Prepu Reduction of risk potential

A client with a second-degree atrioventricular heart block, Type II is admitted to the coronary care unit. How will the nurse explain the need to monitor the client's electrocardiogram (ECG) strip to the spouse?

"The small box will transmit the heart rhythm to the central monitor all the time." In telemetry, a small box transmits the client's heart rhythm to the central unit for constant monitoring. Telemetry has nothing to do with the client needing help. A holter monitor is a device that records the heart's electrical activity and for later review by a physician. The telemetry transmits the heart rhythm regardless of the client's heart rate.

A client with high blood pressure is receiving an antihypertensive drug. When developing a client teaching plan to minimize orthostatic hypotension, which instruction should the nurse include?

"Flex your calf muscles, avoid alcohol, and change positions slowly." Measures that minimize orthostatic hypotension include flexing the calf muscles to boost blood return to the heart, avoiding alcohol and straining at stool, changing positions slowly, eating a high-protein snack at night, wearing elastic stockings, and holding onto a stationary object when rising. Although the client should rest between demanding activities and consume plenty of fluids and fiber (contained in fruits and vegetables) to maintain a balanced diet, these measures don't directly relieve orthostatic hypotension.

When educating the client with type 1 diabetes, the nurse knows that more education is needed when the client says:

"I will be able to switch to insulin pills when my sugar is under control." Oral antidiabetic agents are effective only in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. The need to eliminate sugar, give insulin, and receive proper foot care are all items that indicate the client understands the teaching.

A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?

"You will be lying on your side with your knees to your chest." For the lumbar puncture procedure, the client usually lies on the side in a knees-to-chest position. A position flat on the table, face down does not open the vertebral spaces to allow access for the lumbar puncture. Having the client lie on their back does not allow access to the surgical site.

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function?

30 mg/dL Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulinlike material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed?

A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. A Billroth I procedure involves removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum.

A nurse reviews the care plan for an adolescent receiving chemotherapy for leukemia. The adolescent's platelet count is 50,000 μl. The client also has pneumonia. Which item in the care plan should the nurse revise?

Administer oxygen at a rate of 4 L/minute using a non-humidified nasal cannula. The platelet level is low, placing the client at risk for bleeding. The nose is a vascular region that can bleed easily if the mucosa is dried by unhumidified oxygen. Therefore, the nurse should revise the care plan to reflect use of humidified oxygen. A sign to remind others to avoid needle sticks and to not give anything via the rectum, the presence of two peripheral IVs, and the use of a tympanic temperature device are all aspects of care that would decrease the adolescent's risk of bleeding.

A client presents with peripheral neuropathy and hypothesia of the feet. What is the best nursing intervention?

Assess for signs of injury. A client with hypothesia of the feet will have decreased sensation and numbness. The nurse should assess for signs of injury. If the client is injured, he or she will not be able to feel it; this could lead to the development of infection. Ambulation will not help the client, and elevating the legs may make the problem worse, as blood flow to the feet would be decreased. Keeping the feet cold will also decrease blood flow.

A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes a heart rate of 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and the body is pink. The neonte also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next?

Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx. The neonate should be assigned an Apgar score of 9 because the neonate is pink, is crying vigorously, is moving all extremities, has a heart rate of 110 beats/minute, and has an irregular respiratory effort. The irregular respiratory effort and the presence of mucus in the nasal and oral cavities signify that the neonate requires suctioning. The neonate doesn't require resuscitation.

You are working on a transplant unit and you know to carefully monitor your clients. What is the rationale for closely monitoring clients taking immunosuppressive drugs?

Because of an increased risk of respiratory or urinary system infection After organ transplantation, the client's immune system may attack the new organ's cells because it recognizes them as 'nonself.' Therefore, drugs are used to intentionally suppress the immune system. For example, azathioprine (Imuran), cyclosporine (Sandimmune), and muromonab-CD3 (Orthoclone OKT3) are immunosuppressive drugs. The nurse should follow agency guidelines for controlling infectious diseases or protecting the client who is immunosuppressed. The nurse should observe such clients for signs and symptoms of infection such as fever, sore throat, productive cough, and dysuria. Immunosuppressive drugs do not cause skin or hair problems or any blood-related complications. Heart failure, infusion reactions, and life-threatening infections are associated with taking infliximab.

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure?

Brain natriuretic peptide (BNP) BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.

A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned?

Calcium Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). Their blood pressure is 104/68 mm Hg. Their pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

Contact the physician and report the findings. The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the physician immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?

Difficulty in breathing Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing. The nurses inspects for hematoma, absent distal pulses, after the procedure. When the contrast medium is infused, an urge to cough is often a sensation experienced by the client.

The nurse is performing a neurovascular assessment of a client's injured extremity. Which would the nurse report?

Dusky or mottled skin color Normally, skin color would be similar to the color in other body areas. Pale or dusky skin color indicates an abnormality that needs to be reported. Presence of pulses, capillary refill of 3 seconds, and warm skin are normal findings.

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. What is the best action by the nurse?

Evaluate client protein levels Clients on bed rest suffer from lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. The nurse would evaluate the client's protein status by reviewing laboratory data. If protein stores are low, a dietician consult would be warranted. Increasing viatimin D and overall caloric intake will have little effect on a client's wound healing. A pressure ulcer should never be massaged.

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have?

Iron deficiency anemia People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.

A client being treated for leukemia has an absolute neutrophil count of 400 cells/mm3. What precautions would the nurse include in the plan of care?

Place sign on client's door reminding all persons to wash hands prior to entering. Neutropenia occurs when the absolute neutrophil count falls below 1,000 cells/mm3; a value of less than 500 cells/mm3 reflects a severe risk of infection. The nurse should protect the client by promoting strict hand hygiene for all persons who enter the client's room. The client may be placed in a private room with positive pressure, not negative, as the latter brings exterior air into the client's room. Clients with neutropenia should avoid rectal trauma, which may occur with suppositories or enemas. The nurse will not request routine antipyretic therapy, because this could mask a fever. Development of a fever while neutropenic, known as febrile neutropenia, is an oncological emergency.

A client is diagnosed with multiple site cancers and has received whole-body irradiation. The nurse is concerned about a compromised immune system in this client for which reason?

Radiation destroys lymphocytes. Radiation destroys lymphocytes and decreases the ability to mount an effective immune response. Radiation is not associated with an excess of lymphocytes or an excess or deficiency of hemoglobin.

A client has been prescribed diuretic therapy for hypertension. It has been causing frequent urination at night and now the client is refusing to take the morning dose of furosemide. What would be the best response by the nurse?

Reinforce the reason for the medication. Respect the decision if the client still refuses the medication, and chart the refusal. The client needs to understand the importance of extra fluid removal and how it helps control blood pressure. The nurse needs to be respectful that the client still has a choice in whether to take the medication.

A patient comes to the emergency department with reports of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing?

Sinus tachycardia Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate. Causes include medications that stimulate the sympathetic response (e.g., catecholamines, aminophylline, atropine), stimulants (e.g., caffeine, nicotine), and illicit drugs (e.g., amphetamines, cocaine, Ecstasy).

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the:

Upper left quadrant of the abdomen The spleen is located to the left of the stomach, in the upper left of the abdomen. It plays an important role in the immune system.

A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require

a chest X-ray. Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status but it's difficult to determine if the chest has reexpanded sufficiently.

A client is scheduled for amniocentesis. When preparing the client for the procedure, the nurse should:

ask the client to void. To prepare for amniocentesis, the nurse should ask the client to empty the bladder to reduce the risk of bladder perforation. Before transabdominal ultrasound, the nurse may instruct the client to drink 1 L of fluid to fill the bladder (unless ultrasound is done before amniocentesis to locate the placenta). I.V. anesthesia isn't given for amniocentesis. The client should be supine during the procedure; afterward, place the client on the left side to avoid supine hypotension, promote venous return, and ensure adequate cardiac output.

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine

atony. (A large fetus, extended labor, stimulation with oxytocin, and traumatic birth commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow birth and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after childbirth.)

A client who is 24 weeks pregnant has sickle cell anemia. When preparing the care plan, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy?

dehydration Factors that may precipitate a sickle cell crisis during pregnancy include dehydration, infection, stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia aren't known to precipitate a sickle cell crisis.

A client reports light-headedness, chest pain, and shortness of breath. They physician orders tests to ascertain what is causing the client's problems. Which test is used to identify cardiac rhythms?

electrocardiogram An electrocardiogram is used to identify normal and abnormal cardiac rhythms.

A nurse is conducting a physical examination on a neonate. Which pulse point should the nurse check if a possible coarctation of the aorta is suspected?

femoral With coarctation of the aorta, the nurse should note bounding pulses and increased blood pressure in the upper extremities, as well as decreased or absent pulses and lower blood pressure in the lower extremities. These findings occur because of the narrowing of the aortic arch.

A client tells the nurse that they have been working hard for the past 3 months to control the client's type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check

glycosylated hemoglobin level. Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information only about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

granulocytopenia Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepatitis, infection, and systemic dermatitis aren't adverse reactions to clozapine therapy.

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes rise high off the floor and the heel comes down heavily with each step.

A client's lipid profile reveals an LDL level of 122 mg/dL. This is considered a:

high LDL level. LDL levels above 100 mg/dL are considered high. The goal is to decrease the LDL level below 100 mg/dL.

A nurse is caring for a client in the 13th week of pregnancy who develops hyperemesis gravidarum. The nurse is reviewing the client's laboratory report. Which finding indicates the need for intervention?

ketones in urine Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. A urine specific gravity of 1.010, a serum potassium level of 4 mEq/L (4 mmol/L), and a serum sodium level of 140 mEq/L (140 mmol/L) are all within normal limits.

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority?

massaging the uterus gently If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as ordered. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply.

pH HCO3 PaCO2 Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate (HCO3). The two types of acid-base imbalances are acidosis and alkalosis.