GERIATRIC ASSESSMENT B #2 RACIEL
A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? Atelectasis Flail chest Hemothorax Pneumothorax
Flail chest Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out.
A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor? Hypermagnesemia Hypokalemia Hyperkalemia Hypomagnesemia
Hypokalemia If the nephrotic syndrome is immunologic in origin, it is often treated with the administration of corticosteroids such as methylprednisolone. Corticosteroid use can lead to hypokalemia, which features manifestations of muscle weakness and cardiac arrhythmia.
A nurse is instructing a group of clients regarding nutrition. The teaching should state that which of the following groups of foods contains the highest level of carbohydrates? Milk, eggs, and cheese Butter, oils, and avocados Rice, potatoes, and oranges Chicken, green beans, and apples
Rice, potatoes, and oranges This group of foods contains the highest level of carbohydrates.
A nurse is caring for a male client who reports abdominal pain. Medical History Physical Examination Diagnostic Results Vital Signs Medical History • Diverticulitis 5 years ago • Allergies: Penicillin Physical Examination Day 1 1900: • Client presents with left lower quadrant (LLQ) pain, rated 9 on a 0 to 10 pain scale with nausea and vomiting since yesterday. • Client states, "I am unable to eat or drinking anything without vomiting." Last bowel movement 3 days ago. Bowel sounds hypoactive in all 4 quadrants, abdomen distended, tender to palpation with guarding. • Client is alert and oriented to person, place, and time. Able to move all extremities. +2 peripheral pulses. Lungs clear to auscultation. • 18 g peripheral IV catheter inserted to right forearm with 0.9% sodium chloride infusing at 75 mL/hr continuous via pump. Medical History: • Diverticulitis 5 years ago • Allergies: Penicillin Diagnostic Results Day 1 1915 Sodium: 140 mEq/L (136 mEq/L - 145 mEq/L) Potassium: 3.5 mEq/L (3.5 mEq/L - 5 mEq/L( BUN: 19 mg/dL (10 mg/dL - 20 mg/dL) Creatinine: 1.1 mg/dL (0.6 mg/dL - 1.3 mg/dL) White Blood Cell Count: 28,000/mm3 (5,000 - 10,000/mm3) Red Blood Cell Count 4.8 million/mm3 (4.7 - 6.1 million/mm3) Hemoglobin: 12 g/dL (14 g/dL- 18 g/dL) Hematocrit: 37% (42%-52%) Platelet Count: 230,000/mm3 (150,000 - 400,000/mm3) Stool for Occult Blood: positive (negative) Day 2 0800 Sodium: 136 mEq/L (136 mEq/L - 145 mEq/L) Potassium: 3.2 mEq/L (3.5 mEq/L - 5 mEq/L( BUN: 19 mg/dL (10 mg/dL - 20 mg/dL) Creatinine: 0.9 mg/dL (0.7 mg/dL - 1.3 mg/dL) White Blood Cell Count: 40,000/mm3 (5,000 - 10,000/mm3) Red Blood Cell Count 3.8 million/mm3 (4.7 - 6.1 million/mm3) Hemoglobin: 11 g/dL (14 g/dL- 18 g/dL) Hematocrit: 30% (42%-52%) Platelet Count: 230,000/mm3 (150,000 - 400,000/mm3) Vital Signs Day 1 1900: Temperature 37.4°C (99.3°F) Heart rate 100/min Respiratory rate 20/min Blood pressure 148/76 mm Hg SaO2 95% Day 2 0700: Temperature 38°C (100.3°F) Heart rate 110/min Respiratory rate 22/min Blood pressure 110/64 mm Hg SaO2 93% For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Potential Order Anticipated Contraindicated CT of the abdomen with contrast. Increase fiber intake. Type and cross match blood. Administer ampicillin/sulbactam IV bolus. Administer enema now X1. Change IV fluids to 0.9 % sodium chloride with 20 KCL @ 125 mL/hr
When analyzing cues the nurse should anticipate type and cross matching the client's blood as well preparing the client for a CT of their abdomen with contrast along with administering IV antibiotics due the client's WBC count, fever and history of diverticulitis. The nurse should anticipate initiating IV fluids to 0.9% with KLC and the rate due to dehydration and electrolyte imbalance. Administering an anemia along with increasing the client's fiber is contraindicated for a client who may have diverticulitis. The client has been vomiting since yesterday and unable to tolerate any by mouth. Clients who have diverticulitis have loose stools containing blood.
