Module 9: Monitoring for Health Problems

A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure

flat Rationale: After lumbar puncture, the client must remain flat for as long as 12 hours to help prevent post-procedure spinal headache and leakage of cerebrospinal fluid. Therefore the other options are incorrect.

A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which? Improvement in the client The need for antiretroviral therapy The need to discontinue antiretroviral therapy An effective response to the treatment for HIV

the need for antiretroviral therapy Rationale: The normal CD4+ count is between 500 to 1500 cells per cubic millimeter of blood. Antiretroviral therapy is recommended when the CD4+ count is less than 500 cells per cubic millimeter of blood or below 25%, or when the client shows signs/symptoms of HIV. The other options are incorrect.

A client has made an appt for her annual Pap smear. The nurse who schedules the appt should provide which information to the client

the test cannot be performed while the client is menstruating Rationale: A Pap smear cannot be performed with accurate results during menstruation. The test is usually painless but may be slightly uncomfortable during placement of the speculum or while the cervical scraping is obtained. The client should not douche for at least 24 hours before the test. There is no reason to restrict consumption of spicy foods on the day of the test.

A client is tested for HIV with the use of ELISA and the test result is positive. The nurse should provide which information to the client about the test

the test will need to be confirmed with the use of a Western blot Rationale: The normal value for an ELISA test is negative. A positive ELISA test must be confirmed with the use of the Western Blot. The other options are incorrect.

A client reports for a scheduled EEG. Which statement by the client indicates a need for additional prep for the test

"I didn't shampoo my hair" Rationale: Pre-procedure care for EEG involves client teaching about the procedure, ensuring that the client's hair has been freshly shampooed, and providing a light meal and fluids to prevent hypoglycemia, which could alter brain waves. Medications such as antidepressants, tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure as prescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld.

A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose is therapeutic

16mcg/mL Rationale: The therapeutic serum phenytoin range is 10 to 20 mcg/mL (40 to 79 µmol/L). If the level is below the therapeutic range, the client may continue to experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity.

A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than which value

200mg/dL Rationale: A normal cholesterol value ranges between 140 and 199 mg/dL

A client's baseline VS are temp 98 F, HR 74bpm, resp rate 18/min, and BP 124/76 mmHg. The client suddenly spikes a fever of 103 F. Which resp rate would the nurse anticipate as part of the body's response to the change in client status

22 breaths/min Rationale: Increases in body temperature cause a corresponding increase in respiratory rate because the metabolic needs of the body increase with fever, necessitating more oxygen. The client who has a decrease in body temperature will experience a decrease in respiratory rate.

A client with CVD is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the HCP before administering the dose

3.0 mEq/L Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A result of 3.0 mEq/L (3.0 mmol/L) is low, 3.8 and 4.2 mEq/L (3.8 and 4.2 mmol/L) are normal, and 5.2 mEq/L (5.2 mmol/L) is high. Administering furosemide to a client with a low potassium level and a history of cardiovascular disease could precipitate ventricular dysrhythmias in the client. The normal and high levels do not require withholding of the dose. In fact, the high level may be lowered by administration of the medication, which is a potassium-losing diuretic.

A client admitted to the hospital with a dx of acute pancreatitis has blood drawn for several serum lab tests. Which serum amylase value, noted by the nurse reviewing the results, would be expected in this client at this time

395 units/L Rationale: The normal serum amylase range is 30 to 122 U/L (0.51 to 2.07 μkat/L). In acute pancreatitis, the amylase level is greatly increased; the level starts rising 3 to 6 hours after the onset of pain, peaks at about 24 hours, and returns to normal in 2 to 3 days after the onset of pain. Normal hemoglobin (Hb) level is 14 to 18 g/100 mL in males, and 12 to 16 g/100 mL in females; normal potassium (K+) is 3.5 to 4.5 mEq/L; and normal total calcium (Ca2+) is 8.5 to 10.5 mg/dL.

oxygen by way of NC has been prescribed for a client with emphysema. The nurse checks the HCP's rx to ensure that the prescribed flow is not greater than which liter per min

3L/min Rationale: Because the client with emphysema has long-standing hypercapnia, the respiratory drive is triggered by a low oxygen level rather than by a high carbon dioxide level. Too much oxygen in this client could cause respiratory failure. The client with emphysema usually receives oxygen at a flow rate of 1 to 2 (and no more than 3) L/min.

A nurse is assessing the status of a client with DM. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated HbA1c is less than which value

7% Rationale: An acceptable measure of diabetic control is present if the client's glycosylated HbA1C is 7.0% or less. Specific values may vary slightly, depending on the laboratory and the procedure. The other options indicate poor control of diabetes.

A client w/o a hx of resp disease has a pulse-ox in place after surgery. The nurse monitors the pulse-ox readings to ensure that oxygen saturation remains above which value

95% Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the expected reading is at least 95%. Therefore the other options are incorrect. Readings of 85% and 89% are lower than what is desired in the postoperative period. A level of 100% is most desirable, but the level should remain at least 95%

A nurse is assessing a client who has a closed chest tube drainage system. the nurse notes constant bubbling in the water seal chamber. What actions should the nurse take SATA a) assess the system for an external air leak b) reduce the degree of suction being applied c) clamp the chest tube d) document assessment findings, actions taken and client response e) change the drainage system

Assess the system for an external air leak Document assessment findings, actions taken, and client response Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. If an external air leak is not present and the air leak is a new occurrence, the primary health care provider is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency's policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client's medical record.

