Nclex Review 3/19/19

When a client diagnosed with acute urinary retention is Emergently Catheterized the nurse should initially assess for which priority manifestation that may occur as a result of the catheterization? 1) Dysuria 2) Hypotension 3) Infection 4) Tachycardia

2 Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with - hematuria - hypotension - postobstructive diuresis (Option 2).

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? 1) ECG 2) IV Morphine 2 mg 3) Normal Saline Bolus 4) Urine Sample

3 Rhabdomyolysis occurs when muscle fibers are released into the blood, usually after an intense muscle injury from exercise, heat stroke, or physical trauma. Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys' filtration ability.

Hemoglobin is 15 g/ dl

A hemoglobin level of 15 g/dL (150 g/L) is normal (13.2-17.3 g/dL [132-173 g/L] in adult men; 13 - 17 11.7-15.5 g/dL [117-155 g/L] in adult women) and does not need to be reported to the HCP. 11- 16

Magnessium is 1.5 mEq / L

A magnesium level of 1.5 mEq/L (0.75 mmol/L) is normal (1.5-2.5 mEq/L [0.75-1.25 mmol/L]) and does not need to be reported to the HCP. 1.5 - 2.5 Norm

WBC 14000 / mm³

A white blood cell count of 14,000/mm3 (14.0 × 109/L) is elevated and expected in a client with a serious infection; this does not need to be reported to the HCP.

Insert a urinary catheter for accurate output calculation.

Although it is important to insert an indwelling catheter to monitor fluid balance rehydrating the client is a life-saving measure with higher priority.

Urine Sample

Although obtaining a urine specimen to assess the characteristics is important, laboratory testing would not take priority over treatment to preserve kidney function.

Flapping Tremor no longer visible with arm extension

Asterixis (ie, flapping hand tremors during arm extension) occurs due to elevated blood ammonia levels. Lactulose is commonly used to treat asterixis as it promotes ammonia excretion. Albumin does not affect ammonia excretion.

Interventions in the rehabilitation phase are aimed at improving mobility and independence and minimizing the potential for long-term complications. These interventions include:

Counseling or other psychosocial support Gentle massage with water-based lotion to alleviate itching and minimize scarring Planning for reconstructive surgery Pressure garments to prevent hypertrophic scars and promote circulation (Option 4) Range-of-motion exercises to prevent contractures (Option 2) Sunscreen and protective clothing to prevent sunburns and hyperpigmentation (Option 3)

Abdominal Circumference reduced from admission recording Shortness of breath no longer experienced in supine position

Decreased abdominal circumference and improved respiratory effort occur in clients with ascites after ascitic fluid is removed via paracentesis. Albumin does not directly reduce ascitic fluid volume.

Tachycardia

Inncorrect With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart rate are reduced due to the excitation of the parasympathetic system.

Urine output is 360 ml in 4 hrs

Obligatory urine output is 30 mL/hr, and this client has 90 mL/hr. Urine output is one of the best indicators of adequate rehydration (Option 4)

IV Morphine 2 mg

Pain and symptom management should be a high priority but should not take precedence over preserving the client's kidney function.

Normal BUN

The normal range for BUN is 6-20 mg/dL (2.1-7.1 mmol/L) and

Normal Saline Bolus

The nurse's priority is to prevent kidney damage using rapid IV fluid resuscitation to flush the damaging myoglobin pigment from the body. Common signs of rhabdomyolysis are - dark, oftentimes bloody urine - oliguria - fatigue.

Prepare an insulin drip for intravenious infusion as prescribed

The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening the dehydration and electrolyte imbalances.

Urine Specific Gravity is 1.020

The urine specific gravity is within a normal range (1.003 to 1.030), which can indicate normal hydration (Option 5).

Metronidazole (Flagyl) is an _____ _____ used to treat IBD ( Inflamitory Bowel Disease ) and does not convert LTBI to active disease.

antimicrobial medication

Normal creatinine

creatinine is 0.6-1.3 mg/dL (53-115 µmol/L).