A nurse is teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching? "Disaster drills should be held on a regular basis." "An actual disaster cannot take the place of a disaster drill." "A staff nurse can function as the incident commander." "A physician must triage victims of a disaster in the emergency department."
"Disaster drills should be held on a regular basis." Hospitals should perform disaster drills on a routine basis to ensure effective response in the event of a disaster.
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? "I drink at least 2 quarts of fluid every day." "The last time I voided it was painful and red-tinged." "My period ended 2 days ago." "I don't eat shellfish because it gives me hives."
"I don't eat shellfish because it gives me hives." The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.
A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include? "Rest in bed for at least 2 days." "Keep your head up and straight." "Deep breathe and cough four times a day." "Lie on the side of the surgery when in bed."
"Keep your head up and straight." Keeping the head straight and avoiding looking down prevents increasing intraocular pressure.
A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate? "Let's talk about your concerns about the new policy." "Why didn't you voice your concerns before the new policy was implemented?" "Being open to change is an expectation of the nurses who work on this unit." "You should support this policy change because it was based on evidence-based practice."
"Let's talk about your concerns about the new policy." The nurse manager should meet with the nurse to allow an open forum for the nurse to verbalize the reasons for her reluctance to adopt the new policy.
A nurse is teaching an assistive personnel (AP) about the purpose of a footplate on the bed of a client whose leg is in Buck's traction. Which of the following statements indicates the AP understands the teaching? "The footplate works to anchor the traction." "The footplate helps to prevent foot drop." "The footplate keeps the client from sliding down in bed." "The footplate prevents pressure sores on the heel."
"The footplate helps to prevent foot drop." The purpose of a footplate is to prevent foot drop by providing support and a surface for isometric resistance exercises.
A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma? Painless, raised purple nodules on the hard palate A firm nodule with a hard crust A small macule with a yellow-brown scale Yellow-white patches of growth on the tongue
A firm nodule with a hard crust Squamous cell carcinoma appears as a firm nodule, which can either have a crust or a depressed area in the center. The margins are indurated, and the lesion is fixed to the deeper tissue of the area.
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication? Nonverbal communication conveys less truth than what the client states verbally. The client's sociocultural background influences nonverbal communication. Nonverbal communication is a poor reflection of what the client feels. The client enacts nonverbal communication consciously.
The client's sociocultural background influences nonverbal communication. Sociocultural background has a major influence on what a client's nonverbal behavior means.
A nurse is caring for a client who is receiving magnesium sulfate to treat severe preeclampsia and asks the nurse "Is the medication working?" Which of the following responses should the nurse make? "The medication is working because there are no contractions." "The medication is working, because there is no seizure activity." "The medication is working, because all your lung fields are clear." "The medication is working, because your blood pressure is normal."
"The medication is working, because there is no seizure activity." Magnesium sulfate can be used for various reasons, including antacid, antiarrhythmic, anticonvulsant, electrolyte replacement and laxative. The primary indication for the client who is being treated for preeclampsia is the anticonvulsant properties. It is the preferred drug to prevent seizures in preeclampsia and treat seizures associated with eclampsia.
A nurse is providing discharge teaching to a client following hip arthroplasty. Which of the following pieces of furniture should the nurse instruct the client to sit in at home? A reclining chair with an ottoman A straight-backed chair with an elevated seat A couch with plush cushions A rocking chair with a curved back
A straight-backed chair with an elevated seat A straight-backed chair with an elevated seat allows the client to assume proper positioning when sitting. An elevated seat decreases the risk of hip dislocation.
A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.) Loss of color discrimination. Coarse facial features Enlarged distal extremities Hepatomegaly Moon face
Acromegaly is a chronic metabolic disorder caused by an excess of growth hormone (hyperpituitarism) during adulthood, after normal growth of the skeleton and other organs is complete. Often rising from an adenoma, the tumor compresses the optic nerve and causes visual changes such as loss of color discrimination, narrowed perceptual field, or blindness.
A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching? Bottled water is an appropriate choice to increase fluid intake. The salad bar is a healthy choice when dining out. Soft-boiled eggs are an appropriate source of protein. Eating at a buffet is a good choice to increase caloric intake.
Bottled water is an appropriate choice to increase fluid intake. Clients who have neutropenia are at risk for foodborne illness. Bottled water prevents client exposure to pathogens that may be found in other water sources.
A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88 mm Hg, his body mass index (BMI) is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders? Testicular cancer Cardiovascular disease Depression Thyroid disease
Cardiovascular disease Risk factors for cardiovascular disease include BP elevation, obesity, smoking, and a sedentary lifestyle.
A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan? Instruct the client to deep breathe every 4 hr. Check the client's voice every 2 hr. Place the head of the client's bed in the flat position. Hyperextend the client's neck.
Check the client's voice every 2 hr. The nurse should assess the client's voice every 2 hr to monitor for hoarseness, which is a manifestation of laryngeal nerve damage.
A nurse is assessing a client who is African-American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice? Palms of the hands Hard palate Conjunctiva Back of the neck
Hard palate According to evidence-based practice, inspecting the client's oral mucous membrane and hard palate are the most reliable methods to determine jaundice for a client who is African-American.
A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result? Immunoglobulin G (IgG) Immunoglobulin A (IgA) Immunoglobulin E (IgE) Immunoglobulin M (IgM)
Immunoglobulin E (IgE) A RAST involves measuring the quantity of IgE present in the serum after exposure to specific antigens that are selected based on the client's symptom history. An elevated IgE indicates a positive response to a RAST.
A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? Attending a class given about tracheostomy care Verbalizing all steps in the procedure Performing the procedure independently Asking appropriate questions about suctioning
Performing the procedure independently The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.
A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take? Apply dry, sterile gauze dressings to affected areas. Prepare to administer acyclovir. Instruct family members with a history of chickenpox that they are still at risk for contracting the virus. Apply topical corticosteroids to the affected areas.
Prepare to administer acyclovir. Acyclovir is effective in the treatment of herpes zoster especially if administered within 24 hr of the eruption.
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include? Keep both eyes patched. Restrict head movement. Eye drops to constrict the pupils will be prescribed. Apply cool compresses.
Restrict head movement. The client should restrict head and eye movement to prevent further detachment prior to surgery.
A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings? Unilateral lesions Serous drainage Intense pain Silvery, white scales
Silvery, white scales The characteristic lesions of psoriasis are thick, erythematous plaques covered by silvery scales.
A nurse is conducting a nutritional assessment for a client who weighs (75 kg) 165 lb. The nurse should calculate that the client's Recommended Dietary Allowance for protein is how much per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ________________ g
The RDA for protein is 0.8 mg/kg. To calculate the client's RDA for protein, the nurse would first determine the client's weight in kg, and then multiply by 0.8 mg/kg.165 lb/X kg = 2.2 lb/1 kgX = 75 kg75 kg x 0.8 mg = 60 g
After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions? Apply hydrating lotions. Apply moist heat. Sit in the sun for 10 min per day. Wash with plain soap and water.
Apply hydrating lotions. The nurse should instruct the client to gently apply hydrating lotions that do not contain metal, alcohol, or perfume.
A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client's decisions? Advocate Caregiver Manager Educator
Advocate A client advocate acts to protect clients' rights and helps clients to speak for themselves.