The nurse is admitting a client with a diagnosis of renal calculi. What does the nurse know can contribute to the client's diagnosis? Dehydration Foods low in protein Decreased intake of dairy products Low level of parathyroid hormone (PTH)

Dehydration Rationale: The usual quantity and types of fluid a client drinks are important in relation to urinary tract disease. Dehydration may contribute to urinary tract infections (UTIs), calculi formation, and kidney failure. Large intake of particular foods such as dairy products or high-protein, not low-protein, foods may also lead to calculi formation. High levels, not low levels, of PTH can also contribute to renal calculi.

The nurse is caring for a client with a diagnosis of suspected uric acid calculi. The nurse is carefully checking the history of the client. What areas should the nurse focus on? Select all that apply. History of anemia Dietary supplements Previous problems with fluid overload 8.9 mg/dL (529.9 μmol/L) Family history of urinary calculi Prescribed and OTC medications Previous episodes of stone formation

Dietary supplements Family history of urinary calculi Prescribed and OTC medications Previous episodes of stone formation Rationale: A careful history should include any previous episodes of uric acid stone formation, prescribed and OTC medications, dietary supplements, and family history of urinary calculi. A history of anemia and fluid overload are not related to uric acid calculi areas.

A nurse has a rx to apply a Holter monitor to a client for continuous cardiac monitoring for a 24 hour period. What steps should the nurse take to initiate this rx SATA a) giving the client a device holder to wear around the waist b) giving the client in a diary in which to record activity and symptoms c) telling the client to rest as much as possible during the next 24 hours d) telling the client that occasional slight shocks from the monitor will be felt but that they are harmless e) instructi

Giving the client a device holder to wear around the waist Giving the client a diary in which to record activity and signs/symptoms Rationale: The nurse applies electrocardiogram (ECG) monitoring leads to the chest in the usual fashion and gives the client a sling or holder to carry the transistor radio-sized monitor (walkie-talkie), which is worn around the chest or waist. Clients undergoing Holter monitoring are instructed to maintain a normal schedule and to keep a diary of all activity and signs/symptoms. The client is told to avoid activities — such as operating heavy machinery, electric shavers, or hairdryers; bathing; or showering — that could interfere with the ECG recording. The client does not feel any shocks from the device.

A nurse reviews a client's urinalysis report. Which findings does the nurse recognize as abnormal? Select all that apply. pH of 6.0 Glucose noted Casts apparent An absence of protein The presence of ketones Specific gravity of 1.018

Glucose noted Casts apparent The presence of ketones Rationale: The normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from 1.016 to 1.022. The urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, none of which should be present.

A client in the PACU has an as-needed rx for ondansetron. Which occurence would prompt the nurse to administer this med to the client

N&V Rationale: Ondansetron is an antiemetic that is used in the treatment of postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. This medication is not used to treat any of the problems identified in the other options.

A client is receiving intermittent bolus feedings bu way of a NG tube. In which position should the nurse place the client once the feeding is complete

HOB elevated 30-45 degrees Rationale: Aspiration is a complication of nasogastric tube feeding. The head of the bed should be elevated 30 to 45 degrees for 30 to 60 minutes after each bolus tube feeding to help prevent vomiting and aspiration. The right lateral position is also helpful in that gravity facilitates gastric emptying, which also reduces the risk of vomiting. The flat or supine position should be avoided for at least the first 30 minutes after a tube feeding.

A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure

Left Sim's position Rationale: The client is placed in the left Sims' position, which utilizes the client's anatomy to advantage for introducing the colonoscope, for the procedure. The other options are incorrect.

A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care? Restricting fluid intake for the first 24 hours Periodically testing the urine for occult blood Avoiding the administration of opioid analgesics Having the client ambulate in the room and hall for short distances

Periodically testing the urine for occult blood Rationale: After renal biopsy, bed rest is maintained and the client's vital signs and puncture site are assessed frequently. Urine is tested periodically for occult blood to detect bleeding as a complication. Fluids are encouraged to reduce the risk of clot formation at the biopsy site. Opioid analgesics are often needed to manage the renal colic pain that some clients feel after this procedure.

A nurse is reviewing laboratory results for a newly admitted client. Which serum lab result does the nurse document as abnormal? Serum creatinine 0.2 mg/dL (17.6 μmol/L) Prothrombin time 11.0 to 12.5 seconds; 85% to 100% Sodium cholesterol Serum sodium (NA) 136 to 145 mEq/L or 136/145 mmol/L (SI units)

Serum creatinine 0.2 mg/dL (17.6 μmol/L) Rationale: The normal serum creatinine level ranges from 0.6 to 1.3 mg/dL (53-115 μmol/L). A result of 0.2 mg/dL (17.6 μmol/L) represents a low value; the other incorrect options are normal values.

A nurse is watching as a nursing student suctions a client through a trach tube. Which action son the part of the student would prompt the nurse to intervene and demonstrate correct procedure SATA a) assessing breath sounds before suctioning b) placing the client in a supine position before the procedure c) setting the suction pressure to 60 mmHg d) applying suction throughout the procedure e) hyperoxygenating the client with 100% oxygen before suctioning

Setting the suction pressure to 60 mm Hg Applying suction throughout the procedure Placing the client in a supine position before the procedure Rationale: The client with a tracheostomy tube should be positioned with the head of the bed elevated. Correct suction pressure for the adult client is 80 to 120 mm Hg. Suction is applied intermittently during catheter withdrawal. Breath sounds should be assessed before the procedure to help determine the need for suctioning. The client should be hyperoxygenated with 100% oxygen before suctioning.

