nur 240
ways to take care of yourself in high stress situation
reflecting your own feelings, focusing on what was done right, maintaining physical health
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
Implementing a low-protein diet.
A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug?
Increased bowel movements.
The client with cirrhosis receives 100 mL of 25% serum albumin I.V. Which finding would best indicate that the albumin is having its desired effect?
Increased urine output.
A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?
"Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."
The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has under- stood the teaching?
"I should avoid constipation to decrease chances of bleeding."
A client is to be discharged with a prescription for lactulose (Cephulac). The nurse teaches the client and the client's spouse how to administer this medication. Which of the following statements would indicate that the client has understood the information?
"I'll mix it with apple juice."
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
1. Preventing constipation. 2. Administering lactulose (Cephulac). 3. Monitoring coordination while walking. 4. Checking the pupil reaction. 5. Providing food and fluids high in carbohydrate.
he nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
1. Administration of intravenous Octreotide (Sandostatin). 2. Endoscopy. 3. Administration of a blood product.
A client with jaundice has pruritis and states that he has areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply.
2. Take baking soda baths. 3. Keep nails short and clean. 4. Rub with knuckles instead of nails.
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate?
Anorexia.
The physician orders oral neomycin (Mycifradin) as well as a neomycin enema for a client with cirrhosis. The expected outcome of this therapy is to:
Block ammonia formation.
Metabolic acidosis
DKA and diarrhea
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing?
Decreased mental status.
Which of the following positions would be appropriate for a client with severe ascites?
Fowler's.
The nurse is preparing a client for a paracentesis. The nurse should:
Have the client void immediately before the procedure.
What diet should be implemented for a client who is in the early stages of cirrhosis?
High-calorie, high-carbohydrate.
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
Hyperkalemia.
The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy?
Potassium
The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 37.2° C; heart rate 118; shallow respira- tions 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse?
Raise the head of the bed
Which of the following health promotion activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily routine at home?
Supplement the diet with daily multivitamins.
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
Use an alternating air pressure mattress.
Palliative care
making sure providing family support
assessing ascites
pay attention to respirations and sob
pt education
always reassess situation
A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should:
assess for GI bleeding
Aldactone vs lasix
can still become hypovolemic, monitor electrolyte status
Communication
cant talk, provide as much info to the pt and family
neglligence (breach of duty)
carlessness, conciously ignored a knows risk for for harm to the patient, under the influence of drugs or alcohol
Cirrhossis
pt time will get higher and longer, LFT, protein, clothing which direction
Ways to promote sleep in critical care
ensure pt is comfortable, schedule labs so that sleep isnt disrupted, control noise in the evening, post signs, close the patients door
Pt teaching
give info by closed door, private room
Pain medications help healing
give med before walking, not q2hrs
Assessing sign a pt is in pain
grimacing, increased HR, BP, Resp,
we are advocates to the patient
if the pt has ad and family doesnt want to carry out your no longer advocating if your not following their wishes or doing whats best for them
malpractice
injury or harm to the patient, as result of nurses actions or inaction
Restrained patient
sedation, might need more pain medication sedation, find the cause of the agitation
End of life care, comfort measures what to expect to see
sob, ok to give pain meds and o2 get an order to keep them comfortable
Metabolic alkalosis
vomiting and baking soda
Pt is not doing well and the team thinks they wont make it, communication style would you use
want to be truthful, how they are deteriorating without saying their dyiing, indirectly say the pt isnt doing well
Why a nurse would seek critical care nursing
wanting to achieve professional expertise, put on a resume
Ethics committee and consults that are approppriate
what kind of situations would warrant a consult the patient has an advance directive but this family member doesnt want the family fighting instead of following what the patients wants, person making the decision for the patient is the power of attorney-know what poa is
Family in the ICU that is irrate
why because they dont know whats going on