A nurse is admitting a client to a medical-surgical unit following a fall at home. Medical History Heart failure Iron-deficiency anemia Spironolactone 50 mg PO BID Ferrous sulfate 60 mg PO QD Diagnostic Results Laboratory testResultReference RangeBUN25 mg/dL10 to 20 mg/dLPotassium5.3 mEq/L3.5 to 5 mEq/LHgb16 g/dL12 to 18 g/dLHct47%37% to 52%Urine specific gravity1.0351.005 to 1.030 Nurses' Notes The client is a 78-year-old client who reports nausea and diarrhea for the past 48 hr. The client states, "I felt dizzy getting out of bed this morning and fell." The client reports pain in right hip. Pedal pulses are +1 bilaterally, feet are warm to touch. Neck veins are flat when the client is supine. The client's skin is dry to touch, and tents for 2 min after pinching. Vital Signs HR 118 /min BP 88/60 mm Hg Urine output 90 mL/4 hr Oxygen saturation 95% on room air UNFLAG A nurse is admitting a client to a medical-surgical unit following a fall at home. Medical History Diagnostic Results Nurses' Notes Vital Signs Vital Signs HR 118 /min BP 88/60 mm Hg Urine output 90 mL/4 hr Oxygen saturation 95% on room air The nurse is discussing the client's treatment plan with a provider. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Potential Prescription Anticipated Nonessential Contraindicated Administer supplemental oxygen. Administer spironolactone. Obtain an x-ray of the right hip. Administer an iron supplement. Administer an IV fluid bolus. Obtain the client's weight.
Administer an IV fluid bolus is anticipated. The client has manifestations of dehydration, such as tachycardia, decreased urine output, and an elevated urine specific gravity. Obtain an x-ray of the right hip is anticipated. The client has right hip pain after falling and is at risk for a hip fracture. Obtain the client's weight is anticipated. The client has a history of heart failure and manifestations of dehydration; therefore, the nurse should anticipate obtaining the client's weight to monitor the client's fluid balance. Administer supplemental oxygen is nonessential. The client has an oxygen saturation on room air that is within the expected reference range. Administer spironolactone is contraindicated. Spironolactone is a potassium-sparing diuretic that is contraindicated in clients who have hyperkalemia. Administer an iron supplement is a nonessential. The iron supplement is administered for iron-deficiency anemia. The client's Hgb and Hct levels are within the expected reference range; therefore, the iron supplement is non-essential.
A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? Flushing Dyspnea Bradycardia Vomiting
Dyspnea Circulatory overload causes dyspnea, cough, rales, tachycardia, and jugular vein distention.
A nurse is assessing a client who is 24 hr postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of fat embolism syndrome (FES)? Dyspnea Red-brown petechiae Headache Agitation
Dyspnea Dyspnea is an early manifestation of FES that occurs due to hypoxemia.
A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take? Place a pillow under the affected limb. Apply cool compresses to the affected limb every 6 hr. Promote bed rest for 5-7 days. Encourage increased fluid intake.
Encourage increased fluid intake. Increased fluid intake will prevent dehydration, which can contribute to the development of deep vein thrombophlebitis.
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? Mix the three medications together prior to administering. Dilute each medication with 10 mL of tap water. Maintain the head of the bed in a flat position for 30 min following medication administration. Flush the NG feeding tube with 30 mL of water immediately following medication administration
Flush the NG feeding tube with 30 mL of water immediately following medication administration The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.
A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking? Invoking implied consent Delaying the surgery until a member of the client's family is reached Asking the client to sign the surgical consent form Prescribing naloxone to reverse the effects of the morphine
Invoking implied consent The client is unable to sign the consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency and surgery is in the client's best interest. The neurosurgeon should document the specifics of the situation in the client's medical record.
A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings? Nuchal rigidity Pupils reactive to light Widened pulse pressure Elevated temperature
Widened pulse pressure A widened pulse pressure is a manifestation of increased ICP. Other manifestations include bradycardia, vomiting, and decreased level of consciousness.
A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting which of the following conditions? Malnutrition Hepatitis A Diabetes Cirrhosis
Cirrhosis The nurse should recognizes this client is displaying manifestations of cirrhosis. A history of alcohol use disorder increases the client's risk of developing cirrhosis and coagulation defects are a common complication of cirrhosis.
A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client? Piperacillin/tazobactam Levothyroxine Levodopa/carbidopa Carbamazepine
Levodopa/carbidopa Levodopa/carbidopa is the cornerstone of Parkinson's treatment. The nurse should prepare to instruct the client on the use of this medication.
A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include? Log roll the client every 2 hr. Assist the client to sit upright in a chair for 4 hr at a time. Expect clear drainage on the spinal dressing. Perform neurological checks every 8 hr.
Log roll the client every 2 hr. The nurse should log roll the client from side to back or back to side every 2 hr to maintain spinal alignment and prevent injury to the operative area.
A nurse is teaching about adverse effects of anastrozole with a client who has advanced breast cancer and is postmenopausal. Which of the following adverse effects should the nurse recommend the client report to the provider? Weight gain Stomatitis Cough Musculoskeletal pain
Musculoskeletal pain The client who is experiencing musculoskeletal pain should notify the provider. Musculoskeletal pain is a common adverse effect that affects 50% of clients that is possibly caused from estrogen deprivation.
A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster? Members of the Federal Emergency Management Agency (FEMA) Responding law enforcement officers Representatives from the American Red Cross Nurses and other emergency medical personnel
Nurses and other emergency medical personnel Nurses and other emergency personnel such as physicians, EMTs, and paramedics are responsible for performing triage duties.
A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.) Dark skin Under 40 years of age Overexposure to ultraviolet light Previous skin injury Genetic predisposition
Overexposure to ultraviolet light is correct. Overexposure to ultraviolet light is a risk factor for developing skin cancer. Previous skin injury is correct. Previous skin injury that resulted in a scar is a risk factor for developing skin cancer. Genetic predisposition is correct. Genetic predisposition is a risk factor for developing skin cancer.
A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet? Peanut butter and jelly sandwich Baked potato topped with sour cream Bagel with cream cheese Fruit salad
Peanut butter and jelly sandwich A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich beans for meat protein. Peanut butter is an excellent source of protein. A peanut butter and jelly sandwich, especially if prepared on protein-enriched bread, can provide almost 20 grams of protein.
A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication? Constipation Black-colored stools Staining of teeth Red-colored urine
Red-colored urine Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.
A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? Propranolol Theophylline Montelukast Prednisone
Propranolol Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.
A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take? Pull the curtain around the client's bed. Wash the client's arms and hands first. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus. Fill the bath basin with tap water that is 39° C (102.2° F).
Pull the curtain around the client's bed. The nurse should close the door to the client's room and pull the curtain around the client's bed to ensure the client's right to privacy.
A nurse is planning teaching for the parents of a toddler who follows a vegetarian diet. The nurse should plan to include which of the following foods as the best source of dietary protein for the child? Soy milk Peanut butter Dried beans Whole grains
Soy milk Soy products are a source of complete protein and should be included as the best source of dietary protein for the child.
A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse? The nurse initiates an infusion of 0.9% sodium chloride. The nurse collects a urine specimen. The nurse sends a blood specimen to the laboratory. The nurse starts the transfusion of another unit of blood product.
The nurse starts the transfusion of another unit of blood product. When suspecting a hemolytic reaction, the nurse should immediately stop the transfusion of all blood products. The transfusion of additional products can increase the client's risk for further complication.
