5
A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply. 1. Document this communication in the electronic health record 2. Encourage the client to discuss this decision with the health care proxy 3. Facilitate completion of an advance directive that reflects the client's decision 4. Obtain a signed informed consent from the client 5. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order
1 2 3 Explanation: Advance care planning is a process that includes: Considering treatments that may be needed in the future Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the medical record (Option 1) Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the client in the future (Option 3) Ensuring that the health care proxy (or durable power of attorney for health care) has information and documentation to support that role if this person needs to make decisions for the client (Option 2) The nurse's role as advocate includes discussing options with the client and ensuring that the client's wishes are communicated and documented appropriately so that the health care proxy and health care team will have the necessary information. (Option 4) An informed consent is necessary for the client or surrogate decision maker to approve certain treatments, procedures, and surgeries. The nurse's role in obtaining informed consent is to obtain and witness a signature once the HCP has explained the procedure, its risks and benefits, and answered any questions. This client is not providing consent for any procedure at this time. (Option 5) A DNR order is used to prevent resuscitation in someone with a life-limiting illness. A DNR order does not provide direction for nutrition supplementation.
n which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. 1. Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2. Client on newly prescribed lisinopril and is at 8 weeks gestation 3. Client on nitroglycerine patch for heart failure and blood pressure is 84/56 mm Hg 4. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia 5. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value
1 2 3 Heparin is a natural anticoagulant. Its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-associated thrombocytopenia. Normal platelet range is 150,000-400,000/mm3 (150-400 x 109/L). A mild lowering of platelets may occur and resolve spontaneously around the 4th day of administration. The danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than 50% from baseline), which requires discontinuing heparin (Option 1). Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are teratogenic. Lisinopril can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous system) if taken during pregnancy, especially during the first 13 weeks of gestation. During the 2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low fetal urine output (oligohydramnios) and fetal growth restriction (Option 2). Nitroglycerine causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion (Option 3).
Which positions are correct when caring for clients undergoing therapeutic procedures? Select all that apply. 1. High-Fowler's for a paracentesis in cirrhosis 2. Left side after liver biopsy in hepatitis 3. Semi-Fowler's after a cardiac catheterization 4. Sims for soap-suds enema administration 5. Supine position after lumbar puncture
1 4 5 A therapeutic/comfort paracentesis in cirrhosis requires the client to be upright so that the fluid is in the lower abdomen where the trocar will be placed for draining it (Option 1). When in the Sims, or left lateral recumbent, position, the client is lying on the left side with the left leg straight and the right hip and knee flexed. It is a common position for enema administration (Option 4). Before a lumbar puncture (spinal tap), the client is placed in the fetal position or bent over a table to separate the vertebrae. Afterwards, the client is placed flat in bed in the prone or supine position for 4 to 8 hours. This will minimize the risk for a "spinal" headache from the loss of cerebrospinal fluid (Option 5). (Option 2) Before a liver biopsy, the client is placed supine with the right arm above the head. The client is instructed to exhale fully and to not breathe when the needle is inserted. The risk after a liver biopsy is for internal bleeding as liver pathology affects coagulation factors. After the biopsy, the client is placed supine on the right side for 12-14 hours so that the heavy liver falls down on itself and provides internal direct pressure to minimize bleeding. (Option 3) The client is laid flat for hours after a percutaneous coronary intervention (PCI) to prevent pressure at the insertion site of a major vessel so that there is no hemorrhage or hematoma.
The nurse is reinforcing teaching to the parent of a child diagnosed with ringworm. Which statement by the parent indicates a need for further teaching? 1. "Antifungal cream must be applied to all affected areas to eradicate ringworm from the body." 2. "Hand washing is very important as ringworm can be spread among humans and pets." 3. "My child has been infected by a worm and must be treated to rid it from the body." 4. "My child will be uncomfortable due to itching, but this is not a dangerous condition."
3. "My child has been infected by a worm and must be treated to rid it from the body." Ringworm, or tinea corporis, is a fungal infection on the superficial keratin layers of the skin, hair, and/or nails. Ringworm is a misleading name as the condition is not caused by a worm infestation. However, it is highly contagious and spreads via contact. Management includes teaching appropriate hygiene (eg, washing hands after touching infected areas), limited contact with personal items (eg, hair brush), and treatment with the prescribed shampoos as well as topical and/or oral medications (eg, terbinafine [Lamisil], miconazole)
Which statements related to ethical nursing practices are correct?
Ethical principles guide decision making and appropriate behavior. Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Option 4). Accountability refers to accepting responsibility for one's actions and admitting errors (Option 1). Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia (Option 5). (Option 2) Autonomy is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can provide information and should respect the client's decisions. (Option 3) Confidentiality means that information shared with the nurse is kept in confidence unless permission is given to share or it is required by law to be shared to protect the client and/or community (eg, reportable infectious diseases). If a client discusses suicidal ideation with the nurse, it must be appropriately reported to protect the client from self-harm.
incidence
Incidence is the number of newly diagnosed cases of the disorder within a healthy population within a defined period; the prevalence is the total number with that disorder among the same population during the same period. The summary data indicate that 80 students were newly diagnosed with depression over the five year study period.
The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care?
Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting.
heart meds
Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide). (Option 2) Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure. (Option 3) Metoprolol, bisoprolol, and carvedilol (lols) are the commonly used beta blockers for treatment of chronic heart failure. They block the negative effects of the sympathetic nervous system (increased heart rate) and reduce the cardiac workload. However, they can worsen heart failure if used in the acute setting of this condition. (Option 4) Isosorbide (nitrate) and hydralazine are used in African American clients with heart failure; this combination decreases cardiac workload by reducing preload and afterload. However, it does not decrease excess fluid.
Amitriptyline
Overdoses are generally a priority due to the unpredictability of dosing and client response. Specifically, the tricyclic antidepressant amitriptyline (Elavil) is lethal if taken in overdose, especially if consumed with alcohol. It is estimated that 70%-80% of clients with tricyclic antidepressant overdose die before reaching the hospital. Amitriptyline was historically used for depression; it is now used for insomnia and neuropathic pain. Death results from serious cardiac arrhythmias.
potassium chloride through a peripheral vein to a client with hypokalemia.
The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action.
Ventricular bigeminy
Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP).