An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse that some of the client's lab data are abnormal? Select all that apply. Sodium (NA) 149 mEq/L Hematocrit (HCT) 30% (0.30) Calcium (CA) 9 mg/dL LDL Cholesterol 140 Magnesium (MG) 2.2 mEq/L Bicarbonate 21 mEqL

Sodium (NA) 149 mEq/L Hematocrit (HCT) 30% (0.30) LDL Cholesterol 140 Rationale: A sodium (NA) level of 149 is elevated. Normal NA levels are 135 to 145 mEq/L. Hematocrit (HCT) level of 30% is low. Normal HCT levels are 40% to 54% in males and 37% to 47% in females. Calcium (CA) 9 mg/dL is normal. Normal calcium levels are8.5 to 10.5 mg/dL. LDL Cholesterol 140 is borderline high. Optimal LDL is 100 to 129. Magnesium 2.2 mEq/L is normal. Normal magnesium levels are 1.5 to 2.5 mEq/L. Bicarbonate level of 21 mEqL is low. Normal bicarb is 24 to 28 mEq/L.

A client has just been scheduled for an ERCP. What should the nurse tell the client about the procedure SATA a) that multiple position changes may be necessary to pass the tube b) that informed consent is required c) that no premedication for sedation will be necessary d) that food and fluids will be withheld before the procedure e) that the test takes about 4 hours to complete

That food and fluids will be withheld before the procedure That multiple position changes may be necessary to pass the tube That informed consent is required Rationale: The client must sign informed consent before the procedure, which takes about an hour to perform. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Food and fluids are withheld before the procedure to prevent aspiration. Multiple position changes may be necessary to facilitate the passage of the tube.

A nurse is performing nastotracheal suctioning on a client. Which observations should be cause for concern to the nurse SATA a) the client becomes cyanotic b) clear to opaque secretions are removed c) the client gags during the procedure d) the HR varies from 80 to 82 bpm e) secretions are becoming bloody

The client becomes cyanotic. Secretions are becoming bloody. Rationale: The nurse monitors the client for adverse effects of suctioning, which include cyanosis, an excessively rapid or slow heart rate, and the sudden appearance of bloody secretions. If any of these findings is noted, the nurse stops suctioning and contacts the primary health care provider immediately. The descriptions in the other options are expected findings and not a reason for concern.

A nurse receives a call from a nurse on the PACU, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client

assess the patency of the airway Rationale: The first action of the nurse is to assess the patency of the airway. The nurse then performs an assessment of cardiovascular function, the condition of the surgical site, the patency of tubes and drains for patency, and the function of the central nervous system. If the airway is not patent, immediate measures must be taken to help ensure the survival of the client.

A nurse is watching as an UAP measure the BP of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene SATA a) allowing the client to talk as the BP is being measured b) measuring the BP after the client reports that he just drank a cup of coffee c) having the client sit with the arm bared and supported at heart level d) measuring the BP after the client has sat quietly for 5 min e) used a cuff with a rubber bladder

Using a cuff with a rubber bladder that encircles at least 60% of the limb Measuring the BP after the client reports having just drank a cup (236 ml) of coffee Allowing the client to talk as the blood pressure is being measured Rationale: The client should not smoke tobacco or drink a beverage containing caffeine for at least 30 minutes before having the BP measured. The bladder of the cuff should encircle at least 80% of the limb being measured. The client should be seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should rest quietly for 5 minutes before the reading is taken.

A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned

absence of cough and gag reflexes Rationale: The absence of cough and gag reflexes is of greatest concern to the nurse because it indicates that the client does not have protective airway reflexes and is at risk of aspiration. Bilaterally equal breath sounds are a normal finding indicating an absence of complications such as hemothorax or pneumothorax. A respiratory rate of 20 breaths/min and an oxygen saturation of 97% are normal measurements.

a client who has just undergone surgery suddenly experiences CP, dyspnea and tachypnea. the nurse suspects that the client has a pulm embolism and immediately sets about to take which action

adminstering O2 by way of NC Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the primary health care provider is notified. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial blood gas determinations drawn. The immediate priority, however, is the administration of oxygen.

A client who has just undergone a skin bx is listening to d/c instructions from the nurse. The nurse determines that the client needs further teaching if the client indicates that he plans to do what as part of aftercare

apply cool compresses to the site BID for 20 min Rationale: Cool compresses are not used on biopsy sites. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After dressing removal, the site is kept clean and dry but may be cleansed daily with tap water or saline solution. The primary health care provider may prescribe an antibiotic ointment to minimize local bacterial colonization, and the ointment should be used as directed. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures are usually removed 7 to 10 days after biopsy.

A nurse has a rx to insert a NG tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily

asking the client to swallow as the tube is being advanced Rationale: To facilitate insertion, the nurse asks the client to lower the head slightly, swallow, and take sips of water (if allowed). The head is not hyperextended, because this would open the airway and could result in placement of the nasogastric tube in the trachea. The tube should be iced to make it stiff for easier insertion. If resistance is met, the tube may be withdrawn slightly, then readvanced.

A nurse has a rx to collect a 24 hour urine specimen from a client. Which measure should the nurse take during this procedure

asking the client to void, discarding the specimen and noting the start time Rationale: Because the 24-hour urine collection is a timed quantitative determination, the test must be started with an empty bladder. Therefore the first urine is discarded. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The collection should be refrigerated or placed on ice to help prevent changes in urine composition.

