304 EAQ 1
Which type of collaborative action would the nurse anticipate the need to rapidly implement when caring for a client who has a blood pressure of 80/60 mm Hg and heart rate of 120 beats/minute after a motor vehicle accident? Increase circulating blood volume Administer arterial vasopressors Stimulate increased heart rate Correct electrolyte disturbances
Increase circulating blood volume The client's history of a motor vehicle accident and low blood pressure with tachycardia indicates likely hemorrhage and hypovolemic shock. The initial treatment would be infusion of blood and crystalloids such as normal saline. Vasopressors might be used in septic or neurogenic shock, when hypotension is caused by vasodilation. Increasing heart rate will occur as a compensatory mechanism for hypovolemia, but medications to stimulate heart rate are not needed. There is no indication that the client has electrolyte disturbances.
The nurse is caring for several postoperative clients who have had abdominal surgery. Which independent nursing intervention can help prevent the development of thrombophlebitis? Encouraging adequate fluids Massaging the client's leg gently Applying sequential compression devices Helping the client perform in-bed exercises
Helping the client perform in-bed exercises Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation; early ambulation or exercise of the lower extremities reduces the occurrence of this complication. Although encouraging adequate fluids may help, it is not an independent nursing intervention. Postoperative clients often are nothing-by-mouth until peristalsis returns. Massaging is contraindicated because any developing clot may dislodge. Applying sequential compression devices is helpful, but it is not an independent activity; a sequential compression device requires a health care provider's prescription.
Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline? Remove the IV catheter and restart the saline lock in another site Document the findings per protocol and reassess the site in 8 hours Flush the IV catheter and saline lock again vigorously with normal saline Change the dressing and apply a new clean dressing per IV care protocol
Remove the IV catheter and restart the saline lock in another site The client's report of pain and burning at the site indicates that the tip of the catheter is no longer in the vein and the client needs removal of the current catheter and a new IV access site. Documenting the findings and then reassessing the site in 8 hours would leave the client with no IV access. Flushing vigorously will lead to more pain as more saline is pushed into the infiltrated site. Changing the dressing would leave the client without a patent IV access.
Which factor would a nurse identify as precipitating hyponatremia? Select all that apply. One, some, or all responses may be correct. Would drainage Diuretic therapy Gastrointestinal (GI) suction Parenteral infusion of 0.9% sodium chloride Inappropriate antidiuretic hormone (ADH) secretion
Wound drainage Diuretic therapy Gastrointestinal (GI) suction Inappropriate antidiuretic hormone secretion Would drainage can result in hyponatremia from loss of sodium ions. Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia. Gastrointestinal fluids are rich in sodium ions, which are lost by GI suction. With the syndrome of inappropriate antidiuretic hormone (SIADH), high levels of the antidiuretic hormone (ADH) are produced, causing the body to retain water instead of excreting it normally in the urine. Parenteral infusion of 0.9% sodium chloride, an isotonic solution, should be compatible with body fluids; if given in excess, it may lead to hypernatremia.
Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L (6.7 mmol/L)? Monitor for cardiac dysrhythmias Inquire about changes in bowel patterns Assess for leg muscle twitching or weakness Assess for signs and symptoms of dehydration
Monitor for cardiac dysrhythmias Severe bradycardia and slowing of the cardiac conduction system are the most severe complications of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia.
The registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective teaching? Administering sodium polystyrene sulfonate Instructing a client to increase potassium and sodium intake Monitoring glucose levels hourly Providing potassium-sparing diuretics
Administering sodium polystyrene sulfonate Increased potassium levels indicate hyperkalemia and are observed in clients with adrenal insufficiency. Administering potassium binding and excreting resin, such as sodium polystyrene sulfonate, can reduce the potassium levels. Potassium restriction should be initiated immediately to reduce the potassium levels. Monitoring glucose is required in a client with hypoglycemia, not hyperkalemia. Providing potassium-sparing diuretics may further lead to increase in potassium levels, and these diuretics should be avoided.
Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complications? Pleural effusion Empyema Pneumothorax Atelectasis
Atelectasis Atelectasis occurs after general anesthesia because of decreased respiratory depth and resulting collapse of alveoli. Pleural effusion is not a typical postoperative problem. Empyema would not be expected after surgery. Pneumothorax is not a common postoperative diagnosis.
Which element would the nurse conclude is likely to have contributed to the development of hyponatremia in an older client found unconscious at home and admitted to the hospital with a fractured hip, renal failure, and dehydration who received 3 L of intravenous fluid in 24 hours since admission? Reduced dietary salt intake Intravenous fluid infusion Potassium reabsorption rate Increased glomerular filtration
Intravenous fluid infusion Hemodilution has most likely occurred because 3 L of intravenous fluid will lower the serum sodium level by increasing intravenous fluid and reducing the serum concentration of sodium. A reduced dietary salt intake is not the most likely cause of hyponatremia developing during the first 24 hours of this hospitalization. Changes to the serum potassium reabsorption rate are not likely to have caused hyponatremia in the past 24 hours. A decreased, not increased, glomerular filtration rate occurs with renal failure.
Which explanation would the nurse give regarding purpose of early ambulation to a client who had surgery the previous day? Promote healing of the incision Decrease incidence of urinary tract infections Allow nursing staff to change the bedding Keep blood from pooling in the legs to prevent clots
Keep blood from pooling in the legs to prevent clots The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although nursing staff often change the bed when clients are up ambulating, the purpose of early ambulation is the prevention of client complications, not making nursing actions more convenient for the staff
Which factor affects the client's ability to perform postoperative deep breathing and coughing requirements after a nephrectomy for renal cancer? Location of the client's surgical incision Increased anxiety about the prognosis Inflammatory process associated with surgery Pulmonary congestion from preoperative medications
Location of the client's surgical incision The location of the surgical site in relation to the diaphragm increases incisional pain when deep breathing or coughing. Anxiety about the prognosis should not interfere with the ability to deep breathe and cough, especially when encouraged by the nurse. Inflammatory changes will cause discomfort in the area of any incision but are not necessarily the prime factor preventing deep breathing after a nephrectomy. The client will need to cough and deep breathe if there is congestion in the lungs.
Which clinical finding is a priority requiring collaboration with the primary health care provider when a nurse reviews the medical record of an older adult client admitted with chronic kidney disease? Sodium level Potassium level Creatinine results Blood pressure results
Potassium level The client has an increased potassium level outside the expected range for an adult, placing the client at risk for a cardiac dysrhythmia; the higher priority is treatment for the increased potassium, because elevated levels can be lethal. The serum sodium of 135 mEq/L (135 mmol/L) is expected because of the electrolyte imbalance caused by the presence of chronic kidney failure. A creatinine clearance of 20 mL/min (0.33 mL/s) is low (normal range 95 mL/min in young women; 120 mL/min in young men); however, the client has chronic renal disease and this value reflects the disease process. The priority is the high potassium level. Clients with chronic kidney disease usually have hypertension, and notification is unnecessary.
Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? Pouring warm water over the perineum Ensuring the patency of the catheter Removing the catheter within 24 hours Cleaning the catheter insertion site
Removing the catheter within 24 hours Clients who undergo surgery are at greater risk of acquiring catheter-associated urinary tract infections. . Infections can be prevented by removing the catheter within 24 hours if the client does not need it. Removing the catheter within 24 hours would be the best intervention. Although pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.
After insertion of a central venous catheter through the left subclavian vein, a client reports of chest pain and dyspnea and has decreased breath sounds on the left side. Which action would the nurse take first? Administer oxygen as prescribed Activate the Rapid Response Team Give the prescribed as needed morphine sulfate Assist the client to cough and deep breathe
Administer oxygen as prescribed The client's history of a subclavian vein central line insertion and sudden onset of pain, dyspnea, and decreased breath sounds suggest tension pneumothorax. The nurse will initially administer oxygen. The next action would be to activate the Rapid Response Team, because chest tube placement is likely to be needed to allow lung reexpansion. Morphine sulfate may be needed for pain control, but would not be the initial action. Coughing and deep breathing will not help with dyspnea caused by tension pneumothorax, although the client would be encouraged to cough and deep breathe once the chest tube is in place.
