105 Final UNIT 12-Autoimmune/Malignancy class
A nurse is assessing the patient with left sided heart failure. The patient states that he needs to use three pillows under the head and chest at night to be able to breathe comfortably while sleeping. The nurse documents that the patient is experiencing:
orthopnea. Orthopnea is shortness of breath (dyspnea) that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair.
Which dietary instructions should the nurse include in a teaching plan for the patient with gastroesophageal reflux?
"Eat four to six small meals each day." Teaching about small and frequent meals to GERD patients will improve their symptoms.
A patient diagnosed with mild heart failure is prescribed hydrochlorothiazide (Microzide). The healthcare provider should determine the teaching about the medication has been successful if the patient makes which of these statements?
"It is important for me to change positions slowly because I might become dizzy." This medication is a diuretic and will lower BP and help with fluid retention. Taking this medication can cause dizziness as it lowers BP and promotes fluid loss.
A patient with a gastric ulcer and Helicobacter pylori infection is being treated with triple therapy (bismuth (Pepto Bismol), metronidazole (Flagyl), and amoxicillin) and ranitidine (Zantac). The patient asks why ranitidine is necessary, because the triple therapy will treat the cause of the ulcer. What is the nurse's best response?
"Ranitidine will help to heal the ulcer and prevent recurrence." This medication is a H2 blocker and part of the treatment for ulcers. It reduces the production of acid in the stomach thereby allowing the ulcer to heal.
A patient who has AIDS, has repeated attacks of pneumocystis carini pneumonia. His family asks why he continues to develop this problem. The nurse's most correct response is:
"his immune defense mechanisms are impaired." Patients with AIDS have a compromised immune system and makes them susceptible to opportunistic infections.
The health care provider prescribes glipizide for a patient with type 2 diabetes mellitus who has been having trouble controlling their blood glucose level through diet and exercise. Which medication instruction should the nurse provide?
"Be sure to take glipizide before meals." The patient should take glipizide twice a day, 30 minutes before a meal, because food decreases its absorption. The drug doesn't cause hyponatremia and therefore doesn't necessitate monthly serum sodium measurement. The patient must continue to monitor the blood glucose level during glipizide therapy.
A nurse is caring for a hospitalized patient with Alzheimer's disease who has a history of agitation. Which of the following interventions would help decrease agitation and aggressive behavior in this patient? Select all that apply.
-Assign consistent caregivers -Place the patient in a quiet environment -Keep the daily routine the same Patients with Alzheimer's benefit from a non stimulating environment and consistency.
The nurse is teaching a patient how to use a metered dose inhaler. In order of priority, list the steps and instructions that the nurse should take to teach the patient. (Number 1 is the 1st step and number 6 is the last step).
1. Determine what the patient knows about this type of device. 2. Insert the medication canister into the plastic holder. 3. Shake the inhaler and remove the cap from the mouthpiece. 4. Breathe out through the mouth, then place the mouthpiece into the mouth, holding the inhaler upright. 5. Keep the lips secure around the mouthpiece and inhale and push the top of the canister once. 6. Hold the breath for a few seconds, remove the mouthpiece, and exhale slowly.
The nurse is caring for a first day postoperative surgical patient. Prioritize and arrange the patient's dietary progression.
1. NPO 2. Clear liquid 3. Full liquid 4. Soft To reduce the likelihood of a post operative ileus, post surgical patients must increase their diet as tolerated by going from NPO, clear, full liquids, then to soft diet. Bowel sounds need to be assessed before progressing.
A patient with end stage Alzheimer's disease has difficulty swallowing and is at risk for aspiration pneumonia. How would the nurse administer the medications?
Crush all medications, mix with pudding and administer accordingly Patients with the risk of aspiration pneumonia should be on soft foods including crushed medications. Medications that are time released should not be crushed. An alternate medication or route should be ordered by the HCP.