Ascites

is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis. Ascitic fluid increases abdominal pressure, resulting in weight gain, abdominal distension and discomfort, and shortness of breath.

Lansoprazole (Prevacid) is a ____ _____ _____ used to treat ulcer disease, erosive esophagitis, and gastroesophageal reflux disease. It does not convert LTBI to active disease.

proton pump inhibitor

Obtain serum potassium level results and report it to the primary health care provider

(Option 2) Although it is important to monitor serum potassium results before and during insulin administration rehydrating the client is the highest priority. Dilution will also improve the hyperkalemia.

Paracentesis

(ie, needle insertion through the abdomen into the peritoneum to remove ascitic fluid) is often performed to reduce symptoms of ascites. However, clients undergoing paracentesis must be monitored closely for hypotension as changes in abdominal pressure often result in systemic vasodilation.

Elevate the arm on pillows above the level of the heart

Incorrect Elevating the arm on pillows and providing additional analgesia may help reduce symptoms but may also reduce perfusion of the extremity. Instead, the extremity should be positioned at the level of the heart.

The nurse is providing discharge teaching for a client who suffered full-thickness burns. Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury? 1) I should avoid using lotion to prevent infection 2) I should perform range of motion exercises daily 3) I should avoid direct sun exposure for at least 3 months. 4) I will ware pressure garments to minimize scars

1 The rehabilitation phase begins after the client's wounds have fully healed and lasts about 12 months. The initiation of this phase depends on the extent of the burns and the client's ability to care for themselves.

Apply a heating pad and encourage range of motion exercises

Incorrect Heat should not be applied to a client experiencing altered sensation, as it may burn the client. Active range of motion will not resolve compartment syndrome and delays needed care.

The nurse prepares to administer IV vancomycin to an 80-year-old client with a methicillin-resistant Staphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply. 1) BUN at 60 mg/dl 2) Creatanine is 2.1 mg/dl 3) Glucose is 140 mg/dl 4) Hemoglobin is 15 g/ dl 5) Magnessium is 1.5 mEq / L 6) WBC 14000 / mm³

1 , 2 Vancomycin is a glycopeptide antibiotic that is excreted by the kidneys. It is used to treat serious infections with gram-positive microorganisms (Staphylococcus aureus [methicillin-resistant Staphylococcus aureus]) and diarrhea associated with Clostridium difficile.

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply. 1) Capillary Refill is less than 3 sec 2) Pulse pressure is narrowed 3) Systolic BP is drops only when standing 4) Urine output is 360 ml in 4 hrs 5) Urine Specific Gravity is 1.020

1, 4 , 5

The nurse is caring for a client who received extracorporeal shock wave lithotripsy with ureteral stent placement for treatment of a kidney stone. Which discharge instructions provided by the nurse are appropriate? Select all that apply. 1) Contact your health provider if you get fever or chills 2) Except for using the bathroom. You should stay on bed rest for the next 48 hrs 3) Increase your fluid intake to help flush out the kidney stone fragments 4) It is common to have some blood in the urine up to 24 hours after this procedure 5) You may develop some bruising on your back or side of your abdomen

1,2,3,4,5 Report any symptoms of infection (eg, fever, chills) to the health care provider (Option 1). (Option 2) Ambulation is encouraged after ESWL to facilitate passage of the stone fragments. Increase fluid intake to help flush out the kidney stone fragments (Option 3). Expect to see blood in the urine (hematuria). Urine color should progress from bright red to pink-tinged during the first several hours. Hematuria is concerning if the urine remains bright red for a prolonged period (eg, >24 hours) (Option 4). Expect some bruising and pain of the back and/or flank of the affected side. Analgesics may be required (Option 5).

