Pharmacology/Med Surg- UWORLD

The mnemonic for metabolic syndrome is

"We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose

A client with an acute stroke presentation (brain attack) requires

"permissive hypertension" during the first 24-48 hours to allow for adequate perfusion through the damaged cerebral tissues. However, the blood-brain barrier is no longer intact once the blood pressure is >220/120 mm Hg. Therefore, "mild" lowering is required, usually to a systolic pressure that is not below 170 mm Hg. Nicardipine (Cardene) is a prototype of nifedipine and is a potent calcium channel blocking vasodilator. It takes effect within 1 minute of IV administration. It is essential to monitor that the blood pressure is not being lowered too quickly or too slowly as this would extend the stroke. Hypotension can occur with or without reflex tachycardia. The drug must be discontinued if hypotension or reflex tachycardia occurs.

IBS MANAGEMENT

(IBS) is a common, chronic bowel condition caused by altered intestinal motility. Peristaltic action is affected, causing diarrhea, constipation, or a combination of both. Management focuses on reducing diarrhea or constipation, abdominal pain, and stress. Clients can manage symptoms with diet, medications, exercise, and stress management. To manage IBS, clients should restrict gas-producing foods (eg, bananas, cabbage, onions); caffeine; alcohol; fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) (eg, honey, high-fructose corn syrup, wheat); and other gastrointestinal (GI) irritants (eg, spices, hot/cold food or drink, dairy products, fatty foods). Clients should gradually increase fiber intake (eg, whole grains, legumes, nuts, fruits, vegetables) as tolerated. Foods that are generally well tolerated include proteins, breads, and bland foods

picc

(PICC) lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter.

Nursing priorities when implementing a chemical contamination emergency response plan include the following:

-Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant -Donning personal protective equipment to protect the nurse when providing care (Option 3) -Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and other clients (Option 2). -Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of the specific cause (Options 1 and 4)

A stroke is not considered stabilized until approximately

48 hours have passed without changes. The client's risk of losing the gag reflex is still high as the stroke could be evolving. UAP should feed only stable clients.

Reversible causes of asystole/pulseless electrical activity

5 Hs Hypovolemia Hypokalemia or hyperkalemia Hypoxia Hydrogen ions (acidosis) Hypothermia 5 Ts Tension pneumothorax Tamponade, cardiac Toxins (narcotics, benzodiazepines) Thrombosis (pulmonary or coronary) Trauma

syringe sizes

A 10 mL syringe is generally preferred for administering medications through a CVC. The smaller the syringe, the greater the amount of pressure per square inch (PSI) exerted during injection. If the pressure produced by the IV push is too high, it can damage the CVC. A damaged CVC may result in complications for the client, including embolism or malfunction. A 1 mL or 3 mL syringe may cause too much pressure (Options 1 and 2). The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC.

Holter Monitor

A Holter monitor continuously records a client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's chest and a portable recording unit is kept with the client. At the end of the prescribed period, the client returns the unit to the health care provider's (HCP) office. The data can then be recalled, printed, and analyzed for any abnormalities. Client instructions include the following: Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated with any recorded rhythm disturbances Do not bathe or shower during the test period Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record

PAC

A PAC is a contraction starting from an ectopic focus in the atrium (other than the sinus node) and coming sooner than the next sinus beat. The P wave has a different shape than the P wave that originated in the sinus node.

PEG tube

A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement

PVC

A PVC is a contraction coming from an ectopic focus in the ventricles. It is a premature (early) conduction of a QRS complex. PVCs are wide and distorted in shape compared to a QRS conducted through the normal conduction pathway. PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress. PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). The nurse should assess the client's physiological response, including apical-radial pulse. Treatment is based on the underlying cause of the PVCs (eg, oxygen for hypoxia, reduction of caffeine intake, electrolyte replacement).

radioactive iodine uptake (RAIU) test

A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease). Important nursing considerations: Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results. All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland. Important aspects of client education: Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure (Option 5). Eating may resume 1-2 hours after swallowing the iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the neck to allow clear visualization during the scan. Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications (eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount of iodine used. You will be awake during the procedure but there should be no discomfort (Option 4). Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resum

carotid endarterectomy

A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain.

chest tube excessive drainage

A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management.

manic episode nutritional

A client with bipolar disorder, manic episode, is at risk for under-nutrition and dehydration due to high energy needs secondary to psychomotor agitation. Because most clients with mania are unable to sit down long enough to consume a meal, foods and fluids that are easily consumed "on the run" must be provided.

Insulin Combos

A combination of long-acting insulin (eg, glargine, detemir) with rapid- (eg, lispro, aspart) or short-acting (eg, regular) insulin is often prescribed for clients with diabetes. The different onsets, peaks, and durations mimic the body's natural insulin levels and enhance glycemic control. Long-acting (basal) insulins have no peak and may last 24 hours or longer. Short-acting insulins peak 2-5 hours after administration and last approximately 5-8 hours. Regular or rapid-acting insulins may be given on a sliding scale at prescribed intervals (eg, before meals and at bedtime) and are dosed based on the client's blood glucose measurement. Insulin glargine and regular insulin may be safely given concurrently due to the differences in onset, peak, and duration

mandibular fracture.

A direct blow to the face or a motor vehicle collision is usually the cause of mandibular fracture. The client drools due to inability to close the mouth from edema and misalignment of the jaw. Structural damage, excessive saliva, and bleeding with pooled blood in the mouth can compromise the airway. Therefore, the priority nursing intervention is to suction the mouth and oropharynx to maintain airway patency. Common clinical manifestations in a client with a fractured mandible are pain, edema of the face and jaw, difficulty speaking, drooling, and bleeding. Appropriate nursing interventions include oral suction to maintain airway patency, administration of oxygen and analgesia, and application of ice to the fac

gastroduodenostomy (Biliroth I)

A gastroduodenostomy (Biliroth I) involves removal of the distal two-thirds of the stomach; the remaining stomach is anastomosed to the duodenum. This technique is used to treat stomach cancer and peptic ulcer disease that does not respond to more conservative treatment. Following a gastroduodenostomy, clients should be taught to consume frequent, low-carbohydrate meals with moderate amounts of fat and protein. Due to the decreased size of the stomach, fluids and meal sizes should be reduced to prevent dumping syndrome (the rapid emptying of stomach contents into the small intestine). Other common postoperative interventions, such as deep venous thrombosis prophylaxis (eg, sequential compression device, antiembolism stockings); turning, coughing, and deep breathing; and elevating the head of the bed to prevent aspiration from reflux, also apply (Options 1, 2, and 3). (Option 4) Following the procedure, the nurse should take care not to introduce infection or disrupt the sutures; therefore, the nasogastric tube should not be moved or flushed unless prescribed by the health care provider. (Option 5) The client should avoid high-carbohydrate meals as they cause dumping syndrome and may lead to hypoglycemia. Educational objective: Clients undergoing a gastroduodenostomy (Billroth I) benefit from postoperative management such as deep venous thrombosis prophylaxis; turning, coughing, and deep breathing; and aspiration precautions (elevating the head of the bed). Dietary changes include eating smaller, frequent meals; decreasing carbohydrates; and eating moderate amounts of fat and protein.

hemorrhagic stroke

A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP) (Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes (Option 5). Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should: Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors Administer stool softeners to reduce strain during bowel movements (Option 1) Reduce exertion, maintain strict bed rest, assist with activities of daily living Maintain head in midline position to improve jugular venous return to the heart (Option 2) Enoxaparin is an anticoagulant used to prevent venous thromboembolism (VTE). Anticoagulants are contraindicated in clients with hemorrhagic stroke; the nurse should question any prescriptions that increase risk for bleeding. A client with hemorrhagic stroke should instead receive nonpharmacologic interventions (eg, compression stockings) to prevent VTE. Educational objective: A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding. The nurse should perform frequent neurological assessments, keep the client NPO, maintain seizure precautions and strict bed rest, and limit any activity that may increase bleeding (eg, anticoagulant administration) or intracranial pressure (eg, stimulation, straining during bowel movements).

Pancreatitis Changes

A high-grade fever or abrupt increase in temperature with worsening abdominal pain could be an indication of a pancreatic abscess, a significant complication of acute pancreatitis. A pancreatic abscess requires immediate intervention (eg, antibiotics, surgical drainage) to reduce the risk of rupture and sepsis; therefore, the health care provider should be notified immediately (Option 4). (Option 1) Clients with acute pancreatitis will position themselves in a side-lying position with knees drawn up to the abdomen and trunk flexed to decrease the pain. (Option 2) An early indicator of hypocalcemia, a possible electrolyte disorder of pancreatitis, is numbness and tingling of the lips and fingers. The nurse should further evaluate the client for possible signs of tetany by assessing for a positive Chvostek's sign or Trousseau's sign. Once further assessment is completed, the findings should be reported. (Option 3) The stool in acute pancreatitis is expected to be fatty and foul-smelling. Educational objective: An abrupt increase in temperature or high-grade fever during an episode of acute pancreatitis must be reported to the health care provider immediately as this may be an indication of a pancreatic abscess. The abscess must be treated promptly to prevent sepsis.

A modified radical mastectomy

A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated. The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options 3 and 4). In general, venipuncture is contraindicated in upper extremities affected by: Weakness Paralysis Infection Arteriovenous fistula or graft (used for hemodialysis) Impaired lymphatic drainage (prior mastectomy)

nasoenteric feeding tube

A nasoenteric feeding tube is used for administration of continual or intermittent enteral feedings and medications. The tube is marked at the exit site (nare) with indelible ink during the initial placement x-ray. The tube may have moved out of the correct position if its external length changes. If this occurs, the nurse should contact the health care provider (HCP) and request a prescription for a repeat x-ray to determine tube location. Based on the x-ray results, enteral feeding may be resumed or the HCP may prescribe insertion of a new tube according to institution policy (Option 3). (Option 1) Even if bedside methods to determine placement are used (eg, gastric aspirate pH and appearance), advancing the tube to the original marking does not guarantee correct placement; these methods are not accurate indicators. Tube feedings should not be resumed after tube dislodgment without x-ray verification of correct placement. (Option 2) A prescription for hand mitts to keep a confused client from disrupting enteral nutrition may be appropriate if other less restrictive interventions (eg, keeping tubing out of client's sight, one-on-one sitter) are ineffective or unavailable. However, this should not be the nurse's next action. (Option 4) The guide wire (stylet) is secured before tube insertion and remains in place until placement is verified by x-ray. Once removed, the guide wire should never be reinserted while the tube is in place as it can protrude and damage both the tube and the client's mucosa.

sudden kidney failure

A person with sudden kidney failure that will require immediate dialysis will have a central venous catheter placed. The catheter will be used until an AVG or AVF can be placed and is ready for use. The catheter should always be the last access option for long-term dialysis due to risk of infection and mechanical malfunction (eg, thrombosis).

Risk for Colonoscopy

A risk of a colonoscopy (or any procedure in which a firm scope is inserted into a "hollow tube" organ) is perforation. Signs of perforation include abdominal pain (with shoulder tip pain), positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or boardlike (rigid) abdomen. Another potential complication is rectal bleeding. (Option 1) Abdominal cramping post procedure is an expected finding. It is caused by the stimulation of peristalsis as the bowel is constantly inflated with air during the procedure. (Option 2) The preparation for the procedure, emptying the colon of stool, includes clear liquids, cathartics, and/or enemas. The stool is watery and copious and may continue for a short time after the procedure. It is not a concerning finding. (Option 4) During the procedure, air is inflated into the colon. The client needs to expel this "gas" afterward. It is an expected finding. Educational objective: The complication risks of a colonoscopy are perforation and rectal bleeding. Abdominal cramping, flatus, and watery stool are expected findings. Perforation can lead to peritonitis, with positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or boardlike (rigid) abdomen.

A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases:

A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. The ictal phase is the period of active seizure activity. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.

therapeutic INR on warfarin

A therapeutic INR level is dependent on the reason the client is receiving the warfarin (an anticoagulant). Typically the therapeutic INR range should be 1.5-2 times the normal "control" value (INR of 2-3) for medical reasons such as deep vein thrombosis, atrial fibrillation, or stroke. An INR of 3 to 3.5 is desired for the client with a mechanical heart valve. An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote.

tracheostomy cuff

A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for clients who are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked to cough (if possible) to expectorate the oropharyngeal secretions that have built up above the inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the cuff is then deflated. Additional interventions to decrease the risk of aspiration include the following: Having the client sit upright with the chin flexed slightly toward the chest Monitoring for a wet or garbled-sounding voice Monitoring for signs of fever

Accidental dislodgement of the tube after a fresh (immature, <1 week) tracheostomy

Accidental dislodgement of the tube after a fresh (immature, <1 week) tracheostomy is a medical emergency as the tract is not yet healed (matured). Significant tracheal inflammation, edema, bleeding, and closure of the tract (resulting in airway loss) can occur. The goal is to keep the stoma open to maintain the airway and oxygenate the client. If accidental dislodgement occurs, immediate nursing actions should include pulling the retention sutures apart (if present) to lift the trachea and hold the stoma open or inserting a curved hemostat to hold the stoma open if sutures are not present. If desaturation progresses while awaiting the arrival of the emergency team, the nurse can apply a sterile occlusive dressing over the stoma and ventilate the client with a bag-valve mask over the nose and mouth (using gentle pressure).

Acute angle-closure glaucoma

Acute angle-closure glaucoma is a form of glaucoma that requires immediate medical intervention. Glaucoma disorders are characterized by increased intraocular pressure (IOP) due to decreased outflow of the aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness. In acute angle-closure glaucoma, IOP increases rapidly and drastically, which can lead to the following manifestations: Sudden onset of severe eye pain Reduced central vision Blurred vision Ocular redness Report of seeing halos around lights Although further evaluation and treatment are necessary, this condition develops slowly and is not considered an emergency situation.

Adalimumab

Adalimumab (Humira) is a tumor necrosis factor (TNF) inhibitor, a biologic disease-modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately.

Addison's disease

Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. A deficiency in all 3 classes of adrenal corticosteroids, including glucocorticoids, mineralocorticoids, and androgens, is present in Addison's disease. Addisonian crisis, or acute adrenocortical insufficiency, is a potentially life-threatening complication of Addison's disease. It can lead to shock and should be reported immediately to the PHCP. Addisonian crisis is triggered by stress, and its manifestations include the following: *Hypotension and tachycardia Dehydration Hyperkalemia and hyponatremia Hypoglycemia Fever Weakness and confusion*

The Institute of Medicine (2000) recognizes 4 types of errors. They are:

Adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure)

capillary permeability

After a burn injury, increased capillary permeability leads to third spacing (fluid shifts to areas where normally minimal or absent), allowing proteins, plasma, and electrolytes to leave the vascular space and occupy other spaces and tissues. This creates a state of hypovolemic shock, which poses the highest risk of mortality in the initial phase of the burn process. Therefore, aggressive fluid resuscitation to correct hypovolemia is a priority. Adequate urine output (at least 30 mL/hr, or 0.5 mL/kg/hr) depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion.

Compartment Syndrome

After a new cast is placed, the nurse should elevate the client's limb above the heart for the first 48 hours to increase venous return and decrease edema in the affected extremity. However, the extremity should not be elevated if compartment syndrome develops.

Ischemic Stroke

After an acute ischemic stroke, the body senses the need for increased pressure to perfuse the penumbra (area of swollen and vulnerable but salvageable brain tissue) to keep the stroke from extending. This phenomenon is a protective mechanism ("permissive hypertension") that usually autocorrects within 24-48 hours and does not require treatment. The usual goal is to maintain systolic blood pressure ≥170 mm Hg to ensure adequate cerebral perfusion. Treatment would be indicated for blood pressure >220/120 mm Hg or for hemorrhagic strokes. (Option 1) IV antihypertensives (eg, labetalol [Normodyne], nicardipine [Cardene]) are often used if medication is required for acute stroke treatment. However, rapid blood pressure reduction may prolong the stroke. Blood pressure should be lowered cautiously by about 15% within the first 24 hours. (Option 3) This client is outside the time range for thrombolytic use for stroke treatment (<3-4.5 hours for systemic tissue plasminogen activator [tPA] and 6 hours for intra-arterial tPA). Also, blood pressure must be <185/110 mm Hg prior to administering tPA and must be maintained at ≤180/105 mm Hg for ≥24 hours after starting fibrinolytic therapy. (Option 4) Seizure medication is not routinely administered prophylactically to stroke victims. A more important concern is to monitor for signs of increased intracranial pressure, which could lead to seizures. Educational objective: "Permissive hypertension" is allowed within the first 24-48 hours of an acute ischemic stroke provided that the blood pressure is <220/120 mm Hg. This practice allows adequate cerebral perfusion to keep the stroke from extending.

inadequate Airway clearance

Airway clearance is impaired with inadequate hydration. The client is receiving NS at only 50 mL/hr (1200 mL/24 hr). In addition, fever and tachypnea increase insensible losses through the skin and respiration. A fluid intake of 2,500-3,000 mL/day is recommended in clients with pneumonia; additional fluids are needed to replace insensible losses. Low-pitched wheezing indicates the presence of secretions in the airways. Increasing hydration by increasing the infusion rate to 125 mL/hr (eg, 3,000 mL/day) will help thin secretions and facilitate expectoration of mucus, and is the best choice for this client.

macrolide antibiotics

All macrolide antibiotics (eg, azithromycin, erythromycin, clarithromycin) can cause a prolonged QT interval, which may lead to sudden cardiac death due to torsades de pointes. Therefore, an electrocardiogram (ECG) should be monitored. Concurrent use of macrolide antibiotics with other drugs that prolong QT interval (eg, amiodarone, sotalol, haloperidol, ziprasidone, azole antifungals) will further increase this risk. Macrolides can also cause hepatotoxicity when taken in high doses or in combination with other hepatotoxic medications such as acetaminophen, phenothiazines, and sulfonamides. Elevation of aspartate transaminase and alanine transaminase levels (liver enzymes) may indicate that hepatotoxicity is occurring, and the nurse should report these results to the HCP.

Allen's test

Allen's test is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently. The nurse must assess color, capillary refill, sensation, temperature, and movement per institution policy. Impairment in any of these parameters must be reported immediately because it may indicate impaired circulation to the extremity, and removal of the catheter may be necessary. To maintain patency of the arterial blood pressure monitoring system, an intravenous bag of normal saline solution is placed in a pressure infuser device. The device is set to maintain continual pressure at 300 mm Hg. The pressure drops as the volume of solution in the bag decreases and can be pumped back up. This does not pose an immediate threat to the client

Allergy Skin Testing

Allergy skin testing involves introducing common allergens (antigen) into the skin surface and then observing the site for swelling and induration, which indicate that the client is allergic to the antigen. Several different antigens, as well as positive and negative controls, are usually tested at the same time for accuracy. To ensure an accurate result, the client should avoid taking any antihistamines such as diphenhydramine and loratadine for a week or more prior to the test. Antihistamines block mast cell release of histamines that are responsible for allergic symptoms. Systemic corticosteroids, which are used to treat the inflammatory component of asthma, can interfere with the accuracy of allergy skin testing as well; therefore, the use of these medications should be assessed.

Allopurinol

Allopurinol is a medication frequently used in the prevention of gout. Gout is a buildup of uric acid deposited in the joints that causes pain and inflammation. The medication helps to prevent uric acid deposits in the joints and the formation of uric acid kidney stones. Any rash in a client taking allopurinol, even if mild, should be reported immediately to the HCP. The nurse should direct the client to stop taking the medication immediately, schedule an appointment, and notify the HCP. A rash caused by allopurinol may be followed by more severe hypersensitivity reactions that can be fatal, including Stevens-Johnson syndrome and toxic epidermal necrolysis.

Hemovac

Although the UAP can perform procedures that require observing principles of infection control and transmission of microorganisms, the UAP should not change sterile dressings or perform drain care. That is the responsibility of the RN. (Options 2, 3, and 4) When caring for a client with a closed-wound drainage Hemovac device, emptying and compressing the Hemovac drainage device to reestablish negative pressure and measuring and recording the drainage output are tasks that can be delegated to an experienced UAP. The RN can safely delegate these tasks because the knowledge, skill, and competency of the UAP has been established and the tasks and time frames are clearly defined. Measuring intake and output from drainage devices (eg, Foley, Hemovac, Jackson-Pratt), documenting in the electronic medical record in the place designated for the UAP, observing infection control principles, and maintaining asepsis while providing client care are within the UAP's scope of practice. Educational objective: The RN is responsible for assessing and evaluating the client's wound and wound drainage and maintaining the Hemovac drainage device, including drain site care. These tasks involve use of the nursing process and require

Aminoglycosides

Aminoglycosides (eg, gentamicin, tobramycin, amikacin) are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level (>1.3 mg/dL [115 µmol/L]) to the health care provider as it is a major adverse effect that can indicate reversible nephrotoxicity. An adjustment in the dose and dosing interval may be required

ALS

Amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on maintaining respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis. The client with ALS and worsening ability to speak (dysarthria) may also have dysphagia and respiratory distress; this client should be seen first (Option 1).

