?

The normal potassium level is 3.5 to 5.1 mEq/L. In respiratory acidosis, potassium moves out of the cells, producing hyperkalemia. The normal pH is 7.35 to 7.45. In acidosis, the pH decreases and respiratory rate and depth increases. Paresthesias (numbness and tingling of the fingers and toes) occur in alkalosis

Teaching-Learning Principles

The nurse must determine the client's readiness and motivation to learn and the client's learning needs. The nurse must assess the client's existing knowledge of the information to be presented and base teaching on that knowledge. The ability to learn depends on the client's physical and cognitive abilities. The nurse must consider the client's health beliefs and how they will influence the client's willingness to learn. The nurse must consider the client's age, developmental level, and educational level and use teaching strategies based on these factors.

Nurse Practice Act

The nurse practice act and any practice limitations (e.g., agency policies and procedures) define which aspects of care may be assigned to others and which must be performed by the nurse. Even though a task may be assigned to someone else, the nurse who assigns the task maintains accountability for the overall nursing care of the client.

The nurse is caring for a client with a fractured hip. The client becomes combative, confused, and tries to get out of bed. His vital signs and pulse oximetry results are unchanged. The nurse should:

The nurse should notify the nursing supervisor to see if an available staff member can sit with the client. If staffing doesn't allow, the nurse should see if a family member is available to sit with the client. A client should never be left alone while the nurse summons assistance. The nurse should contact the physician to obtain a restraint order when all other measures fail, and the client should be restrained in the least restrictive manner possible.

A nurse has taught a client's wife how to change the client's foot dressing. Which action should the nurse take to best confirm that the spouse understands the procedure?

The nurse would best evaluate the wife's learning by observing the wife's performance of the activity. Although asking the wife whether she has any questions, feels comfortable, or understands the procedure may be appropriate, these questions do not best reveal the wife's ability to perform the dressing change.

Theophylline (the-off-I-Lin)

Theophylline is used to prevent and treat wheezing, shortness of breath, and chest tightness caused by asthma, chronic bronchitis, emphysema, and other lung diseases. It relaxes and opens air passages in the lungs, making it easier to breathe. Monitor the serum theophylline level. (The therapeutic range is 10-20 mcg/mL. A level greater than 20 mcg/mL indicates toxicity; in this case, the medication is stopped, and the health care provider is notified.)

Antineoplastic Medications:

These drugs, which kill or inhibit the reproduction of neoplastic cells through a variety of actions, are used to treat various types of cancer. Normal cells are also affected by these medications, leading to a wide range of side and adverse effects. Generally several medications are used in combination to increase the therapeutic response. Antineoplastic medications cause the rapid destruction of cells, resulting in the release of uric acid; allopurinol (Zyloprim) is prescribed to lower the serum uric acid level. Monitor complete blood cell count (CBC), white blood cell (WBC) count, platelet count, and electrolyte; initiate bleeding precautions if thrombocytopenia occurs or neutropenia precautions if the WBC count falls. These medications stimulate the vomiting center; take precautions against nausea and vomiting. Monitor the client for hyperuricemia and take precautions against it. Discuss the need for contraception (antineoplastic medications have teratogenic effects) and the potential for infertility, which may be irreversible.

Terbutaline sulfate

This drug is use to stop or delay preterm labor. Terbutaline sulfate may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of "nervousness."

A client is diagnosed with acute myocardial infarction (MI). Which diagnostic laboratory value should the PN anticipate to be the first to elevate and establish a diagnosis of an acute myocardial infarction (MI)?

Tissue damage in the myocardium causes the release of cardiac enzymes into the blood system. Elevation of troponin occur within 2 to 3 hours of an MI and is use to establish the diagnosis. It takes the CK-MB level 6 to 9 hours or longer to elevate.

A nurse assisting with data collection of a client is preparing to auscultate for bowel sounds. In which part of the abdomen should the nurse place the stethoscope first?

To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly against the skin and auscultate in the right lower abdominal quadrant. After auscultating the right lower quadrant, the nurse then auscultate the remaining three quadrants.

A nurse is preparing to administer the diphtheria/tetanus/acellular pertussis vaccine (DTaP) to a 6-month-old infant. Which action should the nurse take to minimize the potential for a local reaction to the vaccine?

To minimize the potential for a local reaction to a vaccine, the nurse selects a needle of adequate length (1 inch, for infants) to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastus lateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older), and an air bubble is used to clear the needle after injection of the vaccine. Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction.

Skin traction:

Traction limits movement and reduces the fracture to help decrease pain, spasms and swelling. Maintaining skin integrity and providing back care is difficult when a client is in traction. The PN should never release the traction, either by removing or by suspending the weights.

Isotretinoin (Accutane)

Treats acne, it is highly teratogenic and can cause fetal abnormalities, must not be used if the client is pregnant. Clients who have been prescribed isotretinoin must follow the strict rules of the iPLEDGE Program.

Percussion:

Tympany is present in most of the abdomen caused by air in the gut (a higher pitch than the lungs). Resonance is a lower-pitched and hollow sound (found in normal lungs). Dullness is a flat sound without echoes; the liver, spleen, and fluid in the peritoneum (ascites) give a dull note, but an unusual dullness may be a clue to an underlying abdominal mass.

A nurse is administering the hepatitis B vaccine to a newborn. Which anatomic site should the nurse select for the injection?

Vaccines administered intramuscularly are given in the vastus lateralis muscle in newborns and in the DELTOID for older infants and children. The dorsogluteal area is avoided because the site has been associated with low antibody seroconversion rates, indicating a reduced immune response. Also, it is generally recommended that the dorsogluteal site be avoided until a child has been walking for at least 1 year. The rectus femoris is not an acceptable site for injections.

Subjective Data

What the client says about himself or herself or what a family member or significant other says about the client during history-taking

The nurse performs a respiratory assessment and auscultates breath sounds that are high-pitched, creaking and accentuated on expiration. Which term best describes the findings?

Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and COPD. Wheezes are produced as air flows through narrowed passageways.

A client receiving PN is exhibiting signs of an air embolism. After immediately placing the client's head lower than the feet, the nurse positions the client in which way?

When air embolism is suspected, the client should be placed in a left side-lying position with the head lower than the feet. This position is used to help minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart.

Activated Partial Thromboplastin Time. (1.5 - 2.5 times normal)

aPTT testing is most commonly prescribed to monitor heparin therapy and screen for coagulation disorders. The normal range is 20 to 36 seconds, depending on the type of activator used. If the client is undergoing intermittent heparin therapy, draw the blood sample 1 hour before the next scheduled dose. Do not draw samples from the arm into which heparin is infusing. Transport the specimen to the laboratory immediately. aPTT should be 1.5 to 2.5 times normal when the client is undergoing heparin therapy; if the aPTT is prolonged (longer than 90 seconds), initiate bleeding precautions. Notify the health care provider because, heparin therapy may need to be reduced or discontinued.

What is a STEMI?

A STEMI is a full-blown heart attack caused by the complete blockage of a heart artery. ... STEMI stands for ST elevation myocardial infarction (MI). "ST elevation" refers to a particular pattern on an EKG heart tracing

A 10-year-old child is undergoing radiation therapy for a brain tumor. What should the nurse include in the skin care for this child?

A child undergoing radiation therapy usually has dry, sensitive skin; the nurse should use plain water to remove perspiration and cellular debris on the skin. Oil-based products are contraindicated because they can cause the radiation beam to scatter, resulting in tissue damage and inadequate irradiation of the tumor site. Soap may remove the marks on the skin that provide accurate directions for the radiation therapist; soap is also drying and should be avoided.

A client diagnosed with lymphoma is receiving chemotherapy. The client's hemoglobin is currently 6 g/dL. The PN assigns an UAP to provide hygiene for this client. What instruction should the PN provide to the UAP?

A hemoglobin of 6 g/dL indicates anemia (normal female: 12 to 16 g/dL, male: 14 to 18 g/dL), which is a common adverse effect of chemotherapy. The UAP should be given instructions about how this will cause weakness and unsteadiness in the client and they will tire easily.

A 16-year-old girl arrives at the women's health center and tells the nurse that she thinks she is pregnant. The nurse obtains subjective data from the client and informs her about the laboratory procedures used to test for pregnancy. Which action should the nurse take in obtaining informed consent to treat the client?

A minor is a client under the age of legality (usually 18 years) as defined by state statute. Parental or guardian consent should be obtained before treatment is initiated for a minor except in the case of an emergency, in situations in which the consent of the minor is sufficient (e.g., treatment related to substance abuse or a sexually transmitted infection, testing for HIV and AIDS, birth control services, pregnancy, or psychiatric services, or if a court order or other legal authorization has been obtained)

Prothrombin time (PT)

A prothrombin time test measures how quickly blood clots. A prothrombin time test uses a sample of your blood. Prothrombin is a protein produced by liver. The test is done to: Monitor the effectiveness of a blood-thinning medication. Diagnose liver problems. Assess blood's ability to clot before have surgery.

A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should be reported to the health care provider immediately?

A small amount of yellowish green oozing indicates infection and should be reported immediately. Serosanguineous oozing is expected.

Sun Exposure

A sunscreen with an appropriate sun protection factor (SPF) should be worn. Skin should be protected from the sun's rays with the use of clothing and a hat. Sun exposure should be avoided between the hours of 10 a.m. and 4 p.m., when rays are most powerful and damaging. Indoor tanning (tanning booths and sun lamps) should be avoided. Radiation can cause skin reactions and may have harmful effects on other body processes.

The client tells the nurse that she has never had a mammogram and asks whether she needs one. On the basis of American Cancer Society (ACS) recommendations, the nurse provides the client with which information?

According to ACS recommendations, yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.