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse's appropriate actions? Select all that apply. 1) Apply a heating pad and encourage range of motion exercises 2) Assess temperature and movement of the fingers 3) Elevate the arm on pillows above the level of the heart 4) Notify the Health care provider 5) Reassure the client, Document findings, and reassess in 1 hr

2,4 Compartment syndrome, a serious postoperative complication, is caused by decreased blood flow to the tissue distal to the injury. results from either decreased compartment size (restrictive dressings, splints, or casts) increased pressure within the compartment (bleeding, inflammation, and edema).

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective? 1) Abdominal Circumference reduced from admission recording 2) Flapping Tremor no longer visible with arm extension 3) Shortness of breath no longer experienced in supine position 4) Vital Signs remain within the clients normal parameters

4 Clients may receive IV albumin (a colloid) after paracentesis, which increases intravascular oncotic pressure resulting in increased intravascular fluid volume. Albumin administration prevents hypotension and tachycardia by mitigating hemodynamic changes associated with paracentesis (Option 4). IV albumin increases intravascular fluid volume ( Blood in pt cirucaltory system ) and may be used to prevent hypotension associated with paracentesis.

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first? 1) Insert a urinary catheter for accurate output calculation. 2) Obtain serum potassium level results and report it to the primary health care provider 3) Prepare an insulin drip for intravenious infusion as prescribed 4) Start and IV line and Infuse normal saline as prescribed

4 Hyperglycemia causes osmotic diuresis, and clients are severely dehydrated. The cardinal signs of dehydration are Low TD - L ethargy. - o rthostatic hypotension - w eakness - T achycardia - T urgor = poor skin turgor - D ry mucosal membranes

Pulse pressure is narrowed

Incorrect Narrowing pulse pressure (the difference between systolic and diastolic) is a sign of hypovolemic shock and would not indicate adequate rehydration. The client arrived with a narrow pulse pressure already.

I should avoid using lotion to prevent infection

Incorrect Daily application of water-based lotion is necessary to minimize scar formation and alleviate itching. Infection is not likely as the rehabilitation phase begins after the wounds are fully healed.

Reassure the client, Document findings, and reassess in 1 hr

Incorrect Documenting findings is important. However, reassurance and reassessment 1 hour later without immediate intervention delays needed care

Dysuria

Incorrect Dysuria from catheterization can be treated with analgesics or antispasmodic medications. Maintaining perfusion and adequate blood pressure is the priority concern.

Glucose is 140 mg/dl

An elevated glucose level (>110 mg/dL [6.1 mmol/L]) is expected in a client with an infection due to physiological stress and gluconeogenesis this does not need to be reported to the HCP.

Systolic BP is drops only when standing

Incorrect This is indicative of orthostatic vital signs. When a client stands, the body normally vasoconstricts to maintain the blood pressure from the effects of gravity. If a client is dehydrated, the body has already maximally vasoconstricted, and there is no compensatory mechanism left to adjust to the position change.

S/S of compartment syndrome

Earliest symptoms may include pain or numbness that is unrelieved by medication. Subsequent findings includes your skin being Pale = pallor Cool = coolness Cyanosis= Blue Absent = diminished/absent pulses With swelling and decreased movement

ECG

With muscle injury, intracellular potassium is released into the circulation, potentially causing dangerous arrythmias. . Therefore, ECG and cardiac monitoring are needed. However, with IV fluid administration, potassium levels decrease rapidly. In addition, clients with rhabdomyolysis have extensive third spacing of the fluids into the injured muscles. Therefore, aggressive fluid resucitation is a high priority.

Sulfasalazine (Azulfidine) is a ______ _______ _______ used to treat IBD and does not convert LTBI to active disease.

gastrointestinal anti-inflammatory medication

Blood urea nitrogen (BUN) and creatinine levels are monitored regularly (usually 2-3 times/week) in clients receiving the drug due to increased risk of ___________, especially in those with _____ _____ _____ , receiving aminoglycosides, and who are >60 years old.

nephrotoxicity impaired renal function