RYGB

An RYGB procedure uses a small proximal portion of the stomach to create a gastric pouch that is anastomosed to the Roux limb of the small intestine, bypassing most of the stomach and a portion of the duodenum. Dumping syndrome, the rapid emptying of gastric contents into the small intestine, is a potential complication. The presence of a large quantity of hyperosmolar intestinal contents causes fluids to shift out of the vascular system into the intestines, leading to symptoms such as nausea, vomiting, diarrhea, weakness, and hypotension. To prevent dumping syndrome, clients should eat multiple small meals, eat a low-carbohydrate diet, and separate their consumption of food and fluids (Option 1). (Option 2) Clients should be taught to consume food and fluids at least 30 minutes apart, and the health care provider may limit total daily fluid consumption. Limiting fluids decreases distension and feelings of fullness. (Option 3) Iron-deficiency anemia is a common side effect after an RYGB as iron is absorbed in the duodenum and proximal jejunum. Taking supplements of iron and calcium can help with this problem but does not prevent dumping syndrome. (Option 4) The smaller gastric pouch decreases the amount of intrinsic factor made by the parietal cells in the stomach, which may cause cobalamin deficiency. The client will need parenteral or intranasal cobalamin replacement; however, this will not prevent dumping syndrome. Educational objective: An RYGB (anastomosis of a small gastric pouch to the Roux limb of the small intestine) has several potential complications, including dumping syndrome, iron deficiency anemia, and cobalamin deficiency. To prevent dumping syndrome, the client should consume small meals, eat a low-carbohydrate diet, and consume food and fluids 30 minutes apart.

Small Bowel Follow Through- STUDY

An SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine. Using this technique, decreased motility (eg, ileus), increased motility (eg, malabsorption syndromes), fistulas, or obstructions are identified. Clients should be instructed as follows: Fast 8 hours prior to the examination. The test usually takes 60-120 minutes, but if obstruction or decreased motility is present, it can take longer. Drink plenty of fluids after the examination to facilitate barium removal. Chalky stools may be present 24-72 hours after the examination. If brown stools do not return after 72 hours or abdominal pain or fullness is present, contact the HCP.

AAA

An abdominal aortic aneurysm (AAA) is a blood-filled bulge in the abdominal aorta caused by weakening in the vessel wall due to increased pressure. Risk factors include male sex, age >65, coronary artery and peripheral vascular diseases, hypertension, and family and smoking history. AAA dissection (blood leakage into a vessel tear) or rupture may manifest as acute-onset abdominal pain radiating to the back and is typically associated with symptoms of hemorrhagic shock (eg, decreased systolic pressure; increased, weak pulses; pallor). This client's symptoms could indicate impending rupture, which can lead to life-threatening vascular hemorrhage.

An acceptable pulse oximetry

An acceptable pulse oximetry reading for a normal, healthy nonsmoking adult is considered 95%-100%. A reading of 90% is low and indicates inadequate depth or rate of respiration with possible respiratory depression

inguinal hernia

An inguinal hernia is the protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the lateral groin. Herniation occurs spontaneously or results from increased intraabdominal pressure (eg, heavy lifting). Inguinal hernias occur most commonly in male clients and are usually repaired with minimally invasive surgery. If intestinal strangulation develops, the client requires emergency treatment to prevent bowel ischemia or perforation. Strangulation symptoms include abdominal distension, severe pain, nausea, and vomiting. To prevent hernia reoccurrence after surgical repair, the client is taught to avoid activities that increase intraabdominal pressure (eg, coughing, heavy lifting) for 6-8 weeks (Option 2). If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open while sneezing.

Anaphylactic shock 1

Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). Circulatory failure and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine), can lead to cardiac/respiratory arrest. The management of anaphylactic shock includes: Ensure patent airway, administer oxygen Remove insect stinger if present IM epinephrine is the drug of choice and should be given to this client. Epinephrine stimulates both alpha- and beta-adrenergic receptors and dilates bronchial smooth muscle (beta 2) and provides vasoconstriction (alpha 1). The IM route (mid anterior lateral thigh) is better than the subcutaneous route. Repeat dose every 5-15 minutes. Place in recumbent position and elevate legs Maintain blood pressure with IV fluids, volume expanders or vasopressors Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema

Anaphylactic shock

Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). It is caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs, foods, and venom. Anaphylactic shock results in hypotension and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine); these can lead to cardiac and respiratory arrest. The management of anaphylactic shock includes: Call for help (activate emergency management systems) - first action Maintain airway and breathing - administer high-flow O2 via non-rebreather mask Epinephrine, intramuscular - the drug of choice and should be given next. Epinephrine stimulates both alpha- and beta-adrenergic receptors, dilates bronchial smooth muscle (beta 2), and provides vasoconstriction (alpha 1). The IM route is better than the subcutaneous route. The dose should be repeated every 5-15 minutes if there is no response. Elevate the legs Volume resuscitation with IV fluids Bronchodilator such as albuterol is administered to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction

Angiotensin-converting enzyme (ACE) inhibitors

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).

Anorexia end of life

Anorexia is an expected complication in clients nearing the end of life and is exacerbated by many variables, including medications, stress, and progression of disease. Caregivers can implement strategies to manage these factors, including the following: Administering prescribed analgesia, antiemetic medications, and appetite stimulants (eg, dexamethasone, megestrol acetate) to enhance client comfort and increase intake (Option 1) Involving the client in meal planning to encourage autonomy and a sense of purpose (Option 2) Promoting foods that are preferred and well tolerated, regardless of nutritional value, to stimulate appetite and increase intake (Option 3) Providing meals with friends/family outside of the "sick room," if possible, to promote stimulation and enjoyment (Option 4) Providing frequent oral care, especially after eating, and using topical treatments to minimize oral discomfort and dry mouth Offering adequate fluid and fiber intake and implementing a bowel regimen to help prevent constipation

Antiplatelet agents

Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider before the client is discharged.

prasugrel

Antiplatelet medication (eg, prasugrel [Effient], clopidogrel [Plavix], ticagrelor [Brilinta]) are often prescribed to a client after a percutaneous coronary intervention such as angioplasty or stent placement. These agents should be stopped at least 5-7 days prior to the surgery to reduce the chance of intraoperative and postoperative bleeding. The nurse should immediately report to the HCP that the client is still taking prasugrel and took it the morning of the surgery. Unless the surgery is emergent, it will most likely be postponed at least a week.

Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include:

Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option 1) Assess feeding tube placement at regular intervals Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option 3) Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H20) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option 4) Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option 5) Avoid bolus tube feedings for clients at high risk for aspiration

Asthma

Asthma is a disorder of the lungs characterized by reversible airway hyper-reactivity and chronic inflammation of the airways. Albuterol (Proventil) is a short-acting beta agonist (SABA) administered as a quick-relief, rescue drug to relieve symptoms (eg, wheezing, breathlessness, chest tightness) associated with intermittent or persistent asthma. Beclomethasone (Beconase) is an inhaled corticosteroid (ICS) normally used as a long-term, first-line drug to control chronic airway inflammation. When using an ICS metered-dose inhaler (MDI), small particles of the medication are deposited and can impact the tongue and mouth. Rinsing the mouth and throat well after using the MDI and not swallowing the water are recommended to help prevent a Candida infection (thrush) (white spots on tongue, buccal mucosa, and throat), a common side effect of ICSs. The use of a spacer with the inhaler can also decrease the risk of developing thrush

Atrial flutter

Atrial flutter is an atrial dysrhythmia identified by recurring, regular, sawtooth-shaped flutter waves that originate from a single ectopic focus in the atria. There is no clinical evidence suggesting that hypomagnesemia leads to atrial flutter, which is associated with underlying heart disease (eg, mitral valve disorders, cardiomyopathy, cor pulmonale).

Bacterial meningitis

Bacterial meningitis and many respiratory illnesses (eg, influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet away from the client. Droplet precautions during routine care, such as during assessment or medication administration, require use of a surgical mask only, as the highest risk of transmission is through inhalation. However, when completing tasks during which there is a risk of contact with client bodily fluids (eg, assistance with toileting, suctioning), the nurse should also don gloves and a gown while in the room. When caring for these clients, the following principles should be observed: Proper hand hygiene is always the first and last element of infection control in any client care setting. Single (private) room isolation is preferred; however, room sharing between clients with the same illness can be allowed if necessary. All surfaces within 3 feet of the bed are considered contaminated. Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room. Personal protective equipment (eg, mask, gown, gloves), used when required, must be discarded before leaving the room. Droplet precautions can be discontinued for bacterial meningitis after the client receives at least 24 hours of appropriate antibiotics.

Diagnosing TB

Bacteriologic testing is performed in clients with suspected TB disease to confirm the diagnosis. A stained sputum smear is examined microscopically for the presence of Mycobacterium tuberculosis (tubercle bacillus), and a culture identifies the growth of the microorganisms. Collect an early morning sputum sterile specimen on 3 consecutive days for an acid-fast bacilli (AFB) smear and culture. Fluids and/or expectorants can be given at bedtime to help liquefy secretions. It is usually easier for clients to produce a specimen upon awakening as secretions collect in the airways during the night.

Sulfonylureas in Geriatric People

Beers Criteria lists medications that may be inappropriate for the geriatric population due to risks outweighing benefits. The nurse collaborates with the health care provider to minimize polypharmacy and reduce adverse effects (eg, falls, confusion). Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin)

When to return blood to blood bank

Before a blood transfusion, the nurse should verify the client's identity, crossmatch the client's determined ABO blood-type and Rhesus (Rh) factor with the unit's blood group label, and verify the unit donor number and expiration date against the blood bank receipt. The nurse should also inspect the blood product for any signs of blood product contamination. Blood products are a protein- and sugar-rich medium for bacterial growth. Indications of contaminated blood include: Green, black, white, or dusky discoloration Accumulations of air Evidence of clotting or presence of inclusions Malodor Units exhibiting any of these signs should be returned to the blood bank

liver biopsy position

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.

Beneficence

Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely.

Beta-adrenergic blockers

Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are used to relieve some of the symptoms of thyrotoxicosis (thyroid storm), a complication of hyperthyroidism in which excessive thyroid hormones are released into the circulation. Beta blockers block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism.

Avoid Salt substitutes with

Both ACE inhibitors ("prils" - captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" - valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be consumed unless approved by the health care provider (HCP

Breast cancer

Breast cancer is the unregulated growth of abnormal breast tissue cells and the second most common cause of cancer deaths among women. When palpated, the breast lump is usually described as hard, irregularly shaped, non-mobile, and nontender. Mammography usually detects breast cancer. Non-modifiable breast cancer risk factors include: Female sex and age ≥50 (Options 4 and 5) First-degree relative (mother or sister) with history of breast cancer (Option 1) BRCA1 and BRCA2 genetic mutations (Option 2) Personal history of endometrial or ovarian cancer Menarche before age 12 or menopause after age 55 Modifiable breast cancer risk factors include: Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause) (Option 5) Postmenopausal weight gain and obesity as fat cells store estrogen (Option 4) History of smoking and alcohol consumption Dietary fat intake Sedentary lifestyle

Buck traction

Buck traction immobilizes hip and femur fractures. A boot or traction tape is applied to the affected extremity and a prescribed weight pulls the limb into traction. The client is typically placed in Trendelenburg or supine position with the foot of the bed raised to maintain countertraction.

Bupropion hydrochloride (Wellbutrin)

Bupropion hydrochloride (Wellbutrin) is an atypical antidepressant used to treat depressive disorders, including major depressive disorder, seasonal affective disorder, and persistent depressive disorder (dysthymia). Preparations of bupropion hydrochloride include immediate-release, sustained release (SR), and extended-release (XL) tablets. Any medication marked SR or XL should not be chewed, cut, or crushed due to the risk of adverse effects from too rapid absorption of the drug. No form of bupropion hydrochloride should be altered; tablets should be swallowed whole, with or without food. Seizures are of particular concern if a client takes a high or toxic dose of bupropion hydrochloride. Clients on any kind of antidepressant need to be monitored closely for worsening depression, sudden or unusual behavior or mood changes, and the emergence of suicidal thoughts and behaviors. Clients with a diagnosis of depression and/or their family members need education and information on the increased risk of suicide (Option 1). Additional instructions to a client about the use of bupropion hydrochloride include the following: Limit alcohol; inform the health care provider if you are used to consuming large amounts of alcohol Do not double up on the medication if a scheduled dose is missed (Option 3) Take the medication at the same time each day It may take several weeks to feel the effects of bupropion hydrochloride (Option 4) Weight loss may occur when taking this medication

C difficile

C difficile is often associated with antibiotic therapy but can also be a nosocomial hospital-acquired infection. Antibiotics, especially broad-spectrum, reduce normal bacteria in the body. This allows other bacteria, such as C difficile, to take over and cause a superinfection. It grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) is an anti-infective drug commonly used to treat C difficile. For severe C difficile infection, oral vancomycin may be used; intravenous vancomycin is ineffective.

CVP

CVP is a measurement of right ventricular preload and reflects fluid volume status. A PA catheter can be used to measure CVP. The proximal port/lumen should be used for measurement as its lumen is located in the right atrium. Normal CVP is 2-8 mm Hg. A low CVP can indicate hypovolemia; a high CVP can indicate right ventricular failure or fluid volume overload. CVP is measured as a mean pressure and should be recorded at the end of expiration. The balloon inflation port cannot be connected to a pressure monitoring system. It is used to inflate the balloon at the tip of the PA catheter, allowing for the measurement of PA wedge pressures. The distal port exits into the PA and reflects PA, not CVP, pressures. The thermistor port is connected to the cardiac output computer. It measures core blood temperature. Educational objective: A PA catheter may be used to monitor CVP. The proximal port must be connected to a pressure monitoring system to measure CVP because its lumen exits into the right atrium.

Vaginal candidiasis

Candida albicans (yeast) can colonize and cause infections of the vulvovaginal region. Vaginal candidiasis often causes itching and painful urination due to urine stinging the inflamed areas of the vulva. Assessment shows a thick, white, curd-like vaginal discharge and reddened vulvar lesions

Cardiac catheterization

Cardiac catheterization involves injection of contrast medium using a catheter to examine for obstruction of the coronary arteries. Most contrast (dye) used in these procedures contains iodine. Complications of IV contrast use include the following: Allergic reactions - Iodinated dye is contraindicated in clients with shellfish allergy due to cross-reactivity (Option 1). Clients should be premedicated with corticosteroids and antihistamines. Contrast nephropathy - Contrast that contains iodine can cause kidney injury, although this risk can be reduced with adequate hydration. However, clients with existing renal impairment (eg, elevated serum creatinine >1.3 mg/dL [115 µmol/L]) should not receive IV contrast unless necessary for a life-saving procedure (Option 4). Metformin (Glucophage) given with large-dose IV iodine contrast can increase the risk for lactic acidosis. As a result, most clinicians discontinue metformin 24-48 hours prior to IV iodine contrast exposure (regardless of baseline creatinine) and restart the drug at least 48 hours later, after documenting stable renal function

Medications commonly prescribed for a client with an open fracture include:

Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin flora (Staphylococcus aureus); it is given prophylactically before and after surgery to prevent infection (Option 1) Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain associated with muscle spasm; carisoprodol (Soma) or methocarbamol (Robaxin) can also be prescribed Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent infection (Clostridium tetani) if immunizations are not up to date (>10 years), unavailable, or unknown (Option 4) Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease inflammation and pain Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia (Option 3)

Celiac disease

Celiac disease is an autoimmune disorder in which chronic inflammation caused by gluten damages the small intestine. The following are important dietary principles to teach clients with celiac disease: All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. Rice, corn, and potatoes are gluten free and are allowed on the diet (Option 3). Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten, such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from their diet reduces the risk for nutritional deficiencies and intestinal cancer (lymphoma). Eating even small amounts of gluten will damage the intestinal villi, although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet.

Clonidine

Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death.

homonymous hemianopsia

Cerebral vascular accidents (strokes) can cause visual and perceptual deficits depending on which part of the brain is affected. Clients with changes in visual field or perception of their body in space can be at risk for safety-related injuries. Homonymous hemianopsia is a loss in half of the visual field on the same side. For example, the client may lose the left side of the visual field in both eyes. A client unable to see the left side of the body is at a higher risk for neglecting that side or being unable to eat food placed on the left side of a plate. These clients are at higher risk for injury because they are unable to incorporate full visual field input. They are taught to turn the head and scan to the side with the visual field deficit to reduce the risk for injury and self-neglect

Basilar Skull fraction

Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and transversed the dura. If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. In this case, the halo/ring test should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF. Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client's nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures.

infective endocarditis (IE).

Certain individuals should receive prophylactic antibiotics prior to dental procedures to prevent infective endocarditis (IE). These include the following: Prosthetic heart valve or prosthetic material used to repair heart valve Previous history of IE Some forms of congenital heart disease Unrepaired cyanotic congenital defect Repaired congenital defect with prosthetic material or device for 6 months after procedure Repaired congenital defect with residual defects at the site or adjacent to the site of a prosthetic patch or device Cardiac transplantation recipients who develop heart valve disease

Chest tube drainage

Chest drainage >100 mL/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products.

myopia

Children with myopia, or nearsightedness, have difficulty seeing objects at a distance. Objects within close range are not a problem. Children report headaches, dizziness, and difficulty seeing objects clearly. Their performance in school is often affected, especially in subjects such as arithmetic and reading. Rubbing of the eyes may be observed, as well as frequent blinking or squinting when attempting to view distant objects. Treatment includes the use of biconcave lenses or laser surgery.

Chlamydia

Chlamydia is the most common sexually transmitted infection (STI) in the United States and Canada. Many clients are asymptomatic or have minor symptoms but can still transmit the infection (Option 2). Appropriate preventive measures are important to reduce the spread of infection. Risk factors include being female or an adolescent; having multiple sexual partners; a history of or coexisting STI; and incorrect/inconsistent condom use. Clients should be taught to abstain from sexual intercourse for 1 week after initiation of drug therapy and until all sexual partners have completed antibiotic treatment to prevent transmission and recurrence (Options 1 and 3). Drug therapy for a chlamydial infection may include doxycycline or azithromycin. General safe sex practices to prevent STI transmission include: Remain in a monogamous sexual relationship Use a condom during all sexual encounters (Option 4) Avoid sex with IV drug users Ask sexual partners about their previous sexual history Restrict the number of sexual partners Avoid sex with potential partners who have visible perineal lesions

Lithium toxicity:

Chronic toxicity can result in: Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks) Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst) (Option 4) Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals.

Chronic venous insufficiency

Chronic venous insufficiency is the inability of the leg veins to efficiently pump blood back to the heart. It can lead to venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin with brown pigmentation are expected manifestations, so this is not the priority assessment.

Cirrhosis

Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes alter blood flow through the liver and decrease the liver's functionality. Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin (Option 3). Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated partial thromboplastin time [aPTT]) are usually elevated (Option 4). Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy (Option 2).

Can you clamp a chest tube during transport?

Clamping the chest tube during transport is contraindicated. Doing so can cause air to accumulate in the pleural cavity as it has no means of escape. This can lead to the development of a tension pneumothorax, a potentially life-threatening condition. A tension pneumothorax results in compression of the unaffected lung and pressure on the heart and great vessels. As the pressure increases, venous return is decreased and cardiac output falls.

Client teaching related to peptic ulcer disease (PUD)

Client teaching related to peptic ulcer disease (PUD) includes lifestyle changes (eg, dietary modifications, stress reduction), PUD complications, and medication administration. Helicobacter pylori infection and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are risk factors for complicated PUD. H pylori treatment includes antibiotics and proton-pump inhibitors for acid suppression. The recommended initial treatment is 7-14 days of triple-drug therapy with omeprazole (Prilosec), amoxicillin, and clarithromycin (Biaxin). (Option 5) Clients with PUD should avoid NSAIDs [eg, aspirin, ibuprofen (Motrin)] as they inhibit prostaglandin synthesis, increase gastric secretion, and reduce the integrity of the mucosal barrier. Educational objective: Clients with peptic ulcer disease should avoid NSAIDs, smoking, and excess use of alcohol or caffeine.