A client experiences a decreased potassium level. The nurse recalls that hypokalemia inhibits the synthesis of which hormone? Aldosterone Somatostatin Norepinephrine Androstenedione
Aldosterone Hypokalemia inhibits synthesis of aldosterone hormone. Somatostatin inhibits the synthesis of insulin. Norepinephrine also inhibits the synthesis of insulin. Androstenedione secretion may not be inhibited by hypokalemia.
Which clinical manifestation would the nurse expect to find in a client with hypokalemia? Select all that apply. One, some, or all responses may be correct Thirst Anorexia Leg ctamps Rapid, thready pulse Dry mucous membranes
Anorexia Leg cramps The gastrointestinal manifestations associated with hypokalemia are caused by decreased neuromuscular irritability of the gastrointestinal tract; this results in anorexia, nausea, vomiting, and decreased peristalsis. Because of potassium's role in the sodium-potassium pump, hypokalemia results in altered neuromuscular functioning, which precipitates leg cramps. Thirst is associated with hypernatremia. Rapid, thready pulse is associated with dehydration and hyponatremia. Dry mucous membranes are associated with hypernatremia.
Which action is the priority when the preoperative nurse learns that a client is taking several herbal supplements? Provide the client with information about the usefulness of herbal therapies Inform the client about taking supplemental vitamins rather than herbs Teach the client about herbal supplements Ask the client which herbs have been taken
Ask the client which herbs have been taken The nurse must find out which herbs the client has been taking because some herbs can prolong bleeding, and the health care provider may need to postpone the surgery until the client has been free of herbal supplements for a period of time. Teaching the client about the usefulness of herbal therapies may be needed at another time, but the priority in the preoperative client is to determine whether the client is at risk for bleeding because of herbal therapy. Teaching about the benefits of vitamin supplements instead of herbal therapy may be needed, but the immediate preoperative time is not the best time for education on this topic. Teaching the client more about herbal supplements may be needed at another time, but the priority in the preoperative time is to determine exactly which herbal therapies the client has been using.
Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery? Assist client to use incentive spirometer Administer prescribed intravenous antibiotic Take client vital signs every 4 hours Auscultate breath sounds every 4 hours
Assist client to use the incentive spirometer The most common respiratory complication after surgeries requiring a general anesthetic is atelectasis, which is prevented by having the client use an incentive spirometer and take deep breaths and cough. Antibiotics are prescribed after abdominal surgery to prevent abdominal infection, not to prevent respiratory complications such as pneumonia. Taking vital signs will help with detecting respiratory complications such as pneumonia, but is not helpful in prevention. Auscultation of breath sounds will detect respiratory complications, but will not prevent atelectasis.
When would the nurse begin rehabilitation planning for the client who is scheduled for a below-the-knee amputation? Before the surgery takes place During the convalescent phase On discharge from the hospital When it is time for a prosthesis
Before the surgery takes place Rehabilitation should begin immediately. This includes preoperative discussion of the nature of the operation and rehabilitation techniques. During the convalescent phase, on discharge from the hospital, and when it is time for a prosthesis are too late; valuable rehabilitation time has been wasted.
Which symptom would the nurse monitor for when caring for a client who has hyponatremia? Increased urine output Deep rapid respirations Change in level of consciousness Distended neck veins
Change in level of consciousness A normal sodium level is between 135 and 145 mEq/L (135-145 mmol/L) of sodium. As sodium levels drop below 140 mEq/L, symptoms reflect cellular overhydration, which results from water movement from the relatively hypotonic serum into cells. Symptoms affect primarily the central nervous system (CNS) and musculoskeletal systems. CNS effects range from headache, fatigue, and anorexia to lethargy, confusion, disorientation, agitation, vomiting, seizures, and coma. Musculoskeletal symptoms may include cramps and weakness. Vital signs will reflect an increased, weak, thready pulse, shallow respirations, and a low urine output. Neck veins are not distended by hyponatremia.