Infections
All microorganisms are capable of producing infections Modern medicine has lead to infections and reduced # of infections Antibiotics, immunizations and public health measures have decreased infections Antibiotic resistant strains have emerged Immunosuppression Pathophysiology -Chain of infection -Microoganisms: Pathogens Virulence Invasiveness -Reservoir and Portal of entry Mode of transmission Host Colonization Infectious Disease Resistance Stages: Infectious Disease Complications Nosocomial Infections: Acquired in health care setting Risk Factors: Chronic diseases Morbid obesity Medications Major surgery Invasive procedures Age Antibiotic-Resistant Microorganisms Nosocomial Infections: Methicillin-resistant Staphyloccus aureus (MRSA) Vancomycin-resistant enterococcus (VRE) Penicillin-resistant Streptoccus pneumococci (PRSP) Clostridium difficele-associated diarrhea (CDAD) Transmission Based Precautions: Airborne Droplet Contact Infectious Process in Older Adults Decrease in activity Poor nutrition/ dehydration Chronic illnesses Chronic medication use Lack of influenza and pneumococcal vaccines Altered mental status and dementias Hospitalization or living in LTC residence May or may not exhibit classic symptoms of infection
2.) A patient who reports being allergic to bananas is at risk for an allergy to: A. Latex B. Saline C. Iodine D. Potassium
An allergy to bananas can be a warning sign for an allergic reaction to latex products. B - Banana allergy does not indicate an allergy to saline C - Banana allergy does not indicate an allergy to iodine D - Banana allergy does not indicate an allergy to potassium
An individual with a latex allergy should avoid which types of foods?
Ask patients about their allergy history, including food allergies. Some patients have a cross-sensitivity between latex allergy and certain foods such as avocados, bananas, kiwi, and pineapples. Instruct patients with known latex sensi-tivity to wear a MedicAlert bracelet.
When obtaining a medication history from a patient, the nurse recognizes which of the following as a medication that can cause peptic ulcer disease or GI bleeding when taken in large amounts?
Aspirin Aspirin is a NSAID and is irritating to the lining of the stomach if taken in large doses or on an empty stomach. You want to avoid taking aspirin if possible or take the enteric coated type.
Inflammation: Nursing Diagnosis/Care
Assessment Subjective Objective Acute Pain Anti-inflammatory meds Analgesics Rest and Elevate Apply heat or cold Impaired Skin Integrity Protect and cleanse Balance rest and exercise Diet Elevate Risk for Infection Monitor vital signs Obtain cultures Fluid intake Hand washing Sterile gloves
Which of the following conditions places a patient at risk for an embolic stroke?
Atrial fibrilation Atrial fibrillation can cause blood clots causing it to go to the brain causing a stroke.
Which of the following drugs is administered preoperatively to minimize respiratory secretions?
Atropine Sulfate (Atropine) Atropine reduces secretions prior to surgery to reduce the risk of aspiration. Chapter 10
Which of the following medications is administered to minimize respiratory secretions preoperatively?
Atropine sulfate Atropine is an anticholinergic medication used to dry up secretions to prevention aspiration.
The nurse prepares a list of home care instructions for a patient following a total hip replacement. Which instructions should the nurse place on the list? Select all that apply.
Avoid crossing legs beyond the midline of the body Use a seat riser when using the toilet or commode Use assistive devices for putting on shoes and socks Hip arthroplasty or hip replacement has certain restrictions. Avoid bending 90 degrees at the waist and adducting the legs. Using assistive devices to follow the restrictions is important. Chapter 43
How is brachytherapy used for cancer patients? What are the safety precautions used when handling this?
Brachytherapy is a form of internal radiation administered through an implant. High doses of radiation is delivered to the tumor, while lower doses are delivered to surrounding tissue via the implant which is placed directly into the tumor. Radioactive material used in brachytherapy are sealed in the form of tubes, containers, wires, seeds, capsules, or needles, which are then inserted into the affected area. It is also possible to ingest a solution or inject a solution into the tumor through a catheter. Great caution must be used during and after administering radiation. The radioactive material can be excreted in saliva, urine, and sweat, and it transmit rays outside of the body. The patient should be in a private room where guests are limited visits of 10 to 30 minutes where they must keep a distance of at least 6 feet away from the patient. Visitors should be instructed not to use the patient's bathroom. The caregiver must keep as much distance from the radiation source, as well as spend minimal time near the source. Lead gloves and aprons should be worn as much as possible a shield from the radiation. Monitoring devices that measure whole-body exposure should be worn to those who work in an area where radiation is routinely administered. Pregnant women should not take care of patients receiving radiation therapy. Body fluids must be disposed of in specially marked containers. Dislodged implants should be placed into a lead container, using a long-handled forceps to collect the device. (Burke pgs. 278-280)
Why are some patients with cancer given both chemotherapy and radiation therapy (as in the case for breast cancer)?