Herbal Sups that increase bleeding

Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements. Herbal supplements that can increase risk for bleeding include: Gingko biloba Garlic Ginseng Ginger Feverfew

Clients taking long-term corticosteroid replacement should be taught the following

Clients taking long-term corticosteroid replacement should be taught the following: Do not discontinue glucocorticoid therapy abruptly. Abrupt discontinuation could lead to addisonian crisis, a life-threatening complication (Option 1). Report any signs and symptoms of infection to the HCP immediately. Corticosteroid use can cause immunosuppression, and infection can develop quickly and spread rapidly. Corticosteroids' anti-inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema (Option 3). Stay attuned to signs and symptoms of stress and increase dose of corticosteroid during times of stress. A stress response (surgery, trauma) can cause a sudden decrease in cortisol levels, triggering addisonian crisis (Option 6). A side effect of corticosteroid therapy is hyperglycemia. Report signs of hyperglycemia, including increased urine, hunger, and thirst. Clients with diabetes mellitus must be vigilant in checking blood glucose levels (Option 4). Corticosteroids are catabolic to bone (osteoporosis) and muscle (muscle weakness). A diet high in calcium (at least 1500 mg/day) and protein (1.5 g/kg/day) but low in fat and simple carbohydrates is recommended. Cataracts are a side effect of corticosteroids, particularly glucocorticoid therapy. Make an appointment with an optometrist yearly to assess for cataracts (Option 2). Corticosteroid medications can cause gastric irritation and should not be taken on an empty stomach (Option 5). Recognize signs and symptoms of Cushing syndrome and report to the PHCP. Develop a regular HCP-approved exercise program.

Mitral Valve Prolapse

Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Client teaching for MVP includes the following: Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms (Option 3) Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms Reduce stress and avoid alcohol use

Clients with airborne infections

Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions.

alcoholism

Clients with alcoholism can have hypoglycemia. They can also have thiamine (vitamin B1) deficiency related to poor nutrient intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can result in Wernicke encephalopathy (WE). Untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis). In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen thiamine deficiency, which in turn can precipitate the development of WE in a previously unaffected individual. Because the signs of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose

Wernicke encephalopathy,

Clients with chronic alcohol abuse suffer from poor nutrition related to improper diet and altered nutrient absorption. Poor thiamine intake and/or absorption can lead to Wernicke encephalopathy, a serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Clients are prescribed thiamine to prevent this condition.

Foods for CKD

Clients with chronic kidney disease (CKD) have decreased glomerular filtration, resulting in retention of fluid, potassium, and phosphorus. Fluid retention is initially treated with sodium restriction and diuretic therapy. Dietary adjustments should also be made to reduce serum potassium and phosphorus. Laboratory values are key to determining allowable foods. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products also contain high phosphorus levels. Examples of allowable foods for CKD clients include apples, pears, grapes, pineapple, blackberries, blueberries, and plums.

chronic kidney disease

Clients with chronic kidney disease are at risk of fluid overload and hyperkalemia. To avoid these complications and prevent progressive kidney damage, clients are advised to follow certain dietary restrictions. These include the following: Sodium restriction involves avoiding high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, and salad dressings (Option 1). Fluid intake must be monitored accurately and often is restricted (Option 4). Potassium restrictions will vary depending on kidney function. Raw carrots, tomatoes, and orange juice are high-potassium foods that clients with advanced kidney disease or on hemodialysis should avoid (Option 3). Low-protein diet (0.6-0.8 g/kg/day) helps prevent kidney disease progression. If the client is already on dialysis, liberal protein intake is recommended to prevent malnutrition.

cirrhosis

Clients with cirrhosis should eat a high-calorie, high-carbohydrate, low-sodium, and low-fat diet; moderate protein intake is recommended. They should avoid hepatotoxic substances (eg, alcohol, acetaminophen) and medications (NSAIDs) that increase bleeding risk and reduce activities that increase intraabdominal pressure.

lactase deficienc

Clients with lactase deficiency (lactose intolerance) experience varying degrees of gastrointestinal symptoms after ingesting milk products, including flatulence, diarrhea, bloating, and cramping. This is due to a deficiency of the enzyme lactase, which is required for digestion of lactose. Treatment includes restricting lactose-containing foods in the diet. These clients may also take lactase enzyme replacements (eg, Lactaid) to decrease symptoms (Option 4). Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified milk (Option 2). Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual tolerance (Option 3). Some dairy products, including aged cheeses and live-culture yogurts, contain little to no lactose and can be tolerated by most clients with lactase deficiency (Option 1). (Option 5) Lactase deficiency is not an immune reaction (allergy) to milk products. Rather, the gastrointestinal symptoms are due to a deficiency of the enzyme lactase and the resultant inability to digest lactose.

Teaching points to assist a client in appropriate use of a cane include:

Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane to provide support and stability when walking. Cane length should equal the distance from the client's greater trochanter to the floor as incorrect cane length can cause back injury. A cane measured from the waist would be too long to provide optimal support (Option 4). Teaching points to assist a client in appropriate use of a cane include: Hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed (20-30 degrees) (Option 1). Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body weight on both legs to provide balance (Option 3). For maximum stability, move the weaker leg forward to the level of the cane, so that body weight is divided between the cane and the stronger leg (Option 2). If minimal support is needed, the cane and weaker leg are advanced forward at the same time. Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and the weaker leg. Always keep at least 2 points of support on the floor at all times.

peripheral arterial disease (PAD)

Clients with peripheral arterial disease (PAD) have decreased sensations from nerve ischemia or coexisting diabetes mellitus. They should never apply direct heat to the extremity due to the risk for a burn wound. Wound healing is impaired in these clients. Swelling in the extremities (edema) could result from venous stasis (venous valve incompetence or varicose veins); these clients are asked to elevate their extremities during rest. However, clients with PAD usually do not have swelling, but rather have decreased blood supply. The extremities should not be elevated above the level of the heart because extreme elevation further impedes arterial blood flow to the feet. Additional teaching for the client with PAD includes the following: Smoking cessation Regular exercise Achieving or maintaining ideal body weight Low-sodium diet Tight glucose control in diabetics Tight blood pressure control Use of lipid management medications Use of antiplatelet medications Proper limb and foot care

Jaw Thrust

Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column.

Clopidogrel (Plavix)

Clopidogrel (Plavix) is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding. The client took this drug 48 hours ago. Therefore, the nurse must notify the HCP. The surgery may be postponed due to the increased risk for intra- and post-operative bleeding

strabismus

Closing one eye when viewing objects is a manifestation of strabismus, a malalignment of the eyes.

Clostridium difficile requires contact precautions

Clostridium difficile requires contact precautions under the guidelines published by the Centers for Disease Control and Prevention. Place the client in single-room isolation (preferred) or cohort with other C difficile-infected clients All surfaces within 3 feet of the bed are considered contaminated Personal protective equipment (gown and gloves) must be discarded before leaving the room Hand hygiene must be performed with soap and water Alcohol-based hand sanitizers do not kill C difficile spores (Option 1) Dedicated medical equipment (stethoscope, blood pressure cuff) should remain in the room

Codeine and COPD

Codeine is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD).

Colonoscopy

Colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no stool left for better visualization during the procedure. These instructions include: Clear liquid diet the day before Nothing by mouth 8-12 hours prior to the examination The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene glycol (GoLYTELY) the day before the test. The type of prep depends on the health care provider's preference and client health status.

Common applications of airborne precautions

Common applications of airborne precautions Tuberculosis Varicella (chickenpox)* Rubeola (measles) Personal Equipment used for airborne precautions N95 particle respirator As needed for procedures with risk of splash or body fluid contact: Nitrile gloves, disposable gown, goggles/shield Rooms Negative air pressurization High-efficiency particulate air filters

Personal protective equipment of droplet precautions

Common applications of droplet precautions Neisseria meningitidis Haemophilus influenzae type B Diphtheria Mumps Rubella Pertussis Streptococcus group A (strep throat) Viral Influenza Personal protective equipment Surgical mask Private room As needed for procedures with risk of splash or body fluid contact: Nitrile gloves, disposable gown, goggles/shield

Common complications following total hip replacemen

Common complications following total hip replacement are bleeding, prosthesis dislocation, deep vein thrombosis, and infection. Total joint replacements carry a risk of serious blood loss; therefore, the nurse should check the drainage device and dressing frequently to monitor blood loss, especially during the first several postoperative hours.Following total hip replacement, the client will have an abduction pillow between the legs to prevent adduction of the affected leg. Adduction of the leg could potentiate dislocation of the prosthesis. It is important that the client not flex the affected hip more than 90 degrees, as this could dislocate the prosthesis. Therefore, the client should be provided elevated toilet seats and chairs that do not recline. The nurse should assess for signs of hip dislocation, including shortening and internal rotation of the leg. Although providing an abduction pillow is important, assessing for hemorrhage is the priority.

Constipation

Constipation is a symptom of many different disease processes (eg, Parkinson's disease, diabetic neuropathy, depression), procedures (eg, abdominal surgery, bowel manipulation), and medications (eg, anticholinergics, diuretics, opioids, antacids, antihypertensives). Immobility, low-fiber diets, decreased fluid intake, and irregular bowel habits increase the likelihood of constipation. Teach the client and/or caregiver the following to prevent constipation: Consume 20-30 g of fiber a day (unless contraindicated); fiber softens stool and increases bulk, stimulating defecation. High-fiber foods include fruits, vegetables, whole grains, nuts, seeds, and legumes (Option 3). Drink 2-3 L of fluids a day (unless contraindicated); avoid caffeinated beverages (eg, coffee, tea, cola) that promote diuresis. Exercise at least 3 times a week; movement stimulates peristalsis and defecation (Option 2) Maintain a healthy bowel regimen - avoid delaying defecation when the urge is felt, defecate at the same time each day, and track bowel movements to identify if there is a change in bowel patterns (Option 1) Avoid laxatives and enemas unless prescribed by a health care provider; overuse can cause dependency

Corticosteroid therapy

Corticosteroid therapy is the primary classification of drugs used to treat Addison's disease, an adrenocortical insufficiency. Signs and symptoms of infection should be reported to the PHCP immediately. Use of corticosteroids can cause immunosuppression. Infection can develop quickly and spread rapidly. Its anti-inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema. In addition, physiological stress such as infection can trigger addisonian crisis, a life-threatening complication of Addison's disease.

"huff" cough

Coughing is an important lung defense mechanism. Clients with chronic obstructive pulmonary disease (COPD) have weakened muscles and narrowed airways that are prone to collapse when under increased pressure. They are therefore unable to generate the high pressure needed to create the explosive rush of air to cough effectively. The low-pressure "huff" cough, which uses a series of mini-coughs, is more effective in mobilizing and expectorating secretions in clients with COPD. When this technique is done correctly, there is less airway collapse, less energy and oxygen consumption, and greater secretion removal. The steps are as follows: Position upright - maximizes lung expansion and gas exchange Inhale through the nose using abdominal breathing and prolong the exhalation through pursed lips for 3 breaths - deflates excess air from lungs Hold breath for 2-3 seconds following an inhalation, keeping the throat open - opens glottic structures and prevents a high-pressure cough Deeply inhale and, while leaning forward, force the breath out gently using the abdominal muscles while making a "ha" sound (huff cough); repeat 2 more times (eg, "ha, ha, ha") - keeps airways open while moving secretions up and out of the lungs. Inhale deeply using abdominal breathing and give one forced huff cough - the last, increased force ("ha") usually results in mucus being expectorated from the larger airways.

trigeminal nerve

Cranial nerve V is the trigeminal nerve. The sensory portion of this nerve is assessed by testing sensation at the ophthalmic (forehead), maxillary (cheekbone), and mandibular (jaw line) branches by light touch. Corneal sensation is also a portion of the trigeminal nerve, but this is typically not tested by the nurse

Cushing syndrome

Cushing syndrome is a result of prolonged exposure to excess corticosteroids, especially glucocorticoids. Common causes include exogenous intake of corticosteroids for other medical conditions or from adrenal hyperfunction (tumor). Clinical features of Cushing syndrome include: Skin manifestations such as easy bruising, purple striae, and skin atrophy (topical preparations), which are a result of collagen loss. Fat redistribution resulting in truncal obesity and moon like face; thin extremities. Fat pads are seen on the neck and supraclavicular areas (Option 5). In women, androgens are produced in the adrenal gland. Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities (oligomenorrhea) (Option 1). Mineralocorticoid (aldosterone) excess can result in hypernatremia, hypokalemia, and hypertension (Option 4). Hyperglycemia as a result of excess corticosteroids. Untreated clients can develop proximal muscle weakness and bone loss (steroids catabolic on muscles and bone)

Cushing syndrome

Cushing syndrome is the result of prolonged exposure to excess corticosteroids, especially glucocorticoid steroids. The most common cause is the administration of corticosteroids, such as prednisone or hydrocortisone, for other conditions. However, pituitary adenomas can secrete adrenocorticotropic hormone (ACTH), which in turn causes the adrenal glands to produce too much cortisol. Clinical manifestations include: Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities (eg, oligomenorrhea). Metabolic complications include truncal obesity (subsequently causing peripheral insulin resistance), hypertension, and hyperglycemia (ie, excess cortisol stimulating gluconeogenesis). Fat accumulation in the face (ie, moon face) and the back of neck (ie, buffalo hump) is common Dermatological changes are possible and include easy bruising, purple striae, and skin atrophy; these result from loss of collagen. Proximal muscle weakness and bone loss (ie, osteoporosis) due to steroid catabolism on muscles and bone can develop in untreated clients.

More on DKA

DKA is a life-threatening complication of type I diabetes characterized by hyperglycemia (>250 mg/dL) that results in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin. The body begins to break down fat stores into ketones, as it does in a state of starvation, causing a metabolic acidosis (low pH and low HCO3). The lack of insulin also results in increased glucose production in the liver, worsening the hyperglycemia. Hyperglycemia causes osmotic diuresis, and clients are severely dehydrated. The cardinal signs of dehydration are poor skin turgor, dry mucosal membranes, tachycardia, orthostatic hypotension, weakness, and lethargy. Despite laboratory values showing hyperkalemia on admission, clients with DKA have a net potassium deficiency and will need careful replacement after fluid resuscitation.

DKA

DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present. Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur. The nurse should start an IV and bolus the client with normal saline or 1/2 normal saline to reverse dehydration. This should occur prior to treating the hyperglycemia with regular insulin IV infusion. Because insulin promotes water, potassium, and glucose entrance into the cell, it can exacerbate vascular dehydration and imbalance of electrolytes, particularly potassium. A potassium level (along with other electrolytes) should also be assessed prior to beginning the prescribed insulin therapy. Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC02 in an attempt to restore the body's normal pH level and should not be reversed

therapeutic aPTT level for a client being heparinized

Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin).

Desmopressin acetate DDAVP

Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered intravenously, orally, or via nasal spray. Effectiveness of therapy with desmopressin would be manifested by decreased urinary output and increased urine specific gravity as the urine becomes less dilute

Diabetes insipidus (DI)

Diabetes insipidus (DI) is a condition in which antidiuretic hormone (ADH) is insufficiently produced or suppressed. Neurogenic DI results from manipulation or interference with ADH release, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. It is characterized by polydipsia (increased thirst) and polyuria (increased urine output) and can lead to dehydration resulting in weight loss (Option 4), hypernatremia, and a high serum osmolality (>295 mOsm/kg [295 mmol/kg]). Urine is dilute and copious (2-20 L/day) (Option 1) with a low specific gravity (<1.003). Educational objective: Diabetes insipidus is a condition in which antidiuretic hormone is insufficiently produced or suppressed, resulting in polydipsia and polyuria (up to 20 L/day). Urine is copious and dilute with a low specific gravity (<1.003). Fluid volume deficit can lead to dehydration, hypernatremia, high serum osmolality, and weight loss.

Diabetes insipidus (DI)

Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration (Option 3). ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP). DI is not associated with low/high blood glucose and should not be confused with diabetes mellitus (DM) as both DI and DM involve symptoms of excessive urination (polyuria).

Diabetes insipidus (DI)

Diabetes insipidus (DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus and stored in the pituitary gland. The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst. When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). This causes hypernatremia (elevated serum sodium due to deficit of free water) and increased serum osmolality, which lead to excessive thirst (polydipsia).

Diabetic neuropathy

Diabetic neuropathy is caused by nerve damage as a result of the metabolic disturbances associated with diabetes mellitus. Autonomic neuropathy is nerve damage to the autonomic nervous system, the system responsible for involuntary body functions such as blood pressure, heart rate, perspiration, sexual function, and digestion. Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension, tachycardia, painless myocardial infarction, bowel incontinence, diarrhea, urinary retention, and hypoglycemic unawareness. The client with postural hypotension is also at risk for falls and should be taught to get up from a lying or sitting position slowly.

dicyclomine hydrochloride

Dicyclomine hydrochloride (Bentyl) is an anticholinergic medication. Anticholinergics are used to relax smooth muscle and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention, and constipation. Therefore, the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary retention. The urge to urinate is normally present at 300 mL; pain is usually felt around 500 mL. This client has urinary retention and should not have the bladder smooth muscle further relaxed.

Dicyclomine

Dicyclomine, an anticholinergic/antispasmodic drug prescribed to manage irritable bowel syndrome, is contraindicated with paralytic ileus, as it decreases intestinal motility and would exacerbate the condition (Option 2).

Digoxin

Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate). The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin. The early symptoms of toxicity are nausea and vomiting. Later signs of toxicity are arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment.

Diverticulitis --> Peritonitis

Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop. When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis). Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound tenderness). The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum. Peritonitis is a potentially lethal complication and should be reported immediately.

Diverticular disease

Diverticular disease of the colon occurs when saclike protrusions form in the large intestine. When diverticula become infected and inflamed, the client has diverticulitis. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes the following: IV antibiotic therapy - to cover the gram-negative and anaerobic organisms that reside in the colon and contribute to diverticulitis; these commonly include metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or Bactrim DS; Septra) or ciprofloxacin (Cipro) (Option 1) NPO status - more acute cases require complete rest of the bowel (NPO status); less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet (Option 3) NG suction - in severe cases of abdominal distention, nausea, or vomiting (Option 2) IV fluids - prevent dehydration Bed rest

Dopamine

Dopamine (Intropin) is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced

During a weather-related emergency, home care visits are classified as:

During a weather-related emergency, home care visits are classified as: High priority - unstable clients who need care and are at risk for hospitalization if not seen. Moderate priority - clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients. Low priority - clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

Electrical cardioversion & A.fib

Electrical cardioversion is a treatment modality considered for AF that has been unresponsive to drug therapy. AF (rapid, irregular atrial contractions) results in ineffective atrial kick and predisposes to thrombus formation (blood clots) in the left atrium. If a client is in AF for more than 48 hours, anticoagulation therapy is needed for 3-4 weeks before cardioversion. Anticoagulation therapy is necessary as cardioversion may dislodge an atrial thrombus, putting the client at risk for a stroke or other sequelae of thromboembolism. If 4 weeks of anticoagulation is not an option, TEE must be performed prior to cardioversion.

Emergency contraception (EC)

Emergency contraception (EC) prevents pregnancy after unprotected intercourse. EC pills (eg, levonorgestrel [Plan B]) should be taken within 5 days of intercourse; however, efficacy is reduced after 3 days (72 hours). The copper intrauterine device (IUD) may be inserted for up to 5 days after intercourse as another form of emergency contraception.

Enteral feedings

Enteral feedings are given to provide nutrition to clients who are unable to take in nutrients by mouth. Placement verification is imperative prior to initiating enteral feedings to prevent complications such as aspiration. Lung aspiration can lead to pneumonia, acute respiratory distress syndrome, and abscess formation. Methods to verify the tube placement include the following: Imaging - visualization of tube placement by x-ray is the standard protocol to ensure proper placement prior to initiating enteral tube feedings Gastric content pH testing - although testing the pH of aspirated contents is an evidence-based method, it is typically used to assess for displacement after initial x-ray verification. It can also be used to test the position of the tube prior to each feed as the frequent x-rays expose the client to radiation. Gastric pH is usually acidic (<5) because of acid secretion. pH ≥6 indicates bronchial secretions and incorrect placement. Air auscultation - verification by auscultating air is not an evidence-based method for placement verification

Contraindicated meds via NG tube

Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect the stomach from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes. Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time frame. Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood levels due to more rapid drug absorption. Therefore, the nurse should first contact the PHCP for clarification.

Epidural hematoma

Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. The bleed is arterial in origin, and so hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death.

Ethambutol

Ethambutol (Myambutol) is used to treat tuberculosis but can cause ocular toxicity, resulting in vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly

crutch paralysis

Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axilla. This leads to a reversible condition known as crutch paralysis, or palsy, which manifests as muscle weakness and/or sensory symptoms (tingling, numbness) of the arm, wrist, and hand. It is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Therefore, clients are taught to support body weight on the hands and arms, not the axillae, when ambulating to ensure that there is a 1-2 in (2.5-5 cm) space between the axilla and the axilla crutch pad. Crutches should be checked for proper length.

Skin cancers

Explanation: Skin cancers are caused by damage to the skin's DNA. This damage is due to exposure to ultraviolet (UV) radiation, primarily from the sun, but also from other sources (eg, tanning beds, sunlamps). The instructions to prevent sunburn and other sun-related damage include the following: Avoid the sun if possible, especially between 10 AM and 4 PM. Cloud coverage does not block UV rays and they can be reflected off water, sand, snow, and concrete. As a result, clients can burn in the shade or while skiing in the winter (Option 4). Wear protective clothing (eg, long sleeves, wide-brimmed hats, umbrellas) when possible. Apply sunscreen: Broad-spectrum sunscreen to block both UVA and UVB rays Daily use of minimum SPF of 15 or 30 if sun sensitive. All sunscreen should be applied 20-30 minutes prior to sun exposure to allow the formation of a protective film on the skin. Regardless of the type of sunscreen used, it should be reapplied at least every 2 hours, if not more often (Options 1 and 2). Because sunscreen is washed off with swimming and sweating, it should be reapplied, even for products labeled "water-resistant" or "very water-resistant" (Option 3). Avoid the use of tanning beds, which provide UV radiation

ATC pain meds for cancer pain

Extended-release oxycodone (Oxycontin) is a long-acting opioid agonist prescribed to manage severe chronic pain when nonopioids and immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are inadequate. The nurse should teach the client's caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours.

Extracorporeal shock wave lithotripsy (ESWL)

Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive procedure used to break up kidney stones. It is typically done on an outpatient basis, although the client will require local or general anesthesia. The shock waves break up the stone(s) into a fine sand that can then be excreted in the urine. Ureteral stents are often placed after the procedure to help with the passage of the sand and prevent buildup within the ureter. The stents are removed within 1-2 weeks. The client will be encouraged to drink large amounts of fluids to facilitate washing out of the stone fragments and sand created by the shock waves (Option 1). Infection is a serious complication after the procedure as the breakup of stones can release organisms and cause sepsis (Option 4). Pain can be severe and require analgesics. (Option 2) Hematuria is common, and the urine should go from bright red to pink-tinged over several hours. Hematuria is concerning if the urine remains bright red over a prolonged period (>24 hr). (Option 3) Bruising on the back or abdomen after the procedure is normal. (Option 5) The client may need to rest for the remainder of the day following anesthesia, but ambulation is encouraged to facilitate removal of stone fragments. Educational objective: Following extracorporeal shock wave lithotripsy for kidney stones, the client should be instructed to increase fluids to wash out stone fragments, ambulate as much as possible after recovery from anesthesia, and expect blood in the urine that should change from red to pink.

Extravasation

Extravasation is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: Stop the infusion immediately and disconnect the IV tubing (Option 5). Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. Elevate the extremity above the heart to reduce edema (Option 2). Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamin

Extravasation

Extravasation is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: Stop the infusion immediately and disconnect the IV tubing (Option 5). Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. Elevate the extremity above the heart to reduce edema (Option 2). Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine) (Option 4).

Failure to sense

Failure to sense appears on an ECG as asynchronous pacer spikes in inappropriate or random locations (eg, pacer spike on the T wave).

Femoral-popliteal bypass surgery

Femoral-popliteal bypass surgery involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow. The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselines. The client's nonpalpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately.

Fentanyl

Fentanyl is a potent (up to 100x the strength of morphine) analgesic used to treat severe pain. There is a significant risk of excess sedation and respiratory depression. Fentanyl patches are intended for severe pain and have a history of opioid tolerance. It takes about 6-12 hours for the drug to take effect after the very first patch application. Alternate short-acting pain medications (eg, morphine) can be used until then. The old fentanyl patch must be removed when applying a new one. Blood fentanyl level is only reduced by 50% about 17 hours after patch removal. There is still some drug remaining on the patch when it is removed after the 72 hours. This can be harmful if children, pets, or caregivers are exposed. The patch must be contained and immediately disposed of (flushed down the toilet, discarded deep into the trash).

Fifth diseas

Fifth disease ("slapped-cheek," erythema infectiosum), which is caused by parvovirus B19. Symptoms, in addition to a bright-red facial rash, include fever and general flulike symptoms. It is harmless unless the client has a hemolytic/immunodeficient condition. Pregnant women should avoid contact with infected individuals as the virus can be transmitted to the fetus and cause anemia.

RACE- put out fire

Fires can be extremely dangerous in health care facilities, where clients may be incapacitated. Nurses must be aware of the agency's fire safety plan. Most agencies use the mnemonic RACE in their protocols to ensure that all employees perform the priority actions consistently. These actions are: R - Rescue any clients in immediate danger and move them to safety (Option 5) A - Alarm - sound the alarm and activate the agency's fire response (Option 4) C - Confine the fire by closing all doors to all rooms and fire doors to the entrance of the unit (Option 2) E - Extinguish the fire, if possible, with a fire extinguisher (Option 1) Visitors may be discouraged from using the elevators after the other actions have taken place (Option 3). Educational objective: When a fire occurs in a health care agency, the nurse should use the mnemonic RACE to remember the priority steps: R - Rescue any clients in immediate danger; A - Alarm, sound the fire alarm; C - Confine the fire by closing doors; E- Extinguish the fire, if possible, with a fire extinguisher.

Fluticasone/salmeterol (Advair)

Fluticasone/salmeterol (Advair) is a combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). Salmeterol is a long-acting inhaled β2-adrenergic agonist that promotes relaxation of the bronchial smooth muscles over 12 hours. Fluticasone decreases inflammation. This medication is used as part of the treatment plan for prevention and long-term control of asthma. Client instructions include: After inhalation, rinse the mouth with water without swallowing to reduce the risk of oral/esophageal candidiasis Avoid smoking and using tobacco products Receive the pneumococcal and influenza vaccines if there is a risk for infection

Folliculitis

Folliculitis is usually due to the presence of staphylococci in moist areas where there is friction. It is most common in the scalp, beard, and extremities in men. It can be treated with medicated soap, topical antibiotics, and warm compresses. The systemic issue in Client 2 is a priority.

prostatectomy

Following a prostatectomy, bleeding is a potential complication that requires a thorough assessment. Any bleeding, passage of clots, decrease in urinary stream, urinary retention, or symptoms of urinary tract infection should be reported to the HCP.

cataract surgery

Following cataract surgery, the client will be instructed that for several days (or until approved by the surgeon), activities that may increase intraocular pressure should be avoided to decrease the risk of damage to sutures or surgical site. These include bending (eg, vacuuming floors, playing golf), lifting more than 5 lb, sneezing, coughing, rubbing or placing pressure on the eye, or straining during a bowel movement. The nurse should encourage this client to increase fluids and fiber in the diet as well as consider an over-the-counter stool softener or laxative. (Option 1) It may take 1-2 weeks before visual acuity is improved. (Option 3) It is common for the client to experience itching ("sand" in the eye), photophobia, and mild pain for several days following surgery. Purulent drainage, increased redness, and severe pain should be reported. (Option 4) Sleeping on 2 pillows will elevate the head of the bed and decrease intraocular pressure.

Fondaparinux (Arixtra)

Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place (Option 2). Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis.

Treatment of frostbite

Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow, vascular stasis, and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear white and hard and unable to sense touch. This can eventually progress to gangrene. Treatment of frostbite should include the following: Remove clothing and jewelry to prevent constriction. Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged (Option 3). Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain (Option 5). Avoid heavy blankets or clothing to prevent tissue sloughing. Provide analgesia as the rewarming procedure is extremely painful (Option 4). As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema (Option 2). Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings (Option 1). Monitor for signs of compartment syndrome.

phenytoin

Gingival hyperplasia or hypertrophy is a known side effect of phenytoin (Dilantin) and is not a reason to stop the drug. Vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it. Signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash, and lymphadenopathy).

Chronic Open Angle Glaucoma

Gradual loss of peripheral vision and difficulty adjusting to different lighting are manifestations of chronic open-angle glaucoma.

Hospital Acquire Pneumonia

HAP is a bacterial infection acquired in a health care facility that was not present on admission. Almost all clients with bacterial pneumonia develop leukocytosis (WBC >11,000/mm3). Antibiotic therapy is the first-line treatment, but antibiotic resistance frequently occurs in HAP. If antibiotic therapy is effective, clinical improvement usually occurs within 3-4 days of initiation of IV antibiotics. The nurse monitors WBC as the best indicator of treatment effectiveness as antibiotics cause bacterial lysis or hinder bacterial DNA reproduction. The reduced number of bacteria and the resulting decrease in inflammation cause a decrease in the number of white blood cells needed to fight the infection. Other indicators of treatment effectiveness include improvement of infiltrates on chest x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production).

Head tilt and chin lift

Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis.

Hemoglobin A1C

Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes. The A1C test measures blood glucose control over a period of 2-3 months; higher measurements indicate higher glycemic levels. High levels may indicate poor adherence to the recommended diet and exercise plan or ineffective antihyperglycemic medication regimen. It is important for the nurse to review the diet, exercise, and medication plan with the client who has a high hemoglobin A1C.

Heparin

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

Hepatic encephalopathy

Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood-brain barrier, leading to neurological dysfunction (Option 1). Lactulose is the most common treatment for hepatic encephalopathy. Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an acidic environment and a hyperosmotic effect (laxative). In this acidic environment, ammonia (NH3) is converted to ammonium (NH4+) and excreted rapidly. Lactulose can be given orally with water, juice, or milk (to improve flavor) or it can be administered via enema (Option 4). For faster results, it can be administered on an empty stomach (Option 2). The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached (improved mental status, decreased ammonia levels) (Option 3). The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia. Educational objective: Increased ammonia levels in the blood can lead to hepatic encephalopathy, a complication of liver disease. Lactulose, a laxative, removes ammonia and is given orally with juice, milk, or water or rectally via enema to produce 2-3 soft bowel movements a day. Therapeutic effects are evident via laboratory results and improving mental status.

Herpes Teaching

Herpes simplex virus type 2 (HSV-2) is usually associated with genital herpes. Lesions are painful and appear as multiple small, vesicular lesions. Management strategies focus on disease spread, including autoinoculation (eg, fingers) and pain relief, and include: Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak (Option 1). After the outbreak has resolved, condoms should be used in future sexual encounters as transmission is possible even in the absence of active lesions. Keep the area with lesions clean and dry. Avoid use of perfumed soaps and bubble baths. Maintain proper hand hygiene and avoid touching the lesions to prevent spreading. Use sitz baths and oatmeal baths to provide comfort and relief of itching and burning.

Herpes zoster (shingles)

Herpes zoster (shingles) is caused by the varicella-zoster virus (VZV), the same virus that causes chickenpox. After initial VZV infection earlier in life, the virus remains dormant in the sensory nerves. Reactivation of VZV can occur when the immune system is compromised (eg, aging, immunosuppression), resulting in the formation of pruritic, painful, fluid-filled blisters. These blisters can manifest along the distribution of one or more nerves (dermatomal distribution), causing a characteristic unilateral linear pattern, or the lesions can be disseminated (spreading beyond adjacent dermatomes). The fluid in the blisters carries a high viral load and is contagious to those who have not had chickenpox or received the varicella vaccine. For the client with disseminated shingles, airborne and contact precautions should be followed. An eye shield should be used if there is a chance of virus-containing fluid splashing into the eyes (eg, bathing). Once the lesions have crusted over, the likelihood of transmitting the virus is greatly reduced, and therefore only standard precautions are required.

Herpes zoster, or shingles

Herpes zoster, or shingles, has a characteristic unilateral, linear pattern of fluid-filled blisters. Affected clients commonly report pain and itching. Herpes zoster infection is due to the varicella-zoster virus (VZV), which also causes chickenpox. After initial VZV infection (chickenpox) in early childhood, the virus remains dormant in the sensory nerves. Reactivation of VZV when the immune system is compromised (eg, aging, immunosuppression) results in the formation of lesions along the distribution of one or more such nerves (dermatomal distribution). Vaccination can prevent shingles. If this rash is determined to be due to shingles, the affected area should be covered to prevent the spread of infection. Therefore, it is a priority to ask if this client has had chickenpox.

Abductor Wedge

Hip Surg. pt

Hyperkalemia

Hyperkalemia can be asymptomatic but may cause fatigue, generalized weakness, or in severe cases muscle paralysis and/or dysrhythmias. Management includes preventing life-threatening dysrhythmias and correcting serum potassium levels. Intravenous calcium gluconate is administered to hyperkalemic clients with ECG changes (eg, peaked T waves). Calcium gluconate itself does not decrease the serum potassium level but temporarily stabilizes the myocardium by raising the threshold for dysrhythmia occurrence. Once the nurse stabilizes the client by administering calcium gluconate, other prescriptions may then be implemented to decrease serum potassium level (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) (Option 1).

Hypertensive crisis

Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3

Hyperthyroidism

Hyperthyroidism refers to sustained hyperfunctioning of the thyroid gland due to excessive secretion thyroid hormones (T3, T4); this leads to an increased metabolic rate. In clients with hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include: Adherence to a high calorie diet (4000-5000 calories per day). Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals (Option 1). Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea) (Option 2). However, high-fiber diets are recommended if the client with hyperthyroidism has constipation. Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks). Avoidance of spicy foods as these can also increase GI stimulation. Educational objective: Hyperthyroidism leads to a high metabolic rate. It is important for the nurse to teach the client nutritional measures, including consumption of a diet high in calories (high in protein, carbohydrates, vitamins, and minerals) to satisfy hunger and prevent weight loss and tissue wasting.

Hypomagnesemia

Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate.

Hypothermia

Hypothermia occurs when the core temperature is below 95 F (35 C) and the body is unable to compensate for heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate defibrillation in these clients.

Hypovolemic shock

Hypovolemic shock, the most common type of shock, occurs when blood volume decreases through hemorrhage or movement of fluid from the intravascular compartment into the interstitial space (third-spacing). Treatment involves preventing additional fluid loss, restoring volume through IV fluids, and improving hemodynamic stability through vasoactive medications (eg, norepinephrine, dopamine). Norepinephrine causes vasoconstriction and improved heart contractibility/output. When the medication is stopped suddenly, its effects end quickly. It should be tapered slowly to avoid the progression or relapse of shock.

IV furosemide

IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg) / (4 mg/min) = 40 min

Tx of torsades de pointes

IV magnesium

Immediate postoperative nursing care

Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit.

infective endocarditis

In IE, the vegetations over the valves can break off and embolize to various organs, resulting in life-threatening complications. These include the following: Stroke - paralysis on one side Spinal cord ischemia - paralysis of both legs Ischemia to the extremities - pain, pallor, and cold foot or arm Intestinal infarction - abdominal pain Splenic infarction - left upper-quadrant pain The nurse or the client (if at home) should report these manifestations immediately to the HCP. (Options 2 and 4) IE commonly presents with fever, arthralgias (multiple joints pains), weakness, and fatigue. These are expected and do not need to be reported during the initial stages of treatment. IE clients typically require intravenous antibiotics for 4-6 weeks. Fever may persist for several days after treatment is started. If the client is persistently febrile after 1-2 weeks of antibiotics, this must be reported as it may indicate ineffective antibiotic therapy. (Option 3) Splinter hemorrhages can occur with infection of the heart valves (endocarditis). They may be caused by vessel damage from swelling of the blood vessels (vasculitis) or tiny clots that damage the small capillaries (microemboli). The presence of splinter hemorrhages is not as critical as the macroemboli causing stroke or painful cold leg. Educational objective: IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur. The onset of hemiplegia or painful, pale, cold foot/leg could indicate embolization and should be reported to the HCP immediately.

central venous access sites

In adult clients, central venous access sites in the upper body (internal jugular or subclavian) are preferred to minimize the risk of infection. Access sites in the inguinal area (femoral) are easily contaminated by urine or feces, and it is difficult to place an occlusive dressing over these sites. A central venous catheter (CVC) should be placed where aseptic technique can be applied. The site should be assessed daily for signs/symptoms of infection (eg, redness, swelling, drainage). The duration of CVC placement should be based on clinical need and judgment that there is no evidence of infection.

first-degree atrioventricular block

In first-degree atrioventricular block, every impulse is conducted to the ventricles, but the time of atrioventricular conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second.

intussusception

Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could indicate intussusception or some other abdominal pathology (eg, appendicitis). Additional findings in intussusception include stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt blood supply, and cause intestinal tears (perforation). It is an emergency, and the client should be brought to the emergency department for further evaluation.

metabolic syndrome (insulin resistance syndrome)

Individuals with metabolic syndrome (insulin resistance syndrome) have an increased risk of diabetes and coronary artery disease. The presence of abdominal obesity causes increased insulin production (hyperinsulinemia); this excess insulin leads to insulin resistance, the primary feature of metabolic syndrome. Metabolic syndrome is characterized by the presence of 3 or more of the following criteria: Increased waist circumference: ≥40 in (102 cm) in men, ≥35 in (89 cm) in women (Option 2) Blood pressure: ≥130 mm Hg systolic or ≥85 mm Hg diastolic or drug treatment for hypertension (Option 3) Triglyceride level: >150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides (Option 5) High-density lipoprotein (HDL) levels: <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL-C Fasting glucose levels: ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose (Option 4) The mnemonic for metabolic syndrome is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose).

Foot Care Diabetes

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Peripheral neuropathy results from damage to the nerves in the extremities. Clients may be unable to feel injuries if they occur and must take extra measures in caring for their feet. Clients should be taught to wear closed-toed, leather-based shoes to prevent injury. Careful, daily attention to foot care can prevent long-term complications. The following instructions can be used in teaching diabetic foot care: Proper footwear - Wear shoes that are comfortable, supportive, and well-fitting (preferably leather). Avoid high-heeled, open-heeled, and open-toed shoes. Wear clean, absorbent (eg, cotton) socks. Daily hygiene and inspection - Use a mild soap and warm water; dry feet thoroughly, especially between toes. Apply lanolin lotion to prevent drying (but not between toes) (Option 1). Inspect for any break in skin integrity using a mirror or a second person to visualize the bottom of the feet. Trim toenails straight across; file edges along contour of the toes. Injury avoidance - Do not walk barefoot, use hot water or heating pads, wear restrictive shoes or clothing, or cross the legs for extended periods (Options 3 and 4). Report problems - Do not self-treat corns, calluses, or ingrown toenails. Cleanse cuts or abrasions with mild soap and water; report non-healing or infected injuries to the health care provider immediately.

Infectious mononucleosis

Infectious mononucleosis is caused by the Epstein-Barr virus. Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16-year-old client should be taken to the emergency department for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery.

Isoniazid

Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy. A teaching plan for a client prescribed INH includes the following: Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity (Option 1) Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH Report changes in vision (eg, blurred vision, vision loss) Report signs/symptoms of severe adverse effects such as: -Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) -Peripheral neuropathy (eg, numbness, tingling of extremities) (Options 4)

failure to capture

It should not be confused with failure to capture, in which pacer spikes are located appropriately but there is no electrical response elicited from the heart (eg, no QRS complex after a pacer spike).

Jaundice

Jaundice is associated with elevated bilirubin levels and yellowing of the sclera (icterus). It often causes intense itching that can be exacerbated by the use of hot water and strong soaps. Therefore, when delegating hygiene tasks, the registered nurse should instruct the unlicensed assistive personnel to use cool water and the minimum necessary amount of mild soap

Levetiracetam

Levetiracetam (Keppra) is an anticonvulsant prescribed for seizure disorders. As with other antiseizure medications, levetiracetam has a depressing effect on the central nervous system (CNS), which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks (Option 1). However, the CNS-depressing effects of levetiracetam may be enhanced if taken with other CNS-depressing substances (eg, alcohol) or medications. New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (Option 3). Like other anticonvulsants, levetiracetam can trigger Stevens-Johnson syndrome, a rare but life-threatening blistering reaction of the skin. Rash, blistering, muscle/joint pain, or conjunctivitis should be reported and assessed immediately (Option 4).

Levofloxacin

Levofloxacin, a fluoroquinolone antibiotic prescribed to treat urinary tract infections, has no known cross-sensitivity to penicillin. However, cross-sensitivity with other fluoroquinolones can occur.

Levothyroxine (Synthroid)

Levothyroxine (Synthroid) is a thyroid hormone replacement drug that is the most common treatment for hypothyroidism, a condition in which thyroid hormone deficit slows the metabolic rate. In primary hypothyroidism, the deficit occurs due to a problem in thyroid gland tissue or hormone synthesis. TSH is released from the pituitary and stimulates the thyroid gland to secrete thyroid hormones (T3, T4). In primary hypothyroidism, when the thyroid does not synthesize enough T3 or T4, the pituitary releases additional TSH to compensate. This results in high levels of circulating TSH. Clients are prescribed levothyroxine (or their dose is augmented) to increase T3 and T4; this lowers TSH and leads to a euthyroid (normal) state Levothyroxine sodium (eg, Levoxyl, Levothroid, Synthroid) is used to replace thyroid hormone in clients with hypothyroidism (inadequate thyroid hormone) and for those who have had their thyroid removed. These clients must understand that this medication must be taken for the rest of their lives (Option 5). A client's dose is adjusted based on serum TSH levels to prevent too much or too little hormone. Clients must be taught to report signs of excess thyroid hormone such as heart palpitations/tachycardia, weight loss, and insomnia (Option 3). (Option 1) Clients with hypothyroidism experience lethargy and somnolence. Hormone replacement therapy will increase metabolic activity and alertness. (Option 2) This medication is a hormone that is normally present in the body, so it is safe to take during pregnancy. The dose may need to be altered due to the metabolic demands of pregnancy, but the drug will not harm the fetus. (Option 4) It is best to take this medication first thing in the morning as it is best absorbed on an empty stomach (1 hour before or 2 hours after a meal). Educational objective: Clients receiving thyroid hormone replacement therapy (levothyroxine sodium) should understand that treatment is lifelong and be taught the signs of excess hormone (eg, tachycardia/palpitations, weight loss, insomnia). The medication is best absorbed on an empty stomach and is safe to take during pregnancy.

Lithium dosing

Lithium carbonate is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a mood disorder) and bipolar disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity can be acute (eg, ingesting a bottle of lithium tablets in a suicide attempt) or chronic (eg, slow accumulation due to decreased renal function or drug-drug interactions). Acute or acute-on-chronic toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea); neurologic manifestations occur later. However, neurologic manifestations occur early in chronic toxicity. Common neurologic manifestations include ataxia, confusion, or agitation, and neuromuscular excitability (eg, tremor, myoclonic jerks). Chronic toxicity also manifests as diabetes insipidus (eg, polyuria, polydipsia).

Lithium for bipolar:

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics).

long-acting nitrate isosorbide mononitrate

Long-acting nitrates are used to reduce the incidence of anginal attacks. Nitrates are effective if the client is able to do activities without the incidence of chest pain. The client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates.

Loop diuretics

Loop diuretics (furosemide, torsemide, bumetanide) are used to treat fluid retention, such as that found in clients with heart failure or cirrhosis. When administering loop diuretics, the nurse can expect the client's kidneys to excrete a significant amount of water and potassium. When potassium is excreted at a fast rate, the client could develop hypokalemia, a medical emergency that can result in other life-threatening complications such as heart arrythmias, as well as muscle cramps and weakness (Option 4). Blood pressure should also be assessed prior to administration of loop diuretics as excess diuresis may cause intravascular volume depletion that results in low blood pressure. A client with baseline hypotension may develop a critically low blood pressure. Excess diuresis can also affect kidneys, and the blood urea nitrogen and creatinine levels can become elevated as well. Therefore, these levels should be assessed

Macular degeneration

Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate with age. This causes distortion (blurred or wavy disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact. Macular degeneration has 2 different etiologies. "Dry" macular degeneration occurs when the microvasculature supplying the macula is blocked, causing ischemia. In "wet" macular degeneration, abnormal blood vessels form and eventually destroy the macula. If it is diagnosed early, further progression of wet macular degeneration can be slowed or stopped using surgery or antineoplastic agents. Age and heredity are the biggest risk factors for macular degeneration.

Magnetic resonance cholangiopancreatography (MRCP)

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used to visualize the biliary and hepatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP) to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications prior to the procedure, including presence of certain metal implants (eg, pacemaker, aneurysm clip, cochlear implant), pregnancy, or any previous allergy or reaction to gadolinium .Most orthopedic implants (eg, rods, pins, artificial joints) are considered safe for MRI imaging.

Serum Creatinine

Males: 0.6-1.2 mg/dL Females: 0.5-1.1 mg/dL

Malignant hyperthermia

Malignant hyperthermia (MH) is a rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and the depolarizing muscle relaxant succinylcholine (Anectine) used to induce general anesthesia. In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity (usually of the jaw and upper body [early sign]), increased oxygen demand and metabolism, and dangerously high temperature (later sign). As MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and health history can help minimize the client's risk

Megaloblastic anemia

Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12 supplement is recommended when dietary intake is inadequate.

Memantide

Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the quality of life for clients and caregivers. Memantine is an N-methyl-D-aspartate (NMDA) antagonist that works by binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from overexposure to glutamate (excess levels of glutamate contribute to brain cell death). Clients with moderate to severe AD may experience improvement in: Cognition - memory, thinking, language Daily functioning - dressing, bathing, grooming, eating Behavioral problems - agitation, depression, hallucinations

Orthodox Jewish Faith & Medications

Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill.

Meningitis

Meningitis is an inflammation of the meninges covering the brain and spinal cord. The key clinical manifestations of bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP). In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure (Option 2). In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and meningitis may include: Administer vasopressors. Obtain relevant labs and blood cultures prior to administering antibiotics. Administer empiric antibiotics, preferably within 30 minutes of admission (Option 1). This client will continue to decline without antibiotic therapy. Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation (Option 4). Assist with a LP for cerebrospinal fluid (CSF) examination and cultures (Option 3). CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy. Educational objective: For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture.

Meningococcal meningitis

Meningococcal meningitis is a highly contagious condition that involves inflammation and bacterial infection in the tissues covering the brain and spinal cord (meninges). It is transmitted through direct contact or by inhaling droplets from infected individuals (ie, upper respiratory tract infections) and is prevalent among those living in close proximity (eg, prisons, dormitories). Characteristic signs include fever, headache, nuchal rigidity (stiff neck), photophobia, nausea, vomiting, and changes in mental status. If any of these are present, prompt testing (eg, lumbar puncture [LP], cultures) and initiation of antibiotic therapy immediately following the LP are critical as this is a life-threatening medical emergency.

Metabolic acidosis

Metabolic acidosis is due to an increase in the production or retention of acid or the depletion of bicarbonate via the kidneys or gastrointestinal (GI) tract. In metabolic acidosis there is a decrease in pH (<7.35) and HCO3- (<22 mEq [22 mmol/L]). Common causes of metabolic acidosis include: GI bicarbonate losses (eg, diarrhea) (Option 2) Ketoacidosis (eg, diabetes, alcoholism, starvation) Lactic acidosis (eg, sepsis, hypoperfusion) (Option 4) Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) (Option 5) Salicylate toxicity

Metabolic syndrome

Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client's risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria include: Abdominal obesity: Waist circumference (≥40 inches [102 cm] in men, ≥35 inches [89 cm] in women) High serum triglycerides >150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment Low levels of high-density lipoprotein (HDL) cholesterol (<40 mg/dL [1.0 mmol/L] in men, <50 mg/dL [1.3 mmol] in women) Hypertension ≥130/85 mm Hg or hypertension drug treatment Fasting blood glucose ≥100 mg/dL (5.6 mmol/L) or hyperglycemia drug treatment The 55-year-old woman (waist circumference 37 inches [94 cm], triglycerides 190 mg/dL [2.2 mmol/L], fasting blood glucose 120 mg/dL [6.7 mmol/L]) is at highest risk for metabolic syndrome with 3 of 5 criteria (obesity, high triglycerides, hyperglycemia)

Methadone

Methadone is a potent narcotic with a longer half-life than its duration of action due to its lipophilic properties. The risk for overdose exists as clients can inadvertently take too many tablets for additional pain relief even though fat cells will continue to release high amounts of the drug into circulation. Early signs of toxicity include nausea/vomiting and lethargy. A client who falls asleep with stimulation (ie, is obtunded) requires additional observation/monitoring. Sedation precedes respiratory depression, a life-threatening complication of severe toxicity (Options 1 and 3). An acceptable pulse oximetry reading for a normal, healthy nonsmoking adult is considered 95%-100%. A reading of 90% is low and indicates inadequate depth or rate of respiration with possible respiratory depression (Option 5). (Option 2) Itching sensation (pruritus) is an expected finding with narcotic use, especially in opioid-naïve clients. It can be managed with an antihistamine. Occasional premature ventricular contractions are a common, insignificant finding in most adults. The client should have cardiac monitoring in the setting of methadone use/overdose as there is a risk of QT interval prolongation (normal 0.34-0.43 sec, or less than half the RR interval), which can lead to cardiac arrhythmias (eg, torsades de pointes).

Metoprolol

Metoprolol is a beta blocker used for heart rate control in tachyarrhythmias

Miconazole

Miconazole (Monistat), an antifungal cream commonly prescribed to treat vaginal candidiasis, is inserted high into the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period. Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately 3-7 days. However, sexual activity is not a significant cause of infection or reinfection of candida, and partner evaluation is not needed. Trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted; therefore, partners should be evaluated and treated. Other teaching points for this client should include: Ensuring proper hygiene of the perineum - cleansing from anterior to posterior (front to back) to prevent accidental introduction of fecal organisms (Option 1) Wearing loosely fitted cotton underwear and avoiding synthetic undergarments to promote ventilation, decrease friction, and reduce moisture (Option 2) Refraining from douching, which can introduce organisms higher up into the vaginal canal and cervix

Midazolam antidote

Midazolam (Versed) is a benzodiazepine commonly used to induce conscious sedation in clients undergoing endoscopic procedures. The initial dose is 1 mg and is titrated up slowly (eg, 2 minutes before each 1-mg increment) until speech becomes slurred. Usually no more than 3.5 mg is necessary to induce conscious sedation. It is commonly administered with an opioid analgesic (eg, morphine, Fentanyl) because of their synergistic effects. Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen desaturation with resultant respiratory arrest. Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines.

Milrinone

Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation. Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic therapies. The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line is becoming more common as a palliative measure for end-stage heart failure. Milrinone infusion requires central venous access (eg, peripherally inserted central catheter) as the medication is a vesicant and can cause extravasation if infused through a peripheral IV line.

Prevention of ventilator-associated pneumonia

Minimize duration of intubation Prevent aspiration Minimize sedation with daily sedation interruptions Semirecumbent position (30-45 degrees) Use endotracheal tube with subglottic drainage Reduce colonization Antibiotic prophylaxis not recommended Antiseptics for oral decontamination Avoid PPI except for patients at high ulcer risk Change circuit only if visibly contaminated Prevention of ventilator-associated pneumonia focuses on minimizing mechanical irritation and bacterial access to the lungs. Specific steps include sealing the endotracheal tube cuffing with ≥20 cm H2O (15 mm Hg), routine oral hygiene with chlorhexidine, elevating the head of the bed, minimizing sedation, and extubating as soon as possible.

Misoprostol

Misoprostol (Cytotec) is a synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug (NSAID) therapy. Antacids, especially those that contain magnesium (eg, Gaviscon), can increase the adverse effects of misoprostol (eg, diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain magnesium (eg, calcium carbonate [Tums]) and contact the health care provider if adverse effects occur (Option 4). Taking misoprostol with food can help decrease gastrointestinal side effects (eg, abdominal pain, cramping, diarrhea). Misoprostol is also used for labor induction and is classified as a pregnancy category X drug. Women of childbearing age must be educated on using reliable birth control and the possible sensation of uterine cramping while taking misoprostol. Clients who suspect they are pregnant must stop taking the medication and contact their health care provider immediately. The client can continue taking ibuprofen (an NSAID) with misoprostol because misoprostol is designed to reduce side effects of ibuprofen. Educational objective: Misoprostol prevents gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug therapy. It should not be taken with antacids but can be taken with food to reduce gastrointestinal upset. Women of childbearing age should be educated on using reliable birth control methods as misoprostol can induce labor.

Mitral valve regurgitation

Mitral valve regurgitation is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are often asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue). This client should be assessed first due to possible heart failure, which would require immediate intervention.

Mobitz II (type II second-degree atrioventricular block)

Mobitz II (type II second-degree atrioventricular block) is usually not associated with electrolyte disturbances but is more often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers).

loop diuretics

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).

A client involved in a motor vehicle collision reports severe pelvic and right heel pain. While waiting for imaging, the nurse assesses the client.

Motor vehicle collisions and motorcycle crashes, followed by falls, are the most common mechanisms for pelvic fractures. The pelvis contains several large vascular structures (eg, internal and external iliac veins and arteries) and abdominal and pelvic organs (eg, small bowel, sigmoid colon, bladder, urethra, uterus, prostate). Therefore, when caring for a client with a fractured pelvis, in addition to pain, the nurse should assess for internal hemorrhage (eg, abdominal distension, vital signs, hematocrit, hemoglobin), paralytic ileus (eg, bowel sounds), neurovascular deficits (eg, extremity circulation, sensation, movement), and abdominal and genitourinary organ injuries (eg, hematuria, urine output <0.5 mL/kg/hr). Abdominal distension could be due to serious intra-abdominal bleeding or injury to the bowel or urinary structures. Absent bowel sounds can indicate the presence of a paralytic ileus related to the trauma and/or a retroperitoneal hematoma; these should be reported to the health care provider (HCP)

cardiac tamponade

Muffled heart sounds and hypotension are classic signs of cardiac tamponade. The small amount of extra fluid in the pericardial sac applies pressure to the cardiac muscle. This pressure prevents the heart from adequately stretching to beat with enough force. Cardiac output decreases with increasing heart compression, resulting in hypotension. Cardiac tamponade is treated by the health care provider, who aspirates fluid from the pericardial sac

Multiple Sclerosis

Multiple sclerosis (MS) is a progressive, demyelinating disease of the central nervous system that interrupts nerve impulses, causing a variety of symptoms. Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of balance, and fatigue are usually present, causing impaired mobility and risk for fall and injury. Walking with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses.

Mycobacterium tuberculosis

Mycobacterium tuberculosis is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). TB, regardless of location, commonly presents with constitutional symptoms, including: Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes: Cough Purulent or blood-tinged sputum Shortness of breath Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in immunocompromised clients and the elderly. Jaundice can be present in disseminated TB with liver involvement. It can also be a side effect associated with drugs used to treat pulmonary TB (eg, isoniazid).

Spinal Immobilization

N - Neurological examination. Focal deficits include numbness and decreased strength. S - Significant traumatic mechanism of injury A - Alertness. The client may be disoriented or have an altered level of consciousness (Option 2). I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1). D - Distracting injury. Another significant injury could distract the client from spinal pain. S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present

stable angina

NTG is a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is placed under the client's tongue. It usually relieves pain in about 3 minutes and lasts 30-40 minutes. The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses (Option 2). If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted (Option 1). Previously, clients were taught to call EMS after the third dose was taken, but newer studies suggest that this leads to a significant delay in treatment. The NTG should be easily accessible at all times. Tablets are packaged in a light-resistant bottle with a metal cap. They should be stored away from light and heat sources, including body heat, to protect from degradation. Clients should be instructed to keep the tablets in the original container. Once opened, the tablets lose potency and should be replaced every 6 months. The car is not a good place to store NTG due to heat (Option 4). (Option 3) Waking up at night with chest pain can signify that angina is occurring at rest and is no longer considered stable angina. This should be reported to the health care provider. Educational objective: Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat; and replacing the bottle every 6 months once opened.

Naproxen

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation. All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following: Gastrointestinal (GI) toxicity - symptoms of GI bleeding such as black tarry stools should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. Kidney injury - long-term use is associated with kidney injury Hypertension and heart failure - NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension Bleeding risk - clients should notify the HCP if taking concurrently with aspirin, other NSAIDs, or anticoagulant or antiplatelet drugs as they can increase the risk of GI bleeding.

opioid medications

Nausea and vomiting are expected side effects of opioid medications(eg, morphine sulfate) when the treatment is initiated. However, tolerance develops quickly and persistent nausea is rare. It is recommended that the client take an anti-emetic with the pain medication

Neurogenic shock

Neurogenic shock belongs to the group of distributive (vasodilatory) shock. It affects the vasomotor center in the medulla and causes a disruption in the sympathetic nervous system (SNS); the parasympathetic nervous system (PNS) remains intact. The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the venous circulation, causing hypotension and bradycardia, the characteristic manifestations of neurogenic shock.FEM

Nitroglycerine

Nitroglycerine causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion

Hypocalcemia

Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy because the parathyroids regulate calcium levels in the blood. When one or more parathyroids are removed, it may take some time for others that have been dormant during hyperparathyroidism (which causes an increase in serum calcium) to begin regulating serum calcium. Trousseau's sign may indicate hypocalcemia before other signs and symptoms of hypocalcemia, such as tetany, occur. Trousseau's sign can be elicited by placing the BP cuff on the arm, inflating to a pressure > than systolic BP, and holding in place for 3 minutes. This will occlude the brachial artery and induce a spasm of the muscles of the hand and forearm when hypocalcemia is present. Chevostek's sign another early indicator of hypocalcemia, should also be assessed. It may be elicited by tapping the face at the angle of the jaw and observing for contraction on the same side of the face.

Neuropathic Pain

Numbness and tingling in both lower extremities are classic examples of neuropathic pain. The common causes of bilateral peripheral neuropathy include the following: Diabetic neuropathy - most common; distribution is usually sock-and-glove pattern Autoimmune neuropathy - Guillain-Barré syndrome Toxic neuropathy - alcohol use Establishing that the sensations the client is experiencing were present before surgery indicates whether this is a complication of surgery. Because the sensation is bilateral and the surgery was on the right knee, the "numbness and tingling" are probably baseline diabetic neuropathy. This should be confirmed by gathering more information from the clien

Dehydration (loss of free water) & serum sodium levels

Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration can impair wound healing. Dehydration (loss of free water) can increase serum sodium levels. The normal value for serum sodium is 135-145 mEq/L (135-145 mmol/L). The value listed, 153 mEq/L (153 mmol/L), is high. Increased serum sodium level (hypernatremia) has an osmotic action that causes water to be pulled from the interstitial spaces into the vascular system. Remember that "water goes where salt is." This action decreases wound healing at a cellular level, reducing the nutrients cells need for repair.

Obstruction (eg, clots, sediment), kinking/compression of catheter tubing

Obstruction (eg, clots, sediment), kinking/compression of catheter tubing, bladder spasms, and improper catheter size can cause leakage of urine from the insertion site of an indwelling urinary catheter. The nurse's first action should be to assess for a mechanical obstruction by inspecting the catheter tubing (Option 1). These interventions may alleviate obstruction: Remove kinking or compression of the catheter or tubing. Attempt to dislodge a visible obstruction by milking the tubing. This involves squeezing and releasing the full length of the tubing, starting from a point close to the client and ending at the drainage bag. If these interventions fail, the nurse should then notify the health care provider (HCP)

premature ventricular contractions are

Occasional premature ventricular contractions are a common, insignificant finding in most adults. The client should have cardiac monitoring in the setting of methadone use/overdose as there is a risk of QT interval prolongation (normal 0.34-0.43 sec, or less than half the RR interval), which can lead to cardiac arrhythmias (eg, torsades de pointes).

Occupational therapy

Occupational therapy emphasizes the skills necessary for activities of daily living (eg, dressing, bathing, cognitive or perception issues); however, walker training is performed by a physical therapist. An overly broad generalization is that occupational therapy is for "above the waist."

Sjögren's syndrome

Ophthalmic lubricants (drops, ointment, gel) replace tears and add moisture to the eyes. They are prescribed to treat dry eyes, a common symptom in clients with Sjögren's syndrome, an autoimmune disorder. Administering an ophthalmic ointment by tightly closing the eyes and rubbing the lid for 2-3 minutes can squeeze the ointment out of the eye and cause injury. The client is taught to gently close the eyes for 2-3 minutes to distribute the medication after applying the ointment.

Urinary Retention & Opiods

Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions.

NSAIDs and HTN

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen.

Pancreatitis

Pancreatitis is an acute inflammation of the pancreas that results in autodigestion. The most common causes are cholelithiasis and alcoholism. Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the pancreas. The pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include hyperglycemia, hypovolemia (capillary leak → third spacing), latent hypoxia or acute respiratory distress syndrome (ARDS), peritonitis, and hypocalcemia. Pancreatitis can cause hypocalcemia, but the etiology is unclear. Chvostek's (facial twitching) and Trousseau's (carpal spasm) signs are an indication of hypocalcemia from the decrease in threshold for contraction. Sustained muscle contraction (tetany) and decreased cardiac contractility (cardiac arrhythmia) are concerns related to hypocalcemia.

Paracentesis

Paracentesis is performed to remove excess fluid from the abdominal cavity or to provide a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for resolving ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Nursing actions include: Explain the procedure, sensations, and expected results Instruct the client to void to prevent puncturing the bladder Assess the client's abdominal girth, weight, and vital signs Place the client in high Fowler's position and remain with the client during the procedure After the procedure, assess and bandage the puncture site and reassess client weight, girth, and vital signs

Parkinson disease

Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement). Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably.

Allergic Reactions

People with latex allergy usually have a cross-allergy to foods such as bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins. Latex sensitivity increases with exposure and should be suspected in the following situations: Allergic contact dermatitis (rash, itching, vesicles) developing 3-4 days after exposure to a rubber latex product. This is a type IV hypersensitivity reaction (delayed onset). Anaphylaxis - many cases of anaphylaxis have been reported in both medical and non-medical settings. These represent a type I hypersensitivity reaction and should be treated with intramuscular epinephrine injections. Some common settings include: Glove use Procedures involving balloon-tipped catheters (eg, arterial catheterization) Blowing up toy balloons Use of bottle nipples, pacifiers Use of condoms or diaphragms during sex Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable epinephrine pen due to cross-sensitivity with many food and industrial products that can be impossible to avoid.

Home management instructions for PAD include:

Peripheral arterial disease (PAD) is a chronic, atherosclerotic disease caused by buildup of plaque within the arteries. PAD commonly affects the lower extremities and can lead to tissue necrosis (gangrene). Home management instructions for PAD include: Lower the extremities below the heart when sitting and lying down - improves arterial blood flow Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue perfusion Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation Stop smoking - prevents vessel spasm and constriction Avoid tight clothing and stress - prevents vasoconstriction Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development

Peritoneal dialysis

Peritoneal dialysis uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid) is infused. The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes (dwell phase). The catheter is then unclamped to allow dialysate to drain via gravity. Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg, stool softeners) (Option 1). The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation (Options 3 and 5). The drainage bag should be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter location. (Options 2 and 4) The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before contacting the health care provider. Educational objective: Insufficient outflow from peritoneal dialysis commonly results from constipation; bowel movements should be monitored and stool softeners administered as prescribed. Additional nursing measures include checking the tubing for kinks or clots; maintaining the drainage bag below the abdomen; and placing clients in a side-lying position or assisting with ambulation.

Petechiae

Petechiae (small pinpoint red/purple spots on mucus membrane or skin) and purpura (irregular purplish blotches) can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptom takes priority over a more localized dermatological presentation.

Phalen's maneuver

Phalen's maneuver is used to diagnose carpal tunnel syndrome.

Phenytoin

Phenytoin (Dilantin) is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. The nurse's priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing calcium (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the absorption and the serum level of this drug.Monitoring of liver function test during therapy is recommended.

Phenytoin

Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin.

Phenytoin

Phenytoin (Dilantin), an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is 10-20 mcg/mL. In the presence of an elevated reference range (32 mcg/mL), if no seizure activity is observed, the nurse would anticipate the HCP to prescribe a decreased daily dose. The nurse will continue to monitor for signs of toxicity (eg, ataxia, nystagmus, slurred speech, decreased mentation). The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist regularly as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily), especially in high doses. Folic acid supplementation can also reduce this side effect. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis).

Pheochromocytoma

Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis. Important points to note when caring for these clients include the following: Hypertension is difficult to treat and is often resistant to multiple drugs. The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver). Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment. Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter.

Physical therapy

Physical therapy focuses on mobility, ambulation, ability to transfer, and use of related equipment. An overly broad generalization is that physical therapy is for "below the waist." Dressing skills would be taught via occupational therapy.

Picaw

Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.

Pneumonia

Pneumonia decreases gas exchange in the affected areas of the lung. This client is experiencing ventilation to perfusion (V/Q) mismatch, because the affected area is receiving adequate perfusion from the pulmonary artery, but lung infiltrates are obstructing effective gas exchange. Arterioles in the affected area compensate by vasoconstricting, which re-directs blood flow away from the hypoxic alveoli and toward better-ventilated areas of the lung. This is known as hypoxic pulmonary vasoconstriction. This client with left lobar pneumonia should be positioned with the good lung down. If the client is positioned on the left side, because of gravity, blood flow will be directed to the area of pulmonary vasoconstriction, V/Q mismatch will increase, and saturation can drop significantly. Positioning the good lung down also promotes re-expansion (of atelectasis) and drainage of the bad lung.

Poison ivy

Poison ivy can cause a contact dermatitis rash in those who are sensitive to the oily resin found on the leaves, stems, and roots of the plant. About 50% of people who come in contact with the plant develop a rash. It is often linear in appearance where the plant brushed against the skin. The rash develops 12-48 hours after exposure and can last for several weeks. The severity of the rash depends on the amount of resin on the skin. It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of the body.

Positive end-expiratory pressure (PEEP)

Positive end-expiratory pressure (PEEP) applies a given pressure at the end of expiration during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. PEEP is usually kept at 5 cm H2O (3.7 mm Hg). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor gas exchange, and refractory hypoxemia. High levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema. (Option 2) PEEP opens up collapsed alveoli and improves gas exchange at a lower fraction of inspired oxygen (FiO2), resulting in increased, not decreased, oxygen saturation. (Option 3) Hemodynamic effects of PEEP include increased intrathoracic pressure, which leads to reduced venous return, decreased preload and cardiac output, and hypotension, not hypertension. (Option 4) Keeping the alveoli open between breaths with PEEP improves gas exchange across the alveolar-capillary membrane, reduces hypoxemia, and allows for the use of a lower FiO2, which can reduce the risk for oxygen toxicity. High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.

Positive pressure ventilation (PPV)

Positive pressure ventilation (PPV) delivers positive pressure to the lungs using a mechanical ventilator (MV), either invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask/facemask, nasal prongs, or a mouthpiece. The most common type used in the acute care setting for clients with acute respiratory failure is the volume cycled positive pressure MV, which delivers a preset volume and concentration of oxygen (eg, 21%-100%) with varying pressure. Positive pressure applied to the lungs compresses the thoracic vessels and increases intrathoracic pressure during inspiration. This leads to reduced venous return, ventricular preload, and cardiac output, which results in hypotension. The hypotensive effect of PPV is even greater in the presence of hypovolemia (eg, hemorrhage, hypovolemic shock) and decreased venous tone (eg, septic shock, neurogenic shock). PPV increases intrathoracic pressure and reduces venous return to the right side of the heart, reducing preload and cardiac output as well.

Postmortem care may be delayed or not performed if

Postmortem care may be delayed or not performed if the family has certain cultural or religious beliefs or if the death is considered to be non-natural, traumatic, or associated with criminal activity.

Pulseless electrical activity (PEA)

Pulseless electrical activity (PEA) occurs when the cardiac monitor shows organized electrical activity but there is not adequate mechanical activity of the heart muscle. There is a lack of perfusion, and the client has no pulse. Possible contributing factors for PEA are listed as Hs and Ts (Table). The focus is on correcting the underlying etiology of the PEA.

Purpura

Purpura refers to reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the skin. Further assessment must be done to evaluate for a potentially serious etiology, such as blood dyscrasia.

RAI Precautions

RAI is the primary form of treatment for individuals with hyperthyroidism. It destroys or damages the thyroid gland (or a part of it). RAI has a delayed response and may take up to 3 months to have a maximum effect. For this reason, other medications should be maintained to lower thyroid hormone synthesis and treat symptoms of hyperthyroidism until RAI begins to have maximum effect (Option 4). Depending on dosage, clients who receive RAI should be taught to use the following precautions for up to 1 week: Avoid close proximity to pregnant women or children Do not breastfeed as RAI may be excreted through breast milk and could harm the infant (Option 1) Do not share utensils with others or use bare hands to handle food that is to be served to others Isolate personal laundry (eg, bed linens, towels, daily clothes) and wash it separately Use a separate toilet from the rest of the family and flush 2-3 times after each use Wash hands frequently and thoroughly, especially after restroom use Drink plenty of fluids Sleep in a separate bed from others and do not sit near others in an enclosed area for a prolonged period of time (eg, train or flight travel)

Radioactive Iodine Precautions

RAI is the primary form of treatment for individuals with hyperthyroidism. It destroys or damages the thyroid gland (or a part of it). RAI has a delayed response and may take up to 3 months to have a maximum effect. For this reason, other medications should be maintained to lower thyroid hormone synthesis and treat symptoms of hyperthyroidism until RAI begins to have maximum effect (Option 4). Depending on dosage, clients who receive RAI should be taught to use the following precautions for up to 1 week: Avoid close proximity to pregnant women or children Do not breastfeed as RAI may be excreted through breast milk and could harm the infant (Option 1) Do not share utensils with others or use bare hands to handle food that is to be served to others Isolate personal laundry (eg, bed linens, towels, daily clothes) and wash it separately Use a separate toilet from the rest of the family and flush 2-3 times after each use Wash hands frequently and thoroughly, especially after restroom use Drink plenty of fluids Sleep in a separate bed from others and do not sit near others in an enclosed area for a prolonged period of time (eg, train or flight travel)

Raynaud phenomenon

Raynaud phenomenon is a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress. It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the appendages (eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis. Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water. Client teaching regarding prevention of vasospasms includes: Wear gloves when handling cold objects (Option 5). Dress in warm layers, particularly in cold weather. Avoid extremes and abrupt changes in temperature. Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). Avoid excessive caffeine intake (Option 1). Refrain from use of tobacco products (Option 4). Implement stress management strategies (eg, yoga, tai chi) (Option 3). If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes.

Recently extubated clients

Recently extubated clients are at high risk for aspiration, airway obstruction (laryngeal edema and/or spasm), and respiratory distress. To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent aspiration of secretions. Warmed, humidified oxygen is administered immediately after extubation to provide high concentrations of supplemental oxygen without drying out the mucosa (Option 2). Oral care is provided to decrease bacteria and contaminants as well as promote comfort (Option 4). Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and prevent atelectasis (Option 5). (Options 1 and 3) Clients are kept NPO after extubation to prevent aspiration. They may have either a bedside swallow screen or a more formal swallow evaluation by a speech therapist prior to swallowing any food, drink, or medication. Educational objective: Recently extubated clients are immediately placed on humidified oxygen and monitored for aspiration, airway obstruction, and respiratory distress. Clients should remain NPO until swallowing function has been evaluated. In addition, clients should be given routine oral care as well as instructions on coughing, deep breathing, and use of incentive spirometry.

Refeeding syndrome

Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. *The key signs of refeeding syndrome are rapid declines in phosphorous, potassium, and/or magnesium (mnemonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency*. Actions to prevent refeeding syndrome include the following: Obtaining baseline electrolytes Initiating nutrition support cautiously with hypocaloric feedings Closely monitoring electrolytes Increasing caloric intake gradually

post thyroidectomy complications

Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated

Retinal detachment

Retinal detachment is separation of the sensory retina from the underlying pigment epithelium with fluid accumulation. It can be a result of spontaneous atrophic retinal breaks or acute trauma. Common symptoms include a painless loss of vision "like a curtain" coming across the field of vision, light flashes, or a gnat/hairnet appearance in the vision field. This report needs emergent evaluation. Untreated symptomatic retinal detachment usually leads to blindness in that eye. In addition, this is the only presentation that is acute: the rule for prioritization is acute before chronic.

Rome criteria for diagnosis of irritable bowel syndrome

Rome criteria for diagnosis of irritable bowel syndrome Recurrent abdominal pain/discomfort ≥3 days a month for last 3 months & ≥2 of the following: Improvement with bowel movement Change in frequency of stool Change in form of stool

SLE

SLE is an autoimmune disorder in which the body's immune system produces autoantibodies that attack the body's tissues and cells. It is characterized by alternating periods of exacerbation (flare) and remission. The skin is one of the target organs commonly affected by the disease. The characteristic cutaneous manifestation of SLE (> 50%) is a flat or raised red rash that forms a butterfly shape across the bridge of the nose and cheeks. It is often related to sunlight exposure (ultraviolet light) and is more pronounced during a disease flare (Option 1). Recurrent oral ulcers are also very common.

Retinal Detachment

Seeing small flashes of light is associated with retinal detachment. Classic signs of retinal detachment include a curtain coming across the vision, floaters or lightning in the vision field, and "gnats/hairnet/cobweb" throughout the vision. Aging can be a cause and result in retinal tears or holes and spontaneous detachment. However, retinal detachment can also be caused by forceful head trauma. Retinal detachment requires emergent consultation and treatment as most untreated, symptomatic detachments result in blindness of the affected eyes.

Selective estrogen receptor modulators (eg, tamoxifen)

Selective estrogen receptor modulators (eg, tamoxifen) have differential action in different tissues (mixed agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of estrogen-receptive breast cancer cells. However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer (Option 3). Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis). Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore, monitoring for life-threatening side effects is very important.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat a number of psychiatric conditions (eg, major depressive disorder, generalized anxiety disorder). Clients usually see therapeutic effects in 1-4 weeks. SSRIs may increase the risk of suicide, especially in young adults (age 18-24) during initial therapy or after a dosage increase. A client who reports increased energy without a change in depressive feelings needs to be assessed and monitored for suicidal ideation or actions as the client may now have the energy to execute the suicide plan (Option 2). Common, expected side effects of SSRIs include: Loss of appetite; weight loss or weight gain (Option 1) Gastrointestinal disturbances (nausea, vomiting, diarrhea) Headaches, dizziness, drowsiness, insomnia (Options 3 and 4) Sexual dysfunction Side effects should gradually diminish over 3 months, although some may persist. If symptoms are intolerable or a particular SSRI is ineffective, the client may be switched to a different antidepressant.

Sepsis is a complication

Sepsis is a complication of pneumonia that can progress to septic shock and/or multisystem organ dysfunction syndrome. To limit progression, the nurse assesses oxygenation (pulse oximeter, arterial blood gases), airway (patency), breathing (respiratory pattern and rate), circulation (vital signs), tissue perfusion (eg, level of consciousness, capillary refill, skin temperature and color, bowel sounds), and urine output.

Sepsis

Sepsis is a systemic inflammatory response to an infection and can occur as a complication of pneumonia in clients who do not respond to antibiotic therapy. It is caused by the entry of bacteria from the alveoli into the bloodstream. Manifestations characteristic of sepsis include heart rate >90 beats/min, temperature >100.9 F (38.3 C), systolic blood pressure <90 mm Hg, altered mental status, and hyperglycemia (>140 mg/dL [7.8 mmol/L]) in the absence of diabetes. The assessment findings most important for the nurse to report to the health care provider include the following: Absent bowel sounds. Paralytic ileus occurs in the presence of sepsis and hypoxia as blood is shunted away from the gastrointestinal tract to the vital organs. Capillary refill 5 seconds. Prolonged capillary refill (>3-4 seconds in an adult) indicates inadequate blood flow to peripheral tissues. Serum glucose >140 mg/dL (7.8 mmol/L). Gluconeogenesis occurs in response to the physiologic stress of infection. Insulin resistance is associated with anaerobic metabolism.

Serial neurologic assessments

Serial neurologic assessments are important as neurologic abnormalities are often initially subtle, making it important to note the trend. Interventions for neurologic issues are most effective when made early. A neurologic assessment includes: Glasgow Coma Scale (GCS)—best eye, verbal, and motor responses. Best verbal response assesses orientation to person, place, and time (time is the most sensitive). Pupils—equal, round, response to light, and accommodate (PERRLA) Motor—strength and movement in all four extremities Vital signs—especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood pressure readings). The nurse is assessing for signs of increased intracranial pressure (ICP). This client is not admitted in the hospital to get a good night sleep. The client is admitted due to the need for serial neurologic assessments by a professional nurse, and that is the priority.

Serotonin syndrome

Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. The diagnosis is primarily clinical and based on medication history and clinical findings. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia).

Shingles (herpes zoster)

Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more likely to occur when a client's immune system is compromised by disease (eg, HIV infection) or treatments (eg, chemotherapy). Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather recirculating to the rest of the hospital. Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions.

Signs of a transfusion reaction

Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include: Stop transfusion immediately and disconnect tubing at the catheter hub. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option 2). Notify health care provider (HCP) and blood bank. Monitor vital signs. Recheck labels, numbers, and the client's blood type. Treat client's symptoms according to the HCP's prescription. Collect blood and urine specimens to evaluate for hemolysis. Return blood and tubing set to the blood bank for additional testing. Complete necessary facility paperwork to document the reaction.

Sjögren's syndrome

Sjögren's syndrome is an autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help (Option 1).

Social workers

Social workers assist with developing coping skills, securing adequate financial resources or housing, and making referrals to volunteer organizations (Option 3). Wound care is a resource for assessing and planning the optimal care of any wound

Speech therapy

Speech therapy focuses on speech and communication but also on swallowing/eating issues (Option 4). A client with a stroke will need to be evaluated for any aspiration risks and taught how to minimize those risks (eg, chin-down positioning, chewing on the non-affected side of the mouth).

crutches

Standard-type crutches remove the weight from one or both legs and shift it to the upper body. Therefore, if a client is lacking the upper body strength or balance required to use crutches, a walker may be prescribed instead. To rise from a chair, the client holds both crutches by the hand grips with the hand on the same side, slides to the edge of the chair, and grasps the armrest with the other hand or places it on the seat. The client then pushes down on the crutches and the armrest, and uses the unaffected leg for support to rise from the chair. To sit in a chair, the procedure is reversed. The client backs up to the chair until the seat is felt against the legs, and moves both crutches into the hand on the same side and holds them by the hand grips. The client then pushes down on the crutches, reaches back to the armrest or seat with the other hand, uses the unaffected leg for support, and lowers the body into the chair.

Statins

Statins (eg, atorvastatin, simvastatin) lower LDL cholesterol. Myopathy, a possible adverse effect, may lead to life-threatening rhabdomyolysis (Option 5).

Steps for inserting a nasogastric tube for gastric decompression include the following:

Steps for inserting a nasogastric tube for gastric decompression include the following: Perform hand hygiene and apply clean gloves (no need for sterile gloves) Place client in high Fowler's position Assess nares and oral cavity and select naris Measure and mark the tube Curve 4-6" tube around index finger and release Lubricate end of tube with water-soluble jelly Instruct client to extend neck back slightly Gently insert tube just past nasopharynx, aiming tip downward Rotate tube slightly if resistance is met, allowing rest periods for client Continue insertion until just above oropharynx Ask client to flex head forward and swallow small sips of water (or dry if NPO) Advance tube to marked point Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method. Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration.

Steps for removing an indwelling catheter include the following:

Steps for removing an indwelling catheter include the following: Perform hand hygiene Ensure privacy and explain the procedure to the client Apply clean gloves Place a waterproof pad underneath the client Remove any adhesive tape or device anchoring the catheter Follow specific manufacturer instructions for balloon deflation Loosen the syringe plunger and connect the empty syringe hub into the inflation port Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration. Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client. If any resistance is met, stop the removal procedure and consult with the urologist for removal Empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy Remove gloves and perform hand hygiene

Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine)

Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: Decreased appetite and weight loss - can lead to growth delays Cardiovascular effects - hypertension and tachycardia (particularly in adults) Appearance of new or exacerbation of vocal/motor tics Excess brain stimulation - restlessness, insomnia Abuse potential - misuse, diversion, addiction

Stimulants for ADHD drug teaching

Stimulants (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of ADHD. Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6:00 PM. The sustained-release preparation should be given in the morning. The dosage in children is usually started low and titrated to the desired response. Children should be monitored closely during initial treatment for development of tics and continuously for adherence and response to therapy

Stress-induced hyperglycemia (gluconeogenesis)

Stress-induced hyperglycemia (gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection. Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill. Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission. Hyperglycemia is associated with increased risk of complications (eg, health care-associated infection, increased length of stay, acute kidney injury). To minimize complications and avoid hypoglycemia, the recommended glucose target range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL [7.8 mmol/L] fasting and <180 mg/dL [10.0 mmol/L] random blood glucose are recommended.

Subs for soda

Sugary beverages, such as regular soft drinks, are key contributors to the excess consumption of calories and the obesity epidemic. Individuals who are attempting to lose weight should consume beverages with few or no calories, including: Water Club soda (flavored or unflavored) Club soda or sparkling water with a splash of fruit juice Unsweetened tea and/or coffee Non-fat or low-fat milk (in limited amounts) A 12-oz (355-mL) serving in a typical can of regular cola-type beverage contains around 140 calories (kcal). For this client, the consumption of 5 cola beverages daily is contributing 255,500 kcal per year and accounts for 73 lb (33.2 kg) (3500 kcal/lb). This client could lose 73 lb (33.2 kg) in a year simply by substituting zero-calorie beverages for cola.

Sulfasalazine (Azulfidine)

Sulfasalazine (Azulfidine) contains sulfapyridine and aspirin (5-ASA) and is used as a topical gastrointestinal anti-inflammatory and immunomodulatory agent in inflammatory bowel disease (IBD). When the 5-ASA is combined with the sulfa preparation, the drug does not become absorbed until it reaches the colon. Dehydration is a risk with IBD as the client can have up to 20 diarrheal stools a day. The client usually does not feel thirsty until after there is a fluid volume deficit. Sulfa can crystallize in the kidney if the client is dehydrated. Normal urine specific gravity is 1.003-1.030. Elevated specific gravity can indicate concentrated urine and be a sign of dehydration

Syndrome of inappropriate antidiuretic hormone

Syndrome of inappropriate antidiuretic hormone (SIADH) secretion results in water retention and dilutional hyponatremia. Clients with SIADH often require hypertonic saline for sodium repletion to increase serum sodium levels with a minimal infused volume of water.

SIADH

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is often caused by the ectopic production of ADH by a malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium drops below 120 mEq/L (120 mmol/L) (normal: 135-145 mEq/L [135-145 mmol/L]). Therefore, hyponatremia is the highest priority to report as it poses the greatest threat to survival. Hyponatremia requires immediate evaluation and treatment (eg, seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider. SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions. SIADH treatment includes: Fluid restriction to <1000 mL/day Oral salt tablets to increase serum sodium (Option 3) Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations Vasopressin receptor antagonists (eg, conivaptan) The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration.

TST

TST (Mantoux) is the standard method for conducting tuberculosis (TB) surveillance of HCWs and involves 2 steps: Injection of purified protein derivative solution under the first layer of skin of the forearm Evaluation of the injection site 48-72 hours later The health care practitioner inspects and palpates the site to determine if a local skin reaction has occurred. Induration (not redness) indicates a positive test, which means that the individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria. Further testing is needed to determine the presence of latent TB infection or active TB disease. Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB. The QuantiFERON-TB (QFT) blood test is an alternative to TST that measures how the immune system reacts to TB bacteria. Like TST, a positive QFT test only indicates that the individual has been infected with TB bacteria. Although the test is more expensive, it requires only a single visit to the health care provider and results are available in 24 hours.

The nurse should encourage a sexually active female client to implement the following interventions to help prevent recurrent UTIs:

Take all antibiotics as prescribed even if symptoms have improved as bacteria may still be present Increase fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent urination, and prevents urinary stasis. The client should void at least every 2-4 hours. Some health care providers recommend drinking cranberry juice as it inhibits bacterial attachment to the bladder wall, but there is no clinical evidence to support its effectiveness in preventing UTIs (Option 2). Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethra Avoid synthetic fabrics as these materials (eg, nylon, spandex) seal in moisture and create an environment conducive to bacterial proliferation; cotton underwear is recommended instead

Terazosin

Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with BPH. It relaxes the smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth muscle in the peripheral vasculature, which can cause orthostatic hypotension, syncope (blacking out), and falls. This is particularly common when the drug is started (first-dose hypotension) or when the dosage is increased. The serious effects can be avoided by instructing the client to take the medication at bedtime, change positions slowly when going from lying to standing, and avoid any medications that also increase smooth muscle relaxation (eg, phosphodiesterase-5 inhibitors [sildenafil or vardenafil] used to treat erectile dysfunction). Some clients may also experience ejaculatory dysfunction (decreased or absent ejaculation).

The Confusion Assessment Method (CAM)

The Confusion Assessment Method (CAM) is used to determine delirium. The signs are acute mental status changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness. The disorganized thinking includes hallucinations. Risk factors for delirium include older age, prior cognitive impairment, presence of infection, severe illness or multiple comorbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and pain. Delirium has an abrupt onset and is a symptom of other problems. Up to 60% of hospitalized elderly clients have delirium prior to or during hospitalization, but it is often missed by nursing.

Dorsalis Pedis

The DP pulse is located on the top or dorsal part of the foot. The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated on the following scale. 0 Absent 1+ Weak 2+ Normal 3+ Increased, full, bounding

Implanted Cardio Defib.

The ICD has the ability to sense and defibrillate life-threatening dysrhythmias. It also includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for bradycardias that may occur after defibrillation. Postoperative care and teaching are similar to pacemaker implantation. The ICD consists of a lead system that is placed via the subclavian vein to the endocardium. The pulse generator is implanted subcutaneously over the pectoral muscle. Clients are instructed not lift the arm on the affected side over the shoulder until approved by the HCP. This is to prevent dislodgement of the lead wire on the endocardium.

Enoxaparin w/ H&H

The Joint Commission Surgical Improvement Project CORE measure set has shown that preventives (eg, heparin, enoxaparin, aspirin) in select surgical procedures, given 24 hours before and after surgery, reduce the risk of venous thromboembolism. However, the estimated blood loss in a client with a fracture can be significant depending on the site (eg, 250-1200 mL). Although this client's admission hematocrit (36% [0.36]) and hemoglobin (12 g/dL [120 g/L]) are only slightly low for an adult male (normal: 39%-50% [0.39-0.50], 13.2-17.3 g/dL [132-173 g/L]), the blood loss may not yet be evident. Therefore, the nurse would validate the prescription for enoxaparin (Lovenox) with the health care provider before administration.

The PMI

The PMI is also called the apical pulse. It reflects the pulsation of the apex of the heart and should be felt medial to the midclavicular line at the 4th or 5th intercostal space. When the PMI is below the 5th intercostal space or left of the midclavicular line, the heart may be enlarged. Educational objective: During cardiac assessment, the nurse should palpate the PMI medial to the midclavicular line at the 4th or 5th intercostal space. Palpation of the PMI below the 5th intercostal space or to the left of the midclavicular line may indicate cardiac enlargement. Copyright © UWorld. All rights reserved.

The Parkland formula

The Parkland formula (4 mL * weight in kg * percentage of body burned) calculates the 24-hour fluid resuscitation requirements in a burn client; half is given during the first 8 hours.

The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating:

The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating: Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids, cell phones) as close to the client as possible Remind the client of the importance of changing position slowly to minimize orthostatic hypotension Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately Keep the bed in the lowest position (locked) as it reduces the distance to the floor in the event of a fall Provide nonskid footwear for the client before ambulating Keep the environment dry and free of clutter and obstacles (eg, intravenous infusion device tubing and poles, electronic device wires and cords)

The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines:

The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines: Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise. Encourage a daily shower (Option 4) as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens (Option 5). Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP (Option 3). Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. Clarify no driving for 4-6 weeks or until the HCP approves. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1). Notify the HCP if the following symptoms occur: Chest pain or shortness of breath that does not subside with rest Fever >101 F (38.3 C) Redness, drainage, or swelling at the incision sites (Option 2).

Body position that is contraindicated in most neurological conditions?

The Trendelenburg position (body laid flat and supine with feet higher than the head by at least 15-30 degrees) is contraindicated in most neurological conditions.

anticoagulant management for pt on heparin & warfarin

The anticoagulant heparin has to be administered intravenously or subcutaneously. The duration is 2-6 hours intravenously and 8-12 hours subcutaneously. It is measured by the aPTT (activated partial thromboplastin time) laboratory value. Warfarin (Coumadin) is taken orally, with onset/therapeutic effects reached after 2-7 days. It is measured by prothrombin time (PT) or International Normalized Ratio (INR). The therapeutic range for aPTT or PT/INR is generally 1.5-2.0 times the control value (up to 3 times the control value at times). An aPTT value above the therapeutic range places the client at risk for excess bleeding. The heparin administration would need to be stopped or decreased.

acute appendicitis

The appendix is a blind pouch located at the junction of the ileum of the small intestine and the beginning of the large intestine (cecum). When infected or obstructed (foreign body, fecal material, tumor, lymph tissue), the appendix becomes inflamed, causing acute appendicitis. Signs and symptoms of acute appendicitis include the following: Pain: Continuous; begins in the periumbilical region and then moves to the right lower quadrant centering at McBurney's point (one-third of the distance from the right anterior superior iliac spine to the umbilicus) Gastrointestinal symptoms: Anorexia, nausea, and vomiting Rebound tenderness and guarding Clients with acute appendicitis attempt to decrease pain by preventing increased intraabdominal pressure (eg, avoiding coughing, sneezing, deep inhalation) and lying still with the right leg flexed.

cerebellum function

The cerebellum is involved in 2 major functions: coordination of voluntary movements and maintenance of balance and posture. Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to-toe (tandem), on toes, and on heels (Option 5). Coordination testing involves the following: Finger tapping - ability to touch each finger of one hand to the hand's thumb (Option 4). Rapid alternating movements - rapid supination and pronation Finger-to-nose testing - clients touch the clinician's finger and then their own nose as the clinician's finger varies in location Heel-to-shin testing - client runs each heel down each shin while in a supine position

percutaneous coronary intervention (PCI)

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.

neuroleptic malignant syndrome (NMS)

The client taking clozapine is exhibiting classic signs of neuroleptic malignant syndrome (NMS), an uncommon but life-threatening adverse reaction to anti-psychotic medications. NMS is characterized by high fever, muscular rigidity, altered mental status, and autonomic dysfunction. Treatment includes supportive care (eg, rehydration, cooling body temperature) and immediate discontinuation of the medication. Due to the life-threatening nature of NMS, this client needs to be seen first to assess for generalized muscle rigidity.

4-point crutch gait

The client who is rehabilitating from an injury of the lower extremity usually progresses from no touch down, non-weight bearing status, using the 3-point gait (Option 2) to touch down with partial weight bearing status, using the 2 point-gait (Option 1), to full weight bearing status, using the 4-point gait. The nurse teaches the client how to use the most advanced gait, the 4-point crutch gait. It requires weight bearing on both legs and is the most stable as there are 3 points of support on the ground at all times (eg, 2 crutches and 1 foot; 2 feet and 1 crutch). It is the easiest to use as it resembles normal walking: advance right crutch, then left foot, and advance left crutch, then right foot.

DVT--> PE

The client with a DVT should be seen first. This client has a current clot and is at risk for development of a pulmonary embolism (PE) if the clot mobilizes. Enoxaparin is a low-molecular-weight heparin given as an anticoagulant and should not be delayed. The nurse should monitor the client for signs and symptoms of bleeding and clinical manifestations of a PE such as dyspnea, chest pain, or hypoxemia.

cirrhosis

The client with cirrhosis is at risk of hepatic encephalopathy. Hypokalemia, high protein intake, gastrointestinal bleeding, constipation, hypovolemia, and infection can precipitate hepatic encephalopathy. Use of furosemide can cause hypokalemia, which must be corrected immediately to prevent the precipitation of hepatic encephalopathy and dangerous arrhythmias.

IV placement

The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm (Options 1 and 4). The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client had a left-sided mastectomy (Option 3). Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection. (Option 2) The antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and may be positional.

therapeutic response to levothyroxine

The client's therapeutic response to levothyroxine (Synthroid) is evaluated by resolution of hypothyroidism symptoms. The expected response includes improved well-being with elevated mood (Option 2), higher energy levels (Option 3), and a heart rate that is within normal limits (Option 1). The nurse should consult the health care provider if the heart rate is >100/min, or if the client reports chest pain, nervousness, or tremors; this may indicate that the dose is higher than necessary. Pharmacological therapy manages the symptoms of hypothyroidism, but it takes up to 8 weeks after initiation to see the full therapeutic effect.

plethysmograph

The erratic pulse oximeter tracing is representative of an artifact plethysmograph waveform caused by motion. When an electronic assessment reading is questionable, the nurse should always assess the client first for possible etiology. The assessment includes the client's oxygenation and perfusion status (skin temperature, color), the level of consciousness (in sedated clients), and restlessness or agitation. This assessment data guides the nurse in the correct analysis of the tracing.

The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline):

The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline): Take on an empty stomach - for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals (Option 3) Avoid antacids or dairy products - tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption (Option 1) Take with a full glass of water - tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion Photosensitivity - severe sunburn can occur with tetracycline. The client should use sunblock (Option 5). Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional contraceptive techniques will be needed

The general procedure for the administration of ophthalmic medications includes the following steps in sequence:

The general procedure for the administration of ophthalmic medications includes the following steps in sequence: Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct (Option 3) Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination (Option 4) Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac (Option 2) Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption (Option 1) Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination Wait 5 minutes before instilling a different medication into the same eye

guaiac fecal occult

The guaiac fecal occult blood test is used to assess for microscopic blood in the stool as a screening tool for colorectal cancer. The steps for collecting a sample include: Assess for recent ingestion (within last 3 days) of red meat or medications (eg, vitamin C, aspirin, anticoagulants, iron, ibuprofen, corticosteroids) that may interfere and produce false test results. Obtain supplies (Hemoccult test paper, wooden applicator, Hemoccult developer), wash hands, and apply nonsterile gloves (Option 2). Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. Collect from 2 different areas of the specimen as some portions of the stool may not contain microscopic blood (Option 4). Close the slide cover and allow the stool specimen to dry for 3-5 minutes. Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide (Option 3). Assess the color of the Hemoccult slide paper within 30-60 seconds. A positive guaiac result will turn the test paper blue, indicating presence of microscopic blood in the stool (Option 5). Dispose of used gloves and the wooden applicator and perform hand hygiene. Document the results (Option 1).

intermittent bolus enteral feedings through a nasogastric tube. Which are appropriate nursing actions prior to starting the feeding?

The head of the bed should be elevated to a minimum of 30 degrees (semi-Fowler position) during enteral feedings and for 30-60 minutes afterward, thereby decreasing aspiration risk. Many institutions have policies that require the nurse to hold the feeding if the client must be supine (eg, diagnostic tests). Gastric residual volumes are checked every 4 hours with continuous feeding or before each intermittent feeding and medication administration. Continuing feedings despite a large volume residual increases the client's risk for emesis and aspiration. Recent evidence suggests that holding the feeding for a residual volume >100 mL is not necessary, and some institutional policies allow a residual volume of up to >500 mL as long as the client is asymptomatic. Flush the tube before and after bolus feedings to keep the tube patent and avoid contamination of the stagnant feeding solution. Sterile fluid is used to help prevent infection in vulnerable clients. (Option 1) Aspirated residual volume should be returned to the stomach. If acidic gastric juices are repeatedly discarded (2,500 mL secreted daily), there is risk for metabolic alkalosis and hypokalemia. (Option 5) Gastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. In addition, any newly inserted nasogastric tube requires x-ray confirmation of tube location.

When you would not head tilt chin lift

The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing.

near-drowning victim

The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option 3). Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated (Option 2). There are passive, active external, and active internal rewarming methods. Passive rewarming methods include removing the client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming involves using heating devices or a warm water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves administering warmed IV fluids and warm humidified oxygen (Options 1 and 5). (Option 4) Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not indicated. Educational objective: Emergency department care of near-drowning victims includes advanced airway management, aggressive oxygenation, establishing IV access and administering IV fluids (warmed if hypothermic), and monitoring for cardiac arrhythmias and fluid imbalances. Copyright © UWorld. All rights reserved.

suspected cervical spine injury

The initial priorities for a client with a suspected cervical spine injury are to ensure a patent airway and immobilize the spine. This includes applying a rigid hard collar, placing the client on a firm surface (eg, a backboard), and moving the client as a unit (logrolling) if required (Options 1, 4, and 5). Note that a soft foam cervical collar does not provide immobilization. A rigid hard collar must be used. Further stabilization can be achieved by taping down the client's head and using straps to keep the client from moving the arms, especially if the client is not cooperating. After the primary injury, secondary injury can occur progressively over subsequent hours as a result of tissue damage caused by hemorrhage or edema in the cord. The priority is to prevent further injury.

Radial Arterial Low Pressure Alarm

The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client to the ICU.

neonatal heel stick

The neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria). Proper technique is essential for minimizing discomfort and preventing complications and includes: Select a location on the medial or lateral side of the outer aspect of the heel (Option 1). Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation (Option 3). Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain (Option 2). Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis. An acceptable alternate method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein). Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed (Option 4).

The nurse must follow the 6 rights of medication administration:

The nurse must follow the 6 rights of medication administration: The right client The right medication The right dose The right time The right route The right documentation

The nurse prioritizes nursing actions for the hospitalized client with pneumonia in the following order:

The nurse prioritizes nursing actions for the hospitalized client with pneumonia in the following order: Oxygen per nasal cannula at 4 L/min - This client is in respiratory distress (respirations 30/min, dusky nail beds). Oxygen administration is the priority action. NS at 125 mL/hr - Most elderly clients with pneumonia present with dehydration (dry mucus membranes, low blood pressure). Initiation of IV fluids is important to thin secretions, facilitate expectoration of mucus, and provide access for antibiotic therapy. Blood cultures x 2 for temperature >102 F (38.9 C) - Cultures should always be drawn before antibiotic administration, as these can be inaccurate if drawn afterward. Identifying the causative pathogen is necessary to ensure that the appropriate antibiotic is prescribed. Cultures are drawn x 2 (from 2 different venipuncture sites) to rule out contaminants. Levofloxacin 750 mg IV every 24 hours - Levofloxacin (Levaquin) is a fluoroquinolone antibiotic recommended for the treatment of pneumococcal pneumonia. Antibiotics should be administered as soon as possible after the pneumonia diagnosis is made and cultures have been drawn. Incentive spirometer every 2 hours - Deep breathing can be performed after the initiation of antibiotics. Incentive spirometry increases alveolar expansion, facilitates removal of secretions, and prevents atelectasis.

Pacer Spikes

The nurse should assess for pacer spikes on the cardiac monitor. For an atrial pacemaker, a pacer spike will precede a P wave. For a ventricular pacemaker, a pacer spike will precede a widened QRS complex. These waveforms indicate electrical capture. The nurse still needs to further assess the client for mechanical capture of the pacemaker. This ensures that the electrical stimulus generates a pulse or heartbeat in the client. To check for mechanical capture, the nurse should palpate the client's pulse rate and compare it with the electrical rate displayed on the cardiac monitor.

Assessing for signs of anaphylaxis

The nurse should instruct the parent to first assess for signs of swelling of the mouth, tongue, lips, and upper airway. The child will have wheezing and difficulty breathing next, followed soon by cardiovascular symptoms. These include lightheadedness due to hypotension, loss of consciousness, and cardiovascular collapse. An anaphylactic reaction is life-threatening and requires rapid assessment and intervention.

inflammatory breast cancer

The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In this aggressive form of cancer, breast lymph channels are blocked by cancer cells, creating breast tissue that becomes red, warm, and has an orange peel (peau d'orange), pitting appearance on the skin surface. The nurse would be most concerned about this client and make an immediate referral to the health care provider for examination and evaluation.

nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes

The oculomotor (cranial nerve III), trochlear (cranial nerve IV), and abducens (cranial nerve VI) are motor nerves of the eye that are tested by having the client track an object, such as a finger, through the fields of vision. The oculomotor nerve is also tested by checking for pupillary constriction and accommodation (constriction with near vision). Deficits in cranial nerves III, IV, and VI can include disconjugate gaze (eyes do not move together), nystagmus (fine, rapid jerking eye movements), or ptosis (drooping of the eyelid).

Chest Tube Air Leak

The presence of an air leak is indicated by continuous bubbling of fluid at the base of the water seal chamber. If the client has a known pneumothorax, intermittent bubbling would be expected. Once the lung has re-expanded and the air leak is sealed, the bubbling will cease. The nurse is expected to assess for the presence or absence of an air leak and to determine whether it originates from the client or the chest tube system.

asthma ND

The priority ND is impaired gas exchange related to alveolar hypoventilation and reduced oxygen available for exchange as evidenced by tachycardia, tachypnea, dyspnea, and hypoxemia. The assessment data that support a deficit in oxygenation and gas exchange include: High-pitched wheezing on inspiration and expiration. Wheezing is usually heard on expiration; when heard on inspiration as well, it indicates an even greater degree of bronchospasm, airway resistance, and hypoxemia. Diminished breath sounds during an asthma attack indicate reduced delivery of inspired oxygen due to hyperinflation, air trapping, and alveolar hypoventilation. Decreased oxygen saturation (pulse oximeter of 87% on room air) in the presence of tachycardia and tachypnea indicates significant impaired gas exchange and hypoxemia.

blood administration

The procedure for safe blood administration includes the following: Obtain a unit of blood from the blood bank and verify the blood product with type and crossmatch results and at least 2 client identifiers with another nurse at the client's bedside. The blood is obtained and infused one unit at a time (Option 2). Assess the client, obtain vital signs for baseline, and teach signs of a transfusion reaction and how to call for help. Use a Y tubing, prime with NS, and then clamp the NS side (Option 6). Spike the blood product, leaving the blood side of the Y tube open while keeping the saline side clamped for infusion. The saline is only used to prime the tubing and flush after the infusion. It does not infuse simultaneously. Set the infusion pump to deliver blood over 2-4 hours as prescribed (Option 5). Rapid infusion of the blood puts the client at greater risk for transfusion reaction and fluid volume overload. Remain with the client for at least the 1st 15 minutes and watch for signs of blood transfusion reaction, including fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. Stop the transfusion immediately if a reaction occurs. The first 15 minutes of infusion should be slow to watch for these reactions. Take another set of vital signs 15 minutes after infusion starts and continue in accordance with facility policy. Always take a final set of vital signs after the infusion is complete. On completion of the blood transfusion, open the saline side clamp of the Y tubing to flush all blood in the tubing through with NS. Return the blood bag with the attached set-up to the laboratory after completion or dispose of in accordance with hospital policy. Use new IV Y tubing set-up for the second unit of blood.

rapid response

The rapid response team is activated to marshal additional experienced and specialized resources for an acute need to try to prevent a client from deterioration into a code/arrest situation. The team has critical care expertise to provide immediate attention to unstable clients in noncritical care units and usually consists of a respiratory therapist, a critical care nurse, and a physician or advanced practice registered nurse. Recommended criteria to consider according to the Institute for Healthcare Improvement include the following: Any provider worried about the client's condition OR An acute change in any of the following: Heart rate <40 or >130/min Systolic blood pressure <90 mm Hg Respiratory rate <8 or >28/min (Option 4) Oxygen saturation <90 despite oxygen Urine output <50 mL/4 hr Level of consciousness (Option 5)

atrial pacing

The rhythm strip of a client with a single-chamber atrial pacemaker displays a pacer spike before the P wave, followed by a QRS complex, on an electrocardiogram (ECG). The P wave may appear normal or somewhat distorted following the spike. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks).

Rule of 9's

The rule of nines is an estimated percentage of total body surface area burned in an adult. The head is 9%, anterior torso 18%, posterior torso 18%, each arm 9%, each leg 18%, and groin 1%. The rule of nines is often used at the initial evaluation and should be recalculated within the first 72 hours.

Beta blockers

The selective beta blockers (eg, metoprolol, atenolol, bisoprolol) are generally given for heart failure and hypertension control due to their beta1-blocking effect. The nonselective beta blockers (eg, propranolol, nadolol), in addition, have a beta2-blocking effect that results in bronchial smooth muscle constriction. Therefore, nonselective beta blockers are generally contraindicated in clients with asthma

CPR

The sequence of basic life support (BLS) for an unconscious, pulseless client includes: Verify unresponsiveness by tapping or gently shaking the client while calling by name or shouting, "Are you all right?" (Option 1). Activate the emergency response system by calling for help if in the hospital, or by calling 911 and obtaining an automated external defibrillator (AED) if outside the hospital (Option 3). The emergency response system should be activated for all unresponsive clients. This allows the nurse to quickly proceed with assessment of pulse and respirations without delaying to retrieve a defibrillator. Simultaneously check the carotid pulse and check the client for breathing for no more than 10 seconds (Option 4). Attempt cardiopulmonary resuscitation if no pulse is felt, starting with chest compressions (circulation, airway, breathing [CAB] sequence) (Option 2). Chest compression rate should be 100-120/min. Chest compression depth should be 2-2.4 in (5-6 cm). Notify the health care provider if not already on scene (Option 5).

Progression of Shock

The shock continuum progresses in severity from the initial (I) to the irreversible (IV) stage. During the initial stage, there is an imbalance of oxygen supply and demand at the tissue and metabolic levels and anaerobic metabolism develops; there may be no recognizable signs and symptoms. As shock progresses to the compensatory (II) stage, the neural, hormonal, and biochemical compensatory mechanisms are activated to maintain homeostasis (oxygenation, cardiac output). Cold and clammy skin indicates failing sympathetic nervous system compensation. The client is moving along the continuum to the progressive (III) stage, which begins when compensatory mechanisms fail. Immediate intervention is necessary to prevent further progression.

Urine specific gravity

The specific gravity evaluates the ability of the kidneys to concentrate solutes in the urine. The normal urine specific gravity value ranges from 1.003 to 1.030. Causes of increased specific gravity include fluid deficit.

The general steps for preparing the sterile field for a wet-to-damp dressing change include

The sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions' policies permit recapped bottles of solution to be reused within 24 hours of opening, and some require disposal of the remaining solution. Therefore, the nurse should intervene when the student uses sterile saline from a bottle that was opened >24 hours ago. The general steps for preparing the sterile field for a wet-to-damp dressing change include: Perform hand hygiene. Open a sterile gauze package that has a partially sealed edge with ungloved hands by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze (Option 2). Hold the inverted opened gauze package 6" (15 cm) above the waterproof sterile field so it does not touch the field, and then drop the gauze dressing onto the sterile field (Option 1). Place the sterile dressings on the sterile field 2" (5 cm) from the edge; the 1" (2.5 cm) margin at each edge is considered unsterile because it is in contact with unsterile surfaces (Option 3). Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy permits).

supraventricular tachycardia

The synchronizer switch must be turned on when cardioversion is planned. The synchronize circuit in the defibrillator is programmed to deliver a shock on the R wave of the QRS complex on the electrocardiogram (ECG). This allows the unit to sense this client's rhythm and time the shock to avoid having it occur during the T wave. A shock delivered during the T wave could cause this client to go into a more lethal rhythm (eg, ventricular tachycardia, ventricular fibrillation). If this client becomes pulseless, the synchronize function should be turned off and the nurse should proceed with defibrillation. Synchronized cardioversion is indicated for ventricular tachycardia with a pulse, supraventricular tachycardia, and atrial fibrillation with a rapid ventricular response.

hepatitis A

The transmission of hepatitis A occurs most commonly through the fecal-oral route through poor hand hygiene and improper food handling by infected persons. It is seen primarily in developing countries. After infection, the hepatitis A virus reproduces in the liver and is secreted in bile. Therefore, hand hygiene (especially after toileting and before meals) is the most important intervention to reduce the occurrence of hepatitis A infection (Option 4). Vaccination against hepatitis A is recommended for all children at age 1 and for adults at risk of contracting the virus (health care workers, men who have sex with men, drug users, those who travel to areas with a high prevalence, those with clotting disorders, and those with liver disease).

The treatment goals for a client with hypoxemia, hypotension, and increased temperature are to improve oxygen saturation and perfusion and to decrease oxygen demands.

The treatment goals for a client with hypoxemia, hypotension, and increased temperature are to improve oxygen saturation and perfusion and to decrease oxygen demands. Priority actions include the following: Administering oxygen using a non-rebreathing mask is the highest priority (airway, breathing). The device delivers high concentrations of oxygen (60%-90%) and is used to treat hypoxemia in an emergency. After hypoxemia and desaturation are corrected, titrate oxygen to maintain a saturation ≥95% with a simple face mask or nasal cannula. Assess lung sounds before and after increasing the IV rate or administering a fluid challenge using an isotonic solution. Auscultation of crackles can indicate fluid overload (pulmonary edema). Assessing baseline lung sounds helps decrease the potential risk for fluid overload. Increase 0.9% IV normal saline rate from 75 mL/hr to 200 mL/hr to treat hypotension and improve perfusion (circulation) to tissues and organs by increasing intravascular volume. Administer acetaminophen (oral, rectal, IV) as needed to reduce temperature and oxygen demands (eg, temperature, tachycardia, tachypnea) and promote comfort. Reassess a full set of vital signs after administering oxygen, fluids, and antipyretic medication to evaluate the client's response to therapies. Educational objective: Assess lung sounds before and after administering intravenous fluids. Auscultation of crackles can indicate fluid overload (pulmonary edema).

Tidaling

The water seal chamber of the chest tube drainage system is filled with sterile water and acts as a one-way valve preventing air from entering the client's chest cavity. The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling. This movement occurs in section B of the water seal chamber and indicates that the system is functioning properly and maintaining appropriate negative pressure. (Section A) This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied. (Section C) The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuous bubbling indicates an air leak in the system. (Section D) This is the drainage collection chamber in which fluid from the client's pleural cavity will collect; the nurse will assess the color and amount and record the output.

PA Catheter

The waveform indicates a "wedged" position of the catheter, meaning that the balloon may be inflated or the catheter has advanced too far into the PA, occluding that branch of the PA. PA wedge pressures are measured periodically to assess left ventricular function or left ventricular end diastolic pressure (ventricular preload). The balloon should be inflated for only 10-15 seconds and then allowed to deflate passively. A balloon that is inflated for a long period may cause PA rupture or damage. Locking the balloon port of the PA catheter will prevent the balloon from being accidentally inflated.

DVT

This client with a tender calf that feels warm to the touch is exhibiting signs and symptoms of a possible deep vein thrombosis (DVT). Additionally, the client has several risk factors for DVT (age >60, being hospitalized and in bed for 3 days). The nurse will need to notify the health care provider (HCP) immediately. However, prior to this, the nurse must perform a thorough assessment of the client to report to the HCP. The priority action by the nurse should include a thorough neurovascular assessment of the extremities, including presence and quality of dorsalis pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison.

Normal Platelet Count

This is a normal platelet count (150,000/mm3-400,000/mm3 [150-400 x 109/L]).

neurogenic shock

This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher). Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion.

Thoracentesis

Thoracentesis is commonly used to treat pleural effusion. The health care provider (HCP) will prepare the skin, inject a local anesthetic, and then insert a needle between the ribs into the pleural space where the fluid is located. A complication of thoracentesis is pneumothorax, which occurs when the needle goes into the lung and causes the lung to slowly deflate, like a balloon with a small hole in it. Bleeding is another, yet less common, complication of the procedure. Signs of pneumothorax include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed) (Options 2, 3, and 4). Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow to the brain (Option 1). A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring. (Option 5) Infection would be a later complication (occurring a few days after the procedure), so monitoring temperature is not required during the initial postprocedure period. (Option 6) Urine output should not be affected by thoracentesis or the drugs administered for this procedure. Educational objective: Following thoracentesis, the nurse should monitor for signs of pneumothorax, including level of alertness, respiratory rate, respiratory effort, oxygen saturation, and lung sounds.

Thrombolytic agents are contraindicated in clients w???

Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi. Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg). Therefore, the health care provider should be consulted for clarification. Administering alteplase in the presence of these conditions can cause hemorrhage, including life-threatening intracerebral hemorrhage

Timed urine collection tests

Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding

tiotropium

Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic, inhaled medication used to control chronic obstructive pulmonary disease (COPD). It is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client proper administration prior to the first dose, emphasizing that the capsule should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly.

Tissue plasminogen activator (tPA)

Tissue plasminogen activator (tPA) dissolves clots and restores perfusion in clients with ischemic stroke. It must be administered within a 3- to 4½-hour window from onset of symptoms for full effectiveness. The nurse assesses for contraindications to tPA due to the risk of hemorrhage. The client should not have a history of intracranial hemorrhage or be actively bleeding. Surgery within the last 2 weeks is a contraindication as tPA dissolves all clots in the body and may disrupt the surgical site. This client indicates a recent stomach surgery, which would need further clarification to determine eligibility to receive tPA

phlebostatic axis

To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall. If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis.

clients with above-the-knee amputation

To prevent hip flexion contractures in clients with above-the-knee amputation, the residual limb should not be elevated, especially after 24 hours. Instead, edema should be managed using a figure eight compression bandage. The bandage should be worn at all times until the residual limb is healed, and care should be taken not to wrap it too tightly. Hip flexion contractures can also be avoided by placing the client in prone position with hip in extension for 30 minutes 3 or 4 times a day.

safe transfers and repositioning are achieved using the following guideline

To reduce the risk of client and staff injury, safe transfers and repositioning are achieved using the following guidelines: Use a gait/transfer belt to transfer a partially weight-bearing client to a chair (Option 2). Use 2 or more caregivers to reposition clients who are uncooperative or unable to assist (eg, comatose, medicated) (Option 3). Use a full-body sling lift to move/transfer nonparticipating clients. Use 2-3 caregivers to move cooperative clients weighing less than 200 lb (91 kg). Use 3 or more caregivers to move cooperative clients weighing more than 200 lb (91 kg

Tonsillectomy

Tonsillectomy is usually performed as an outpatient procedure. Postoperative bleeding is an uncommon but important complication and it can last up to 2 weeks. It manifests with frequent or continuous swallowing and/or cough from the trickling blood; some clients may also develop restlessness. Discharge teaching includes: Avoid coughing, clearing the throat, or blowing of the nose Limit physical activity Milk products are discouraged due to their coating effect, which can prompt clearing of the throat Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation

Torsades de pointes

Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV magnesium (Option 3). Treatment may also include defibrillation and discontinuation of any QT-prolonging medications.

Wound Dehiscence

Total separation of wound layers with protrusion of the internal viscera through the incision is known as evisceration. Evisceration is a medical emergency that can lead to localized ischemia, peritonitis, and shock. Emergency surgical repair is necessary. Clients at risk for poor wound healing (eg, obesity, diabetes mellitus) are at increased risk for evisceration. When an abdominal wound evisceration occurs, the nurse should take the following actions: Remain calm and stay with the client. Have someone notify the HCP immediately and bring sterile supplies. Instruct the client not to cough or strain. Place the client in low Fowler's position (no more than 20 degrees) with knees slightly flexed to relieve pressure on the abdominal incision and have the client maintain absolute bed rest to prevent tissue injury. Assess vital signs (and repeat every 15 minutes) to detect possible signs and symptoms of shock (eg, hypotension, tachycardia, tachypnea). Cover the viscera with sterile dressings saturated in NS solution to prevent bacterial invasion and keep the exposed viscera from drying out. Document interventions taken and the appearance of the wound and eviscerated organ (eg, color, drainage). If the blood supply is interrupted, the protruding organs can become ischemic (dusky) and necrotic (black).

Toxic epidermal necrolysis

Toxic epidermal necrolysis is an acute skin disorder, most commonly associated with a medication reaction, that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion (ie, denuded skin). It is a severe form of Stevens-Johnson syndrome. The major cause of death related to toxic epidermal necrolysis is sepsis; therefore, infection prevention is critical. Basic supportive care includes: Wound care: Sterile, moist dressings are applied to open areas of skin (Option 2). Infection prevention: Strict sterile technique and reverse isolation decrease infection risk. The nurse should also monitor for any signs of infection (eg, fever) (Option 3). Fluids and nutrition: Vital signs and urine output are monitored for signs of hypovolemia. Oral feeding should be initiated early to promote wound healing; a nasogastric tube may be necessary. Hypothermia prevention: Maintain a room temperature of 85 F (29.4 C) or more, and use passive rewarming methods such as sterile, single-use warming blankets or digitally regulated warming pads (Option 4). Pain management: Analgesics are administered around the clock and before painful procedures. Eye care: Sterile, cool compresses are applied to relieve discomfort. Lubricants may relieve dryness and prevent corneal abrasion

Treatment of hypokalemia

Treatment of hypokalemia may require an IV infusion of potassium chloride (KCL). The infusion rate should not exceed 10 mEq/hr (10 mmol/hr). Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. IV KCL should be diluted and never given in a concentrated amount. Furthermore, too rapid infusion can cause cardiac arrest. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump.

Dopamine

Treats Dopamine is a vasopressor used to treat symptomatic hypotension.

TB

Tuberculosis is an infection caused by the Mycobacterium tuberculosis microorganism. A client with active, primary TB disease has a positive tuberculin skin test (TST), usually feels sick, has symptoms, and can spread the disease to others if not treated with medications. A client with a latent TB infection (LTBI) has a positive TST, negative chest x-ray, is asymptomatic, cannot transmit the disease to others, and can complete a full course of treatment to prevent activation of the disease. Malignancy, immunosuppressant medications, including chemotherapy, and prolonged debilitating disease (eg, HIV), can convert LTBI to active disease. A client with LTBI who begins treatment with a corticosteroid (Prednisone) is at increased risk for conversion to active TB disease. Therefore, the nurse should notify the HCP.

Tumor lysis syndrome

Tumor lysis syndrome is due to rapid lysis of cells and the resulting release of intracellular ions potassium and phosphorous into serum. Phosphorus binds calcium and causes hypocalcemia. Metabolism (catabolism) of released cellular nucleic acids leads to severe hyperuricemia. IV hydration and hypouricemic medications (eg, allopurinol) are usually prescribed to promote excretion of purines and prevent acute kidney injury.

Who requires the nurses presence to be moved?

Unstable clients and spinal cord stabilization require the presence of a nurse for repositioning or moving The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is at risk for hip dislocation. A wedge may be needed to maintain abduction; nursing judgment is required (

Urine Specimen Collection from catheter tubing

Urine specimens must be collected aseptically from the port located on the catheter tubing of an indwelling urinary catheter. Obtaining urine from a collection bag is improper technique, and it would not be considered a viable specimen (Option 2). In this case, the collected urine should be measured and discarded (Option 1). Colonization and multiplication of bacteria within the stagnant urine in the collection bag may occur and cause incorrect results. In addition, some urinary drainage bags are impregnated with an antimicrobial agent to help prevent catheter-associated urinary tract infections; these agents can also negatively affect the results of a urinalysis or culture. To collect a urine specimen: Clean the collection port with an alcohol swab Aspirate urine with a sterile syringe Use aseptic technique to transfer the specimen to a sterile specimen cup

Vancomycin

Vancomycin can cause nephrotoxicity, which occurs most often in clients who already have some degree of renal impairment. Serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days. If an increasing trend is identified, the nurse should consult with the health care provider (HCP) and/or pharmacist before administering the dose.

Vancomycin

Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next dose.

renal system diagnostic testing should report which post-procedure finding to the health care provider

Various diagnostic tests, including bladder scans, urine cultures, cystoscopy, renal arteriograms, and renal scans, assess the renal system. It is necessary to understand the purpose and procedures for each examination when evaluating complications arising from these assessments. Portable ultrasonic bladder scanners are used at the bedside to determine the amount of residual urine in the bladder. Amounts >100 mL should be reported as the client may be experiencing urinary retention

VAP Continued

Ventilator-associated pneumonia (VAP), classified as a diagnosis of pneumonia more than 48 hours post-endotracheal intubation, is a key area of preventable morbidity and mortality in the hospitalized client. Assessment of suspected pneumonia would denote fever, elevated white blood cell count, purulent or odorous sputum, crackles on auscultation, and pulmonary opacities on x-ray. Prevention of pneumonia in a client on ventilation focuses on minimizing time spent on ventilation, reducing bacterial colonization with sterile equipment, regular oral hygiene (Option 5), and aspiration prevention protocols (Options 1, 2, and 3). Proton pump inhibitors (eg, omeprazole) and histamine-2 antagonists (eg, ranitidine) are commonly prescribed during inpatient client care, but the natural acidity of stomach acid is important in killing bacteria. Prophylaxis should be prescribed only to clients at clear risk for developing stress ulcers. (Option 4) Endotracheal suctioning should be performed only when clinically indicated and not on a scheduled basis. Aggressive suctioning causes irritation of the tracheobronchial tree and has been linked to a higher incidence of pneumonia.

Ventricular bigeminy

Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted.

Ventricular tachycardia

Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle.

Warfarin in pregnancy

Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception

Warfarin Coumadin

Warfarin (Coumadin) is used to prolong clotting so that the desired result is a "therapeutic" range rather than the client's "normal" control value when not on the drug. Therapeutic range is considered roughly 1.5-2.5 times the control (International Normalized Ratio [INR] of 2-3), but up to 3-4 times the control (INR of 2.5-3.5) in high-risk situations such as an artificial heart valve.

Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps to prevent infections in clients with urinary catheters include the following:

Wash hands thoroughly and regularly Perform routine perineal hygiene with soap and water each shift and after bowel movements Keep drainage system off the floor or contaminated surfaces Keep the catheter bag below the level of the bladder Ensure each client has a separate, clean container to empty collection bag and measure urine Use sterile technique when collecting a urine specimen Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder Avoid prolonged kinking, clamping, or obstruction of the catheter tubing Encourage oral fluid intake in clients who are awake and if not contraindicated Secure the catheter in accordance with hospital policy (tape or Velcro device) Inspect the catheter and tubing for integrity, secure connections, and possible kinks

Acidosis is

When acidosis is ≤7.1, the cardiac tissue is affected. Acidosis is treated with sodium bicarbonate, ventilation, and adequate perfusion

When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following:

When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following: Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 µmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus). Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications (Option 3). Monitor blood pressure during the infusion. Hypotension is a possible adverse effect (Option 4) Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities (Option 2). Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing). Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy (Option 5).

interpreter

When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide information in the sequence it will occur; and obtain feedback of comprehension beyond merely nodding.

order of inhalers

When both MDIs are to be taken at the same time, clients are instructed to take the SABA first to open the airways and then the ICS to provide better delivery of the medication. It is important for the nurse to clarify indications and sequencing as the SABA is a rescue drug taken on an as-needed basis and is not always taken with the IC

phlebotomy peripheral vein

When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

Adenosine

an antiarrhythmic used to treat supraventricular tachycardia.

Arterial Fibrillation

characteristics of atrial fibrillation (AF) include an irregularly irregular rhythm and replacement of P waves by fibrillatory waves. Although electrolyte disturbances increase the likelihood of developing AF, clients can have this chronic condition managed with anticoagulation therapy. AF is usually associated with an underlying heart disease and is rarely immediately life-threatening.

Saw palmetto

herbal preparation, and clients most often use it to treat benign prostatic hyperplasia.

Mannitol (Osmitrol)

is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function.

Clients with nasal polyps often have sensitivity to

nonsteroidal anti-inflammatory drugs (NSAIDS), including aspirin. In addition, NSAIDs can exacerbate asthma symptoms. Therefore, acetaminophen may be a better choice for these clients

Cushing's triad

of bradycardia, bradypnea/abnormal breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood pressure readings).

reversal agent for heparin

protamine

Hypovolemia S/s

symptoms of hypovolemia, which include hypotension, tachycardia, and decreased urinary output. Therefore, the priority ND is deficient fluid volume related to active intravascular loss that is secondary to hemorrhage, gastric suction, wound drainage, and possible third spacing as evidenced by decreased urine output, hypotension, and tachycardia. The adverse effects of the epidural anesthesia can contribute to hypotension as well. This ND poses the greatest threat to survival because if not corrected, it can lead to decreased cardiac output, acute renal failure, and hypovolemic shock.

St John's wort

t John's wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with other antidepressants.

reversal agent for warfarin

vitamin k