Medical surgical Nursing
a nurse is collecting data from a client who has a new diagnosis of pheochromocytoma. Which of the following findings should the nurse expect?
***Hypertension The nurse should expect a client who has a pheochromocytoma to exhibit severe hypertension. The client's systolic blood pressure can be as high as 300 mm Hg, with a diastolic blood pressure exceeding 150 mm Hg. Other manifestations include nausea, weakness, and severe headache. Pheochromocytoma is a rare tumor of the adrenal gland that secretes excessive amounts of epinephrine and norepinephrine. Bradycardia The nurse should expect a client who has pheochromocytoma to exhibit tachycardia due to excessive production of epinephrine and norepinephrine. Other manifestations include nausea, weakness, and severe headache. Abdominal pain Dry mouth
tap water enema for constipation reports abd cramp during instillation
*Slow the rate of fluid flow.The nurse should slow down the flow of the enema fluid to allow the intestinal spasm to pass if cramping occurs during administration of the enema. Lowering the height of the enema bag will decrease the rate the fluid enters the bowel. Tap water enemas consist of 500 mL to 1 L of fluid that is instilled into the bowel to soften feces. The volume of fluid stimulates peristalsis. Encourage the client to bear down.MY ANSWERThe nurse should encourage the client to take slow, deep breaths to ease the cramping. Bearing down will cause early release of the enema fluid, which will decrease the effectiveness of the enema. Allow the client to expel some fluid before continuing.The nurse should slow the rate of instillation until the cramping eases. Allowing the client to expel some of the enema solution before the procedure is finished will decrease the effectiveness of the enema. Document that the client did not tolerate the enema.Cramping is an expected response to an enema. The nurse should instill as much of the enema as the client can tolerate and then document the results of the expelled enema.
a nurse is caring for a client who has heart failure and the new prescription for furosemide. the nurse should monitor the client for which of the following manifestations as an adverse effect of the medications?
Alopecia: Alopecia is not an adverse effect of furosemide. The nurse should monitor the client for other dermatologic adverse effects of furosemide, such as pruritus, rash, and urticaria. Hypoglycemia: The nurse should monitor the client for hyperglycemia as an adverse effect of furosemide. The nurse should inform the client about manifestations of hyperglycemia, such as polydipsia, polyuria, polyphagia, fatigue, and muscle weakness. Seizures: The nurse should monitor the client for other CNS adverse effects of furosemide, such as blurred vision, dizziness, and headache. ****Tinnitus The nurse should monitor the client for tinnitus or hearing loss as adverse effects of furosemide. Ototoxicity, or the potential to damage hearing, is unique to loop diuretics such as furosemide.
neutropenia reinforce teaching?
Bathe with antimicrobial soap daily. Take temperature daily. Avoid gardening.
foods that cause migraine
Chocolate is correct. Migraine headaches are the result of alterations in cerebral blood flow and can last for several days. Identifying triggers to the development of migraines is a nonpharmacological way of management. The nurse should recommend the client keep a food diary to identify foods that trigger migraines. A common food trigger the nurse should include in the teaching is chocolate.Oranges is correct. A common food trigger the nurse should include in the teaching is citrus fruits. Oranges, as well as other citrus fruits, can trigger migraine headaches.Tomatoes is incorrect. A common food trigger the nurse should include in the teaching is food containing tyramine, such as raisins, bananas, and avocados; however, tomatoes should not trigger migraine headaches.Ground beef is incorrect. A common food trigger the nurse should include in the teaching is meat that contains nitrites, such as bacon or salami. However, ground beef is a meat that does not contain nitrites and should not trigger migraine headaches.Artificial sweeteners is correct. A common food trigger the nurse should include in the teaching is artificial sweeteners. Products such as aspartame, sucralose, and saccharine can trigger migraine headaches.
reinforce teaching for chronic renal failure c epoetin alfa what to include?
Epoetin alfa is a hormone that stimulates the production of red blood cells. It is used in the treatment of specific types of anemia. Therapeutic effects are indicated by an increase in hematocrit resulting in a decreased requirement for blood transfusions.
When caring for a client with a chest tube the nurse notes continuous bubbling in the chest tube water seal chamber What does this indicate?
Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the drainage system. For this finding, the nurse should notify the charge nurse.
reinforce teaching pernicious anemia *understand teaching
Following initial therapy with parenteral cyanocobalamin, the client can receive cyanocobalamin intranasally when the client achieves hematologic remission. The client reaches hematologic remission when folic acid, vitamin B12, iron, hemoglobin, hematocrit, and reticulocyte count return to expected levels. Pernicious anemia is a disorder in which the client lacks an intrinsic factor in the gastric juices, which prevents the absorption of vitamin B12. Manifestations of pernicious anemia include pallor, fatigue, problems with balance, and paresthesia. *need to increase k *whole life *lack intristic factor no PO
delegation to the LPN
Inserting an NG tube is correct. Inserting an NG tube is within the LPN's scope of practice. The RN should use the rights of delegation to ensure the LPN has the competency to perform this task and should provide specific communication regarding the procedure. Assessing a client who reports chest pain is incorrect. Assessment requires an RN; however, an LPN can assist with data collection from a client. The RN should use the rights of delegation when determining which tasks to assign to the LPN. While an LPN can assist with data collection, the RN should identify that the client who reports chest pain is not stable and requires an assessment by an RN.Monitoring an IV infusion site is correct. Monitoring an IV infusion site is within the LPN's scope of practice. The RN should use the rights of delegation when determining which tasks to assign to the LPN. The LPN can monitor an IV infusion site and can also administer IV fluids and medications in some states.Teaching a client how to empty an ostomy pouch is incorrect. The RN should use the rights of delegation when determining which tasks to assign to the LPN. The RN cannot legally delegate parts of the nursing process. Teaching involves aspects of the nursing process; therefore, primary teaching requires an RN. However, an LPN can reinforce teaching.Administering IM medications is correct. Administering IM medications is within the LPN's scope of practice. The RN should use the rights of delegation when determining which tasks to assign to the LPN. Administering IM medications is within the LPN's scope of practice.