A nurse is caring for a 74-year-old female client who reports experiencing increased shortness of breath. Nurses' Notes 1310: A&O x 3. Skin cool, clammy, pale. Respirations labored at 30/min, shallow. Coarse crackles throughout bilateral lung fields. O2 saturation 88% on room air. Jugular vein distention (JVD) present bilaterally. Heart sounds moderate and regular, rate 98/min. BP 114/78 mm Hg. Temperature 37.8º C (99.9º F). Denies pain. Medical History 1000: 74-year-old female who is obese admitted with increased weight gain of 4.5 kg (10 lb) over the last 4 days. Diet has consisted of canned soup and cold meat sandwiches. Denies shortness of breath at rest, dyspnea on exertion. Respirations slightly labored at 22/min. O2 saturation 95% on room air. Few fine rales auscultated bilateral bases. Heart sounds moderate and regular. 3+ pitting edema present bilateral lower extremities. Skin cool, dry, and intact. Abdomen distended, denies discomfort on palpation. Alert and oriented x 3. PERRLA. Past medical history: hypertension x 20 years that is controlled with medication, coronary artery disease (CAD), left ventricular hypertrophy and right-sided heart failure, COPD. History of smoking 2 packs of cigarettes a week. Current medications: Losartan/Hydrochlorothiazide 50/12.5 mg PO dailyAspirin 81 mg PO dailyNitroglycerin 0.3 mg sublingual PRN chest pain UNFLAG A nurse is caring for a 74-year-old female client who reports experiencing increased shortness of breath. Nurses' Notes Medical History Medical History 1000: 74-year-old female who is obese admitted with increased weight gain of 4.5 kg (10 lb) over the last 4 days. Diet has consisted of canned soup and cold meat sandwiches. Denies shortness of breath at rest, dyspnea on exertion. Respirations slightly labored at 22/min. O2 saturation 95% on room air. Few fine rales auscultated bilateral bases. Heart sounds moderate and regular. 3+ pitting edema present bilateral lower extremities. Skin cool, dry, and intact. Abdomen distended, denies discomfort on palpation. Alert and oriented x 3. PERRLA. Past medical history: hypertension x 20 years that is controlled with medication, coronary artery disease (CAD), left ventricular hypertrophy and right-sided heart failure, COPD. History of smoking 2 packs of cigarettes a week. Current medications: Losartan/Hydrochlorothiazide 50/12.5 mg PO dailyAspirin 81 mg PO dailyNitroglycerin 0.3 mg sublingual PRN chest pain Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Action to Take 1 Action to Take 2 Condition Most Likely Experiencing Parameter to Monitor 1 Parameter to Monitor 2
The nurse should take action by apply O2 at 2 L/min via nasal cannula and elevate the head of the client's bed because the client's condition is worsening related to their congestive heart failure . The nurse should continue to monitor the parameters of the client's respiratory rate and oxygen saturation to assess the client's progress. The client's respirations have increased in rate and are more labored. The client's oxygen saturation level has decreased and their lung sounds have deteriorated from a few fine crackles in bilateral bases to coarse crackles throughout.
A charge nurse is teaching a new nurse how to initiate IV access on a client. Which of the following actions by the new nurse indicates an understanding of the teaching? Shaves the selected insertion site with a razor prior to the procedure. Washes hands with soap and water before the procedure Applies sterile gloves prior to inserting the IV catheter Applies the tourniquet 1 inch above the selected insertion site
Washes hands with soap and water before the procedure The nurse should perform hand hygiene prior to starting the procedure
A nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching? "Because I'm dark-complected, I won't have to worry about skin cancer." "I should apply sunscreen prior to going outside, even in the winter months." "I used to lie in the sun all the time, but now I know the tanning bed is a better option." "My father was treated for melanoma, but skin cancer isn't related to genetics."
"I should apply sunscreen prior to going outside, even in the winter months." Almost all cases of skin cancer diagnosed each year are considered to be sun related. Clients should use sunscreen daily to minimize the negative effects of ultraviolet rays and should reapply it every 2 hr.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis
Respiratory acidosis Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).
A nurse is caring for a client who has an NG tube set to low intermittent suction. The nurse irrigates the NG tube twice with 30 mL of normal saline solution during his shift. At the end of the shift, the NG canister contains 475 mL. What amount of NG drainage should the nurse record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ___________mL
The nurse should measure the total drainage in the NG collection device and subtract the amount of irrigant in order to obtain the true amount of drainage. STEP 1: What is the unit of measurement the nurse should calculate? mL STEP 2: What is the amount of drainage in the NG canister? Quantity = 475 mg STEP 3: What is the amount of irrigation used? Irrigation = 60 mL (30 x 2) STEP 4: Should the nurse convert the units of measurement? No STEP 5: Set up an equation and solve for X. Quantity - Irrigation = X 475 - 60 = X 415 = X STEP 7: Round if necessary. STEP 8: Reassess to determine whether the amount to administer makes sense. If there is 475 mL of drainage in the canister and the nurse irrigated the NG tube twice with 30 mL each time, it makes sense that subtracting the irrigation amount from the amount in the canister determines the true amount of drainage (475 mL - 60 mL = 415 mL). The nurse should document 715 mL of NG drainage in the client's I&O record.