Which collaborative intervention will the nurse anticipate when a postoperative client has these changes in heart rate (HR) and blood pressure (BP) with position changes: Lying HR = 70 beats/minute, BP = 110/70 mm Hg; Sitting HR = 78 beats/minute, BP = 106/66 mm Hg; Standing HR = 85 beats/minute, BP = 108/64 mm Hg? Increase in diuretic dose Decrease in activity level Intravenous fluid infusion Continue current plan of care
Continue current plan of care Because the assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure), there is no indication that a change in the current therapeutic plan is needed. An increase in diuretic dose would cause hypovolemia. Because the client does not have postural hypotension and there is no other indication of poor activity tolerance, the client can continue or increase the current activity level. Intravenous fluids are not needed because there is no significant change in HR or BP with position change.
The nurse is teaching a client about a sodium-restricted diet. Which foods should the nurse encourage the client to consume? Select all that apply. One, some, or all responses may be correct Fruits Sliced deli meats Condiments Fresh vegetables Processed cheese
Fruits Fresh vegetables Most fruits and vegetables are allowed in a sodium-restricted diet. Sliced deli meats are processed and high in sodium. Condiments such as ketchup are high in sodium. Most processed foods such as processed cheese have sodium added to enhance taste and preserve food.
Which finding for a client who has a potassium level of 2.8 mEq/L (2.8 mmol/L) would be of most concern to the nurse? Abdominal cramps Irregular heart rate Decreased reflexes Muscle weakness
Irregular heart rate The most serious complications of hypokalemia are due to changes in cardiac function, including potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation. Abdominal cramps occur with hypokalemia, but are not fatal. Decreased reflexes occur with hypokalemia, but are not fatal. Muscle weakness occurs with hypokalemia and may progress to paralysis, but is not immediately fatal.
Which action would the nurse take first when a client suddenly reports lightheadedness and blood pressure drops while waiting in the preoperative holding area for endovascular repair of an abdominal aortic aneurysm? Prepare the blood transfusions Notify the surgeon immediately Ensure the surgical consent form is signed Administer the prescribed preoperative sedative
Notify the surgeon immediately Because the client's symptoms indicate a likely rupture of the aneurysm, immediate surgical intervention is needed. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. Surgical consent will be obtained, but the surgeon needs to be rapidly available to intervene. Preoperative medications will eventually be administered, but they mask clinical manifestations of shock and would not be given until the health care provider evaluates the client.
Which term would the nurse use to document a drop in blood pressure when a client moves rapidly from a lying to a standing position? Malignant hypotension Orthostatic dehydration Orthostatic hypotension Vasomotor instability
Orthostatic hypotension Orthostatic hypotension specifically refers to an abnormally low blood pressure that occurs when an individual assumes a standing position. Orthostatic hypotension is also known as postural hypotension. It may be a result of internal bleeding, fluid depletion, or loss of neurovascular control preventing vasoconstriction from regulating blood pressure. Malignant hypotension and orthostatic dehydration are inaccurate terms that are not used. Vasomotor instability occurs during menopause and results in hot flashes and night sweats.
Which finding would the nurse expect when assessing a client hospitalized for dehydration? Select all that apply. One, some, or all responses may be correct. Protruding eyeballs Postural hypotension Client reports eating an average of two meals daily Skin on forehead remains tented after being pinched Weight loss of 4 ounces (0.11 kg) over 4 days
Postural hypotension Skin on forehead remains tented after being pinched Postural hypotension is an indicator of dehydration. To determine dehydration in the adult, the nurse should test for decreased skin turgor. To assess for dehydration, pinch the skin over a bone with little or no underlying fat, such as the sternum or forehead. If the skin remains tented after it is released, the client is dehydrated. The eyeballs may be sunken, not protruding, in the presence of dehydration. The client's report of eating two meals a day does not indicate dehydration. A weight loss of 4 ounces (0.11 kilogram) does not indicate dehydration.