pt reports amenotthea and insomnia what to report?
The client's T4 is above the expected reference range of 4 to 12 mcg/dL, which indicates hyperthyroidism. The nurse should report this value to the provider so that treatment for hyperthyroidism can begin.
fx femur c R distress, fever, petechiae what to do AFTER notifying provider?
The nurse should identify that the client is experiencing manifestations of a fat embolism, a life-threatening complication of long bone fractures. This occurs when fat globules lodge in small vessels, leading to vessel rupture. The nurse should place the client in high-Fowler's position to facilitate lung expansion and oxygenation. high-flow oxygen via a nonrebreather mask
EEG teaching
The nurse should instruct the client to shampoo her hair to remove any oils or residue from styling products that might interfere with the adhesion of the scalp electrodes. Electrodes are attached to the client's scalp using electrode paste. An EEG is a diagnostic test that determines electrical activity in the brain and identifies the presence of seizures or other conditions involving the cortex of the brain. -takes 45 min to 2 hrs -coffee, tea, caffeine, and alcohol are restricted for 24 to 48 hr because these can interfere with the results.
reinforcing teaching gastric bleeding needs lavage by closed system irrigation
The nurse should place the client in a semi-Fowler's or high-Fowler's position to enhance the flow of the irrigating solution during the gastric lavage. Gastric lavage removes large amounts of blood, including clots, and other gastric contents, and irrigates the lining of the stomach.
preparing for closed irrigation of an indwelling cather for pt who had abd surgery plan
The nurse should plan to discontinue the irrigation and contact the provider if resistance is felt. This can indicate the client has a total occlusion of the catheter or that the catheter is displaced. need to be slowly injected
TB precautions
While transporting the client within the facility, the nurse should have the client wear a surgical mask to protect others from coming in contact with tuberculosis. A client who has tuberculosis requires airborne isolation precautions because tuberculosis can remain in the air for several hours.
bronchoscopy
administer supplemental 02 Prior to the procedure, the nurse should administer oxygen and then continue to monitor the client's oxygen saturation level throughout and following the bronchoscopy. A bronchoscopy is performed as either a diagnostic or a therapeutic procedure and involves visualizing the larynx and tracheobronchial tree. with neck hyperextended
CA schedule for CT -pt dont want scan done -what should u say?
"You might change your mind about treatment if the results of the CT scan show improvement." "I think you should discuss this with your family before making your decision." "You should have it done for your family's sake, even if you do not want to know the results." ***"I will inform your provider that you have chosen not to have the CT scan performed."
testicular self-examination
***"Examine your testicles after a warm shower." After exposure to warm water in a shower or bath, the scrotum relaxes and becomes easy to palpate. The testicle should feel smooth and round, and the client should report any lumps to his provider. "Press each testicle inwardly with your fingertips." (you should roll) "Rinse any soap off your hands before examining your testicles." "Perform the self-examination every 2 months." (should be monthly)
12 lead ECG for client with angina pectoris teaching
***"Lie still and relax for the procedure." The nurse should instruct the client to relax and remain still during the recording of the ECG because movement and tense muscles can interfere with the results of the ECG. An ECG is a recording of the client's electrical activity of the heart. The electrical activity of the heart is detected by electrodes that are placed on the client's trunk and extremities in specific locations. "Expect mild tingling at the electrode sites." "The electrodes will remain in place for 24 hours." "A medication will be given during the procedure."
a nurse is monitoring a client who has a new prescription for furosemide for peripheral edema. For which of the following adverse effects should the nurse monitor?
******Muscle weakness Furosemide is a loop diuretic, which is used to treat hypertension and edema. Furosemide can cause excess excretion of potassium. The nurse should monitor the client for manifestations of hypokalemia such as nausea, muscle weakness, and spasms. A strong, bounding pulse Furosemide is a loop diuretic, which is used to treat hypertension and edema. The nurse should monitor the client for manifestations of dehydration, which include weak pulse, decreased urine output, and poor skin turgor. Hypertension Furosemide is a loop diuretic, which is used to treat hypertension and edema. The nurse should monitor the client for manifestations of orthostatic hypotension, such as dizziness when standing up. Motor ataxia: Furosemide is a loop diuretic, which is used to treat hypertension and edema. The nurse should monitor the client for muscle spasms, which is an adverse effect of furosemide