A client who experienced the sudden onset of resp distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action

auscultate both lungs for the presence of breath sounds Rationale: Immediately after an endotracheal tube is inserted, tube placement is verified. Initially the lungs are assessed for bilateral breath sounds and the chest is observed to see whether it rises and falls symmetrically with ventilation. After it has been determined that the client is being adequately ventilated, the tube is taped in place and placement is verified by means of chest x-ray. The depth of tube insertion is documented.

a client who has undergone renal bx complains of pain, radiating to the front of the abdomen, at the bx site. For which finding should the nurse assess the client

bleeding Rationale: Bleeding should be suspected if pain originates at the biopsy site and begins to radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs/symptoms of infection would not appear immediately after a biopsy. There is no information in the question to indicate the presence of renal colic.

A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. which action should the nurse take first

check for kinks in the drainage system Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest drainage system. The nurse also observes the client for signs/symptoms of respiratory distress or mediastinal shift; and if such signs/symptoms are noted, the primary health care provider is notified. Checking the heart rate and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new drainage system to the client's chest tube is done once the fluid drainage chamber is full. A specific procedure is followed when a new drainage system is connected to a client's chest tube.

a nurse is assessing a postop client on an hourly basis. The nurse notes that the client's UOP for the past hour was 25mL. On the basis of this finding, the nurse should take which action first

check the client's overall I&O record Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. Neither an increase in the rate of the IV infusion nor administration of a 250-mL bolus of normal saline (0.9%) would be implemented without a prescription from the primary health care provider. The primary health care provider is called once the nurse has gathered all necessary assessment data, including the overall fluid status and vital signs.

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first

check the degree of suction being applied Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning. Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions.

a client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority

checking for the return of the gag reflex Rationale: After bronchoscopy, the nurse assesses the client for the return of the gag and swallow reflexes and keeps the client on nothing-by-mouth status until these protective reflexes return. Preoperative sedation and local anesthesia can impair the swallowing and protective laryngeal reflexes for several hours. Encouraging large amounts of fluids is unnecessary, because there is no use of contrast dye in this procedure. Additionally, fluids would not be given until the gag reflex had returned. Ambulation is not indicated until the client is alert and awake. Pain medication is usually not needed.

Blood for arterial blood gas determinations is drawn on a client with PNA and testing reveals a pH of 7.45, PaCO2 of 30mmHg, and HCO3 of 19 mEq/L. The nurse interprets these resutls as indivative of which disorder

compensated resp alkalosis Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). The normal HCO3 (bicarbonate) is 22-26 mEq/L (22-26 mmol/L). In a respiratory condition, opposite effects will be seen in pH and PaCO2. In respiratory alkalosis, pH is increased and PaCO2 is decreased. Compensation occurs when the pH returns to within the normal range, even though either the carbon dioxide or bicarbonate (or both) is abnormal value. In a metabolic condition, pH and bicarbonate move in the same direction. Clients with pneumonia are at risk for respiratory alkalosis as a result of hypoxemia.

A nurse is monitoring a client who has undergone pleural bx. Which finding causes the nurse to suspect that the client is experiencing a complication

complaints of SOB Rationale: The nurse observes the client for dyspnea, excessive pain, pallor, and diaphoresis after pleural biopsy, each of which could indicate the presence of a complication such as hemothorax or intercostal nerve injury. Abnormal signs/symptoms should be reported to the primary health care provider. Mild pain is expected because the procedure itself is painful. Warm, dry skin and a capillary refill of less than 3 seconds are both normal findings.

A nurse administers scopolamine as prescribed to a client. For which s/e of this med does the nurse monitor the client

complaints of dry mouth Rationale: Scopolamine, an anticholinergic medication, often causes the side effects of dry mouth, urine retention, decreased sweating, and pupil dilation. The other options are incorrect.

A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action

cover the abdominal wound with a sterile dressing moistened with sterile saline sltn Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in a low Fowler's position or supine with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The primary health care provider is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response.

a nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action

cover the insertion site with a sterile occlusive dressing Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the client back into bed, and contacts the primary health care provider. The nurse does not reinsert the chest tube. The primary health care provider will reinsert the chest tube, as necessary.

A nurse is preparing to examine a client's skin using a Wood light. What should the nurse do to facilitate his procedure

darken the exam room Rationale: Examination of the skin under a Wood light, or handheld long-wavelength UV light, is carried out in a darkened room. The light is used to illuminate areas of skin infection, which are seen as blue-green or red fluorescence. The skin does not need to be shaved, and a local anesthetic is not necessary. This is a noninvasive examination, so informed consent is not required.

A client with COPD who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2L/min. The nurse responds that this would be harmful b/c it could cause which effect

decrease the client's oxygen based resp drive Rationale: Normally the respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD, this natural drive becomes ineffective after exposure to a high carbon dioxide level over a prolonged period. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD cannot increase the oxygen level independently because this could halt the respiratory drive, leading to respiratory failure.

A nurse is admitting a client with a dx of hypothermia to the hospital. Which signs does the nurse anticipate that this client will exhibit

decreased HR and decreased BP Rationale: Hypothermia decreases the heart rate and blood pressure, because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases, with corresponding drops in both heart rate and blood pressure.

A client is recieving a continuous IV infusion of heparin for the tx of DVT. The client's aPTT level is 88sec. The client's baseline before the initiation of therapy was 30sec. Which action does the nurse anticipate is needed

decreasing the rate of heparin infusion Rationale: The normal aPTT varies between 25 and 35 seconds (25 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is designed to keep the aPTT between 1.5 and 2.5 times normal. Therefore the client's aPTT is somewhat increased but does not indicate a critical value. The infusion rate should be slowed and the aPTT rechecked as prescribed. A persistently increased aPTT indicates a risk for bleeding.

a nurse is suctioning a client through a trach tube. During the procedure, the client begins to cough and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. Which action should the nurse take first

disconnect the suction source from the catheter Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse immediately disconnects the suction source from the catheter but leaves the catheter in the trachea. The nurse then connects the oxygen source to the catheter. The primary health care provider is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if the bronchospasm is not relieved.

A client with a hx of lung disease is at risk for resp acidosis. For which s/s does the nurse assess this client

disorientation and dyspnea Rationale: The client with respiratory acidosis would exhibit the signs/symptoms identified in the correct option. The client will experience dyspnea and may be disoriented as a result of hypoxia and retention of carbon dioxide. Metabolic acidosis and alkalosis are marked by drowsiness, headache, and tachypnea and dysrhythmias and decreased respiratory rate and depth, respectively. The client with respiratory alkalosis is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities.

A client has undergone pericardiocentesis to treat cardiac tamponade. for which signs should the nurse assess the client to determine whether the tamponade is recurring

distant muffled heart sounds Rationale: After effective pericardiocentesis, an increase in blood pressure and a decrease in CVP are expected. The pulse may slow because less cardiac work is needed to produce adequate cardiac output. Distant muffled heart sounds that were noted before the test should become clear with effective pericardiocentesis. A return of distant muffled heart sounds indicates returning pericardial effusion and possible tamponade.Test-Taking Strategy: Focus on the subject, r

Polyethylene glucol-electrolyte solution is rx'd for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate

document the diarrhea in the medical record Rationale: Polyethylene glycol-electrolyte solution, also known as GoLYTELY, is a bowel evacuant used in preparation for colonoscopy to cleanse the bowel. It is expected to cause mild diarrhea and will clear the bowel in 4 to 5 hours. Therefore the appropriate action is for the nurse to document the results in the medical record. The other options are incorrect or unnecessary.

A pelvic u/s is prescribed o evaluate a client's ovarian mass. What should the nurse giving preprocedure instructions tell the client that it is important to do before the procedure

drink 6-8 glasses of water without voiding Rationale: Pelvic ultrasound requires the ingestion of a large volume of water just before the procedure. A full bladder helps ensure that the bladder is easily visualized and not mistaken for a pelvic growth. A client undergoing abdominal (not pelvic) ultrasound may have to refrain from eating or drinking for several hours before the procedure.

A client is scheduled to undergo a CT with contrast for evaluation of an abdominal mass. The nurse should provide the client with which information about the test

dye is injected and may cause a warm flushing sensation Rationale: A contrast-aided CT scan involves the injection of dye to enhance the images that are obtained. The dye may cause a warm flushing sensation when it is injected. If an iodine dye is used, the client should be asked about allergies to seafood or iodine. The CT scan, which causes no pain, generally lasts between 15 and 60 minutes. Fluids are encouraged after the procedure to help eliminate dye by way of the kidneys.

A client who has received sodium bicarb in large amounts is at risk for metabolic alkalosis. For which s/s does the nurse assess this client

dysrhythmias, and decreased resp rate and depth Rationale: The client with metabolic alkalosis is likely to exhibit dysrhythmias and a decreased respiratory rate and depth as a compensatory mechanism. The client with metabolic acidosis would exhibit the signs/symptoms such as drowsiness, headache, and tachypnea. The client with respiratory acidosis or alkalosis would exhibit the disorientation and dyspnea or tachypnea, dizziness, and paresthesias, respectively.

A client has just returned to the nursing unit after CT with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client

encourage fluid intake Rationale: After CT scanning, the client may resume all usual activities. The client should be encouraged to consume extra fluids to replace those lost during diuresis of the contrast dye. Medications do not have to be withheld. There is no reason to administer a laxative; also, a primary health care provider's prescription is needed for this intervention.

A nurse is preparing a client for transfer to the OR. Which action should the nurse take in the care of this client at this time

ensuring that the client has voided Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the operating room. Rather, the primary health care provider writes a specific prescription outlining which medications may be given with a sip of water. The client is usually prescribed to have nothing by mouth for 8 hours before surgery, not 24 hours. The time of transfer to the operating room is not the time to practice breathing exercises. This should have been done earlier.

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum lab studies. Which abnormal lab results should the nurse report to the surgeon's office SATA a) hgb 8.9 b) Na 141 c) Platelets 210 d) hct 30% e) serum creatinine 0.8

hgb 8.9 hct 30% Rationale: Routine screening tests include complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood cell count includes the hemoglobin and hematocrit analysis. All of these values are within their normal ranges except the hemoglobin and hematocrit. If a client has low hemoglobin and hematocrit levels, the surgery may be postponed by the surgeon. The normal hemoglobin level for a male ranges from 13.2 to 17.3 g/dL (132-173 g/L) and for a female, 11.7 to 15.5 g/dL (117-155 g/L). The normal hematocrit for a male ranges from 39% to 50% (0.39-0.50) and for a female, 35% to 47% (0.35-0.47).

A nurse has a rx to d/c a client's NG tube. The nurse auscultates the client's bowel sounds, positions the client properly and flushes the tube with 15mL of air to clear secretions. The nurse then instructs the client to take a deep breath and do what

hold the breath during tube removal Rationale: The client is asked to take a deep breath because the airway will be temporarily obstructed during tube removal. The client is then asked to hold the breath while the tube is being withdrawn. Bearing down and exhaling could each interfere with tube removal by increasing intrathoracic pressure. Normal breathing could result in aspiration of gastric secretions during inhalation.

A client who is mouth breathing is receiving oxygen by facemask. The UAP asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal

humidify the oxygen that is bypassing the client's nose Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. The remaining options are incorrect; additionally, a client who is breathing through the mouth is not at risk for nosebleeds.

a client has been given a dx of multiple myeloma. Which result does the nurse reviewing the client's lab findings recognize as being specifically related to this dx

increased calcium level Rationale: Multiple myeloma is characterized by hypercalcemia, anemia, increased BUN, and an increased number of plasma cells in the bone marrow. Hypercalcemia is a result of the release of calcium from deteriorating bone tissue. An increased WBC count may or may not be present and is not specifically related to this disease.

A nurse is monitoring the resp status of a client who has just undergone surgery and is wearing a pulseox. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate

low BP Rationale: Hypotension, shock, and the use of peripheral vasoconstricting medications may each result in inaccurate pulse oximetry readings because of the impairment of peripheral perfusion. The other options listed would not produce inaccurate readings.

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the HOB and the client complains of dizziness. which action should the nurse take first

lower the HOB slowly until the dizziness is relieved Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned upright for the first time after surgery. If this occurs, the nurse should first lower the head of the bed slowly until the dizziness is relieved. The nurse then checks the client's pulse and blood pressure. Because the problem is circulatory, not respiratory, checking the oxygen saturation level and having the client take some deep breaths are not the first actions to be taken.

A client is brought to the ED by a neighbor. The client is lethargic and has a fruity odor on the breath. The ABG results are pH 7.25, PaCO2 34mmHg, PaO2 86mmHg, HCO3 14 mEq/L. Which acid-base disturbance does the nurse recognize in these results

met acid Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). The normal HCO3 (bicarbonate) is 22-26 mEq/L (22-26 mmol/L). The normal PaO2 is 80-100 mm Hg (10.6-13.33 kPa). Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L (22 mmol/L); metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L (26 mmol/L). This client's ABG values are consistent with metabolic acidosis.

A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client

met acidosis Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. In conditions such as diarrhea, these fluids may be lost from the body before they can be reabsorbed. The decreased bicarbonate level produces the actual base deficit of metabolic acidosis.

A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids". For which acid-base disturbance does the nurse recognize a risk

met alkalosis Rationale: Oral antacids commonly contain sodium or calcium bicarbonate or other alkaline components. These substances bind to the hydrochloric acid in the stomach to neutralize it. Excessive use of oral antacids containing sodium or calcium bicarbonate can cause metabolic alkalosis over time.

A client with type 1 DM has a BGL of 620. After the nurse calls the HCP to report the finding and monitors the client closely for which condition

metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism, which are acidotic, can cause the condition known as diabetic ketoacidosis. The other options are incorrect and are not likely to occur in the client with diabetes mellitus.

A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client

metabolic alkalosis Rationale: Loss of gastric fluid by way of nasogastric suction or vomiting results in metabolic alkalosis. This is because of the loss of hydrochloric acid, a potent acid. The situation results in an alkalotic condition. The respiratory system is not involved.

A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a CXR. The report states that the client's affected lung is fully reexpanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding

no fluctuation in the water seal chamber Rationale: When the client's lung is fully re-expanded, the drainage system will no longer drain and fluctuation in the water seal chamber will be absent. This is because the lung has re-expanded and the pleural space is again a potential space. Continuous bubbling in the water seal chamber indicates an air leak in the system. Continuous gentle suction in the suction control chamber means that suction is being applied to the system.

A client who just returned from the recovery room after a T&A is restless and the HR is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. the nurse should take which immediate action

notify the surgeon Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional assessment data, but the surgeon must be contacted immediately.

A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing

oranges Rationale: Citrus fruits and juices are especially high in vitamin C. Other sources are potatoes, tomatoes, and other fruits and vegetables. Meats and dairy products are not especially high in vitamin C. Meats are high in protein. Dairy products are high in calcium.

A client has been scheduled for an MRI. Which condition, is a contraindication to MRI, does the nurse check the client's medical hx

pacemaker insertion Rationale: The candidate for MRI must be free of metal devices or implants. A careful history is conducted to determine whether any such metal objects, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, and intrauterine devices, are inside the client. These may heat up in the magnetic field generated by the MRI device, become dislodged, or malfunction during the procedure. The other medical problems listed do not pose a risk or contraindication for this procedure.

a client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding

pallor and coolness of the right leg Rationale: Complications of renal angiography include allergic reaction to the dye, dye-induced renal damage, and a number of vascular complications, including hemorrhage, thrombosis, and embolism. The nurse detects these complications by monitoring the client for signs/symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the insertion site, and signs of diminished circulation to the affected leg. The incorrect options are normal findings.

A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily for which reason

palpating both carotid pulses simultaneously could cause the HR and BP to drop Rationale: Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop. In addition, the manual pressure could interfere with the flow of blood to the brain, possibly causing dizziness and syncope.

A nurse is preparing for intershift report when a UAP pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who reutrned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's BP is 88/60 mmHg. Which action should the nurse take first

place the client in a modified Trendelenburg position Rationale: The client is exhibiting signs/symptoms of shock and requires emergency intervention. The first action is to place the client in a modified Trendelenburg position (flat with the legs elevated) to increase blood return from the legs, which in turn increases venous return and subsequently the blood pressure. The nurse calls the primary health care provider, verifies the client's blood volume status by assessing urine output, and ensures that the IV infusion is proceeding without complications.

A nurse checks the residual volume from a client's NG tube feeding before administering an intermittent tube feeding and finds 35mL of gastric contents. What should the nurse do before administering the prescribed 100mL of formula to the client

pour the residual volume into the NG tube through a syringe with the plunger removed Rationale: After checking the residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents, with the use of the syringe, into the nasogastric tube. Removal of the contents could disturb the client's electrolyte balance. The other options are incorrect.

A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume

pulse rate Rationale: Cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Remember that pulse rate multiplied by stroke volume equals cardiac output. An increase in pulse is often sufficient with small amounts of volume depletion to maintain the blood pressure. Pulmonary artery systolic pressure and pulmonary artery end-diastolic pressure, measurements obtained with the use of a pulmonary artery catheter, provide information about the pressures in the pulmonary artery and in the left ventricle at the end of diastole.

A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important

questioning the client about allergies to iodine or shellfish Rationale: Some IVP dyes are iodine based; if the dye to be used in this procedure is one of them and the client has an allergy to iodine or shellfish, he may experience an allergic reaction, manifested as itching, hives, rash, a tight feeling in the throat, shortness of breath, or bronchospasm. For this reason, assessing the client for allergies is the priority. The dye is injected intravenously. The client may or may not receive premedication. Nothing-by-mouth status is generally imposed after midnight on the day before the test.

A client is scheduled for a barium swallow in 2 days. The nurse, providing preprocedure instructions, should tell the client to implement which measure

remove all metal and jewelry before the test Rationale: A barium swallow, or esophagography, is an x-ray in which a substance called barium is used to provide contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove all jewelry before the test so it won't interfere with x-ray visualization of the field. The client should fast for 8 to 12 hours before the test, depending on the primary health care provider's instructions. Most oral medications are withheld before the test. The client should self-monitor for constipation, which may occur as a result of the presence of barium in the GI tract, after the procedure.

A client with histoplasmosis has the following ABG results: pH 7.30, PaCO2 58mmHg, PaO2 75mmHg, HCO3 26 mEq/L. Which acid-base disturbance does the nurse recognize in these results

resp acid Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). The normal HCO3 (bicarbonate) is 22-26 mEq/L (22-26 mmol/L). The normal PaO2 is 80-100 mm Hg (10.6-13.33 kPa). Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. In a respiratory condition, an opposite effect is seen between the pH and the PCO2. In respiratory acidosis, the pH is decreased and the PCO2 is increased. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L (22mmol/L); metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L (26 mmol/L). This client's ABG values are consistent with respiratory acidosis.

A nurse reviews the blood gas results of a client in resp distress. The pH is 7.32 and the PaCO2 is 50mmHg. Which acid-base imbalance does the nurse recognize in these findings

resp acidosis Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). In respiratory acidosis, the pH is low and the PCO2 is increased. This is an expected finding in a client with respiratory distress, because the client may retain carbon dioxide as a result of ventilatory failure.

A client has the following ABG results: pH 7.51, PaCO2 31 mmHg, PaO2 94mmHg, HCO3 24 mEq/L. Which acid-base disturbance does the nurse recognize in these results

resp alkalosis Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). The normal HCO3 (bicarbonate) is 22-26 mEq/L (22-26 mmol/L). The normal PaO2 is 80-100 mm Hg (10.6-13.33 kPa). Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO2. In respiratory alkalosis the pH is increased and the PCO2 is decreased. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L (22 mmol/L); metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L (26 mmol/L). This client's ABG findings are consistent with respiratory alkalosis.

A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contract medium by monitoring for the presence of which

resp distress Rationale: Signs/symptoms of an allergic reaction to contrast dye include early signs/symptoms, such as localized itching and edema, followed by more severe signs/symptoms, such as respiratory distress, stridor, and decreased blood pressure. Discomfort in the catheter insertion area is to be expected and is not a sign/symptom of allergic reaction. Hematoma formation, which is abnormal and indicates bleeding, should be reported to the primary health care provider. Bradycardia is unrelated to the situation set forth in the question.

A nurse is reviewing the results of serum lab studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease

serum bilirubin Rationale: Laboratory indicators of hepatitis include increased liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. An increased BUN may indicate renal dysfunction. The hemoglobin level is unrelated to this diagnosis.

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The HCP has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client's room before allowing the client to drink

suction equipment Rationale: Aspiration is a concern when fluids are offered to a client who has just undergone surgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia. The nurse checks the gag and swallow reflexes before offering fluids to the client, but suction equipment still must be available. An oxygen saturation monitor is unnecessary when fluids are being administered, nor is a napkin or straw necessary; in fact, the straw could contribute to the formation of flatus, resulting in gastrointestinal discomfort.

A client who is anxious about an impending surgery is at risk for resp alkalosis. For which s/s of resp alkalosis does the nurse assess this client

tachypnea, dizziness, and paresthesias Rationale: The client who is anxious is at risk for respiratory alkalosis as a result of hyperventilation. The client is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities. The client with respiratory acidosis would exhibit disorientation and dyspnea. The client with metabolic acidosis or alkalosis would exhibit signs/symptoms such as drowsiness, headache, and tachypnea and dysrhythmias and decreased respiratory rate and depth, respectively.

A client who has undergone an EGD returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take

take the client's vital signs Rationale: The nurse would first assess the client for the return of the gag reflex, which is part of managing the client's airway. The client's vital signs should be checked next; a sudden sharp increase in temperature could indicate perforation of the gastrointestinal tract (this would be accompanied by other signs/symptoms, such as pain, as well). Monitoring the client for sore throat and heartburn is also important but is of lesser priority than ensuring a patent airway. Water or any other fluid would not be given to the client until the gag reflex had returned and the client was stable.

A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client

taping the connections b/w the chest tube and the drainage system Rationale: The nurse tapes all system connections to prevent accidental disconnection. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. Assessment for crepitus is performed once every 8 hours or more often if needed. Sterile water is only added to the suction control chamber as needed to replace evaporative loss.

A client who has sustained a MI is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure

telling the client that the procedure is painless and takes 30-60 min to complete Rationale: In echocardiography, ultrasound is used to evaluate the heart's structure and motion. It is a noninvasive, risk-free, pain-free test that involves no special preparation and is commonly performed at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. The other options are incorrect.

A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test

that deodorants, powders, or creams in the axillary or breast area must be washed off before the test Rationale: The client should avoid using deodorants, powders, or creams on the day of the mammogram; such products used in the axillary or breast must be washed off before the test. The client may experience some discomfort because it is necessary to compress the breast tissue to obtain a clear image. The client may eat and drink before the procedure, which generally takes 15 to 30 minutes to complete.

A nurse is reading the CXR report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm about the carina. The nurse interprets that the tube is positioned above which anatomical area

the bifurcation of the right and left main stem bronchi Rationale: The normal position of the tube is above the bifurcation of the right and left main stem bronchi. The carina is a cartilaginous ridge that separates the openings of the two main stem (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main stem bronchus as a result of the natural curvature of the airway. This is hazardous because only the right lung will be ventilated. It is easily detected, however, because only the right lung will have breath sounds and rise and fall with ventilation. The other options are incorrect.

A nurse is assessing the chest tube drainage system of a postop client who has undergone the right upper lobectomy. The closed drainage system contains 300mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. On the basis of these findings, what should the nurse assess first

the chest tube connections Rationale: The client's dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires primary health care provider intervention. Although the interventions identified in the other options should also be taken in this situation, they should be performed only after the nurse has tried to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client's signs/symptoms should resolve.

A nurse provides info to a client who is scheduled for cardiac catheterization to r/o coronary occlusion. The nurse should provide which information to the client

the client may have feelings of warmth or flushing during the procedure Rationale: The nurse tells the client about to undergo cardiac catheterization room that the procedure is performed in a darkened room in the radiology department. A local anesthetic is used, so there is little or no pain with catheter insertion. The procedure may take as long as 2 hours, during which time the client may feel various sensations including a feeling of warmth or flushing, with catheter passage and dye injection. The x-ray table is hard and may be tilted periodically to obtain the best possible views.

a client has a chest drainage system in place. the fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which

the tube is patent Rationale: With normal breathing and a patent chest tube, the fluid level in the water seal chamber rises with inspiration and falls with expiration. The system should not be affected by airway secretions, because the chest tube drains fluid (not airway secretions) from the pleural space. The other options are incorrect interpretations.

A nurse is providing post-procedure instructions to a client returning home after athroscopy of the shoulder. The nurse should provide the client with which information

to report to the HCP the development of fever or redness and heat at the site Rationale: After arthroscopy, signs/symptoms of infection such as fever or redness and heat at the site should be reported to the primary health care provider. The client may resume the usual diet immediately. The arm does not have to be completely immobilized once sensation has returned, but the client is usually encouraged to refrain from strenuous activity for at least a few days.

A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the HCP SATA a) unequal chest expansion b) resp rate of 22/min c) complaints of discomfort at the needle insertion site d) diminished breath sounds in the right lung e) HR of 82bpm

unequal chest expansion diminished breath sounds in the right lung Rationale: After thoracentesis, the nurse assesses the client for signs/symptoms of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Each of these signs/symptoms must be reported to the primary health care provider immediately. Complaints of discomfort at the needle insertion site, a pulse rate of 82 beats/min, and a respiratory rate of 22 breaths/min are expected findings after this procedure.

A HCP is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client

upright Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. The client ideally empties the bladder, and then sits upright in a chair with the feet flat on the floor. The other positions are incorrect for this procedure.

A client with DM is scheduled to have blood drawn in the morning for a fasting blood glucose determination. What does the nurse tell the client that it is acceptable to consume on the morning of the test

water Rationale: A client scheduled for a fasting blood glucose level draw should not eat or drink anything except water after midnight. This is done to ensure accurate test results, which forms the basis for adjustments or continuation of treatment. The other options are inaccurate, and the client should not consume these items before the test.

A nurse in a HCP's office has just made an appt for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client

wear comfortable rubber-soled shoes such as sneakers Rationale: The client should wear comfortable rubber-soled shoes, such as sneakers, for the procedure. The client wears light, loose, comfortable clothing; a shirt that buttons in front is helpful for electrocardiogram (ECG) lead placement. The client should be NPO after bedtime, or for a minimum of 2 hours before the test, and should avoid tobacco, alcohol, and caffeine on the day of the test.