Breast Cancer is not one disease, but many depending on the breast tissue, the effect of estrogen on the tumor and the age of the person at onset. The two most significant risk factors for breast cancer is are female gender and age over fifty. Radiation therapy is typically used after breast cancer surgery to destroy any remaining cancer cells that could cause recurrence or metastases. it is normally used in combination with lumpectomy for early stage breast cancer. If s tumor is unusually large, radiation can shrink the tumor before surgery. Palliative radiation is also used to treat chest wall recurrence and help control pain and prevent fractures with bone metastases. Radiation delivered by external beam tissue implants. Chemotherapy is commonly sued when the lymph nodes in the axilla are involved is also used to prolong life in late metastatic disease. (Burke 851-852) Radiation therapy causes lethal injury to cellular DNA . It is used to kill the tumor, reduce the size, to decrease pain, or relieve obstruction, and when beginning metastases are suspected. External radiation places the source of the radiation at a distance from the patient and delivers a relatively uniform dose. Brachytherapy is internal; the radioactive material (implant) is placed directly into the tumor site, delivering a high dose to the tumor and lower dose to the normal tissues around it. it requires special safety measures a combination of these two therapies are often used. In brachytherapy, the radiation source is sealed in tubes, containers, wires, seeds, capsules, or needles that are inserted into the affected tissue or body cavity. Internal radiation may be ingested or injected as solution or a be introduced into the tumor through a catheter. The radioactive substance may transmit rays outside the body or be secreted in fluids. External radiation does not place the family at risk because the patient does not emit radioactive particles. implanted or ingested radiation, however, can be dangerous for those living with, caring for, or treating the patient. Chemotherapy can cure some cancers (leukemias, lymphomas, solid tumors). It may be used to decrease tumor size, as an adjunct to surgery or radiation, or to prevent or treat metastases. Chemotherapy disrupts malignant and rapidly dividing cells by interpreting cell metabolism and replication. It reduces the cell's ability to synthesize needed enzymes and chemicals. Some chemotherapy drugs work during specific phases of the cell cycle; others work through the entire cell cycle. Chemotherapy may be used in conjunction with biotherapy. All chemotherapy has adverse toxic effects;the type and severity of these effects depend on the drugs and doses used. Most chemotherapy regimens involve combinations of drugs given over varying periods of time. Treatment is given in cycles with rest periods in between. Treatment is continued until the disease enters remission or until particular protocol is abandoned ( due to lack of improvement or toxic effects) and a new one is tried. Burke 278-283 I'm thinking radiation will shrink and stop it from metastasizing and chemotherapy will kill it or put it into remission.
Caution Early warning Signs
C Change in bowel or bladder A A lesion that does not heal U Unexplained weight loss, fever, bleeding or discharge T Thickening or lump in breast or elsewhere I Ingestion or difficulty swallowing O Obvious change in skin, wart or mole N Nagging pain, cough or persistent hoarseness
Cancer
C Comfort A Altered Body Image N Nutrition C Chemotherapy E Evaluate Response to Meds R respite for caretakers
A nurse is caring for a client who is infected with HIV. The nurse knows that the client's viral load signifies: A. The amount of HIV in the blood B. The process of the virus replicating itself C. The number of T helper cells in the blood D. Levels of HIV medications
Correct Answer:A. The amount of HIV in the bloodWhen caring for a client infected with HIV, the viral load indicates the amount of HIV present in the blood. A client with a higher viral load is at greater risk of becoming ill from opportunistic infections.
A diabetic patient who has undergone abdominal surgery experiences wound evisceration. Which of the following is the most appropriate immediate nursing action?
Cover the wound with sterile gauze moistened with sterile normal saline. Keeping the area sterile is important and applying a moist gauze will prevent anything sticking to the wound bed.
Which of the following medications may be prescribed to prevent a thromboembolic stroke?
Clopidogrel (plavix) Clopidogrel is an anti platelet which taken daily will minimize the occurrence for a stroke.
Which action should the nurse teach the diabetic patient as being most beneficial in delaying the onset of microvascular and macrovascular complications?