Which prescription would the nurse question when a client's serum sodium is 123 mEq/L (123 mmol/L)? Add table salt to each meal Fluid restriction of 1000 mL per day Assess neurological status every 2 hours Provide 0.45% sodium chloride (NaCl) intravenously at 125/h
Provide 0.45% sodium chloride (NaCl) intravenously at 125 mL/h Because 0.45 % NaCl (one-half normal saline) is a hypotonic solution, it is contraindicated. It would actually compound the issue instead of correcting the hyponatremia. Treatment for hyponatremia can include restricting fluid intake and increasing sodium intake either via oral intake or, in severe cases, intravenous fluids. The presence of hyponatremia, as well as correction of hyponatremia if done too quickly, can cause fluid shifts in the brain, resulting in altered mental status. It is important for the nurse to assess for neurological changes.
The nurse is providing preoperative teaching to a client who is scheduled for abdominal surgery. The client is fidgeting, slightly diaphoretic, and asking simple questions about information that was already provided during the education session. Which initial step would the nurse take? Repeat the information, speaking slowly and distinctly Reduce the client's level of anxiety Teach the client about measures to lessen preoperative anxiety Ask the client to verbalize concerns and questions
Reduce the client's level of anxiety Anxiety experienced by a preoperative client can be a disruptive force that may affect the client's ability to cope psychologically and physiologically. Anxiety must be alleviated for other nursing measures to be effective. Although it may be necessary to repeat the information, the client is not likely to retain the education until his or her anxiety is reduced. Learning is hampered by high anxiety levels. If the client's anxiety is not addressed, it is unlikely that the client will be able to identify questions that he or she has.
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse would monitor which laboratory result? Sodium and chloride levels Bicarbonate and sulfate levels Magnesium and protein levels Calcium and phosphate levels
Sodium and chloride levels Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.
A medical-surgical nurse completes the admission assessment on a client diagnosed with a urinary tract infection. The client's admitting weight is 165 lb (74.8 kg). The vital signs are temperature 96°F (35.6°C), pulse 110 beats per minute, respirations 20 per minute, and blood pressure 88/56 mm Hg. The client received 3 L of normal saline in the emergency department. The total urine output for the past 2 hours was 20 mL via a urinary drainage system. Which intervention would the nurse recommend to the primary health care provider? Transfer the client to a critical care unit Discontinue the urinary catheter immediately Administer another 1 L bolus of sodium chloride Begin a dopamine hydrochloride drip for renal perfusion
Transfer the client to a critical care unit The client has a known infection, is exhibiting signs of sepsis, and is unresponsive to fluid therapy as evidenced by the low blood pressure. The client is showing signs of renal failure. The client is manifesting probable signs of septic shock requiring a higher level of care. This question requires the medical/surgical nurse to synthesize the client's manifestations and make an evaluation of the need for more invasive care than is available on the admitting unit. The urinary catheter is necessary to continue monitoring the urine output in this acute client. Giving another fluid is plausible, but this client weighs 75 kg, requiring a maximum of 3 L of fluid to be given before a diagnosis of severe sepsis. The client requires more invasive monitoring than can be done on a medical/surgical unit to determine if more fluid or vasopressors are required.
Which action is essential before the nurse administers preoperative medication to a client scheduled for incision and drainage of a wound abscess? Verify the consent Have the client void Check the vital signs Remove the client's dentures
Verify the consent Consent must be acquired when the client is fully oriented and in a clear mental state. Informed consent is one way to help ensure patient safety. It helps protect the client from any unwanted procedures and protects the surgeon and the facility from lawsuit claims related to unauthorized surgery or uninformed patients. Although important, having the client void, checking the vital signs, and removing the client's dentures can be implemented before surgery even if the client has received medication.