Controlling hyperglycemia High blood sugar causes complications and macrovascular changes such as CKD, HTN, retinopathy.
What is the priority nursing diagnosis for a patient newly diagnosed with hyperthyroidism?
Decreased cardiac output related to tachycardia In hyperthyroidism, there is an increase in metabolism. Cardiac output will be low due to increased in heart rate. Chapter 35
Describe possible side effects with external radiation and the nursing management.
Do not remove the markings from the radiation site. Also, if using lotion, make sure they are unscented. Want to avoid any perfumes. External radiation (also called teletherapy) places the source of radiation at a distance from the patient and delivers a relatively uniform dose. Possible adverse effects of radiation therapy include: skin damage (blanching, erythema, sloughing), ulcerations of mucous membranes, vulnerability to infection, bone marrow suppression, gastrointestinal effects (nausea, vomiting, diarrhea, bleeding), exudate in the lungs (called radiation pneumonia), and fistulas or necrosis of adjacent tissues. Nursing responsibilities: Monitor VS, including temperature. Monitor blood cell counts, frequently, especially when bone marrow suppression is a risk due to chemotherapy. Protect skin and mucous membranes from injury. Teach hygiene measures, use of moisturizing lotion to prevent dryness and cracking, frequent position changes, and immediate attention to skin breaks and lesions. Encourage a balanced diet high in protein, minerals and vitamins. Monitor VS and assess for obvious or occult bleeding. Avoid invasive procedures such as rectal suppositories, urinary catheterization, and parental injections, if possible. Diagnostic procedures (ex. biopsy or lumbar puncture should nto be done if the platelet count is less than 50,000. Apply pressure to injection sites for 3 to 5 minutes and to arterial punctures for 15 to 20 minutes. Instruct to avoid picking or forcefully blowing the nose, forceful coughing or sneezing, and straining to have bowel movement. Encourage cold, bland, semisoft, and liquid foods for the patient with stomatitis; anesthetic mouthwash before eating. Administer antiemetic medications. Encourage low fat meals with dry foods such as crackers and toast; avoid liquids with meals, sit upright for an hour after meals. Carefully assess and evaluate for manifestations of oral mucous membranes. Instruct to clean teeth gently in the morning, after meals, and at bedtime; soft brush, new toothbrush monthly. Culturate any oral lesions, and report the problem to physician. Administer prescribed analgesic medication on a regular schedule; for pain. Nursing responsibilities (patient/family teaching) for treated skin area: Wash the radiation site with plain water only, no soap; do not apply deodorant, lotions, medications, perfume, or powder to the site during treatment. Do not wash off the treatment marks. Do not rub, scratch, or scrub treated skin areas. If it is necessary to shave the treated area, use electric razor. Apply neither heat or cold to the treatment site. Inspect skin for damage or changes; report. Wear loose, soft clothing over the treated area. Protect skin from sun exposure during treatment and for at least 1 year after radiation therapy; wear protective clothing and sun blocker with SPF 15 or greater. (Burke, pg 278, 280, 287-289)
Which of the following interventions should the nurse implement for an older patient with Ineffective Airway Clearance as a result of pneumonia? Select all that apply.
Encourage ambulation Assist to cough and deep breathe Take antibiotics as ordered Mobilizing and killing the bacteria is important to teach. The patient with pneumonia should be drinking a minimum of 2 L/day, ambulating as tolerated, using the incentive spirometer and taking prescribed mediations. Limiting food intake is not recommended. The patient is weak and is encouraged to keep up with food and fluids. Chapter 23
A patient diagnosed with AIDS has had chronic diarrhea for the last 6 months and has lost 18 pounds in that time. Besides weight loss, assessment findings include tented skin turgor, dry mucous membranes and listlessness. Which of the following nursing diagnoses focuses on this patient's most immediate problem?
Fluid Volume Deficit related to diarrhea and abnormal fluid loss
The nurse is caring for a patient who develops epistaxis. Which of the following nursing interventions is advisable?
Have the patient tilt the head forward and apply pressure by pinching the nares toward the septum Having the head tilted forward minimizes the risk for aspiration. Chapter 22
Nurses can best help older patients prevent hypertension by teaching:
How to maintain a normal blood pressure. Maintaining a normal BP encompasses the other lifestyle changes.
AIDS
How you dont catch it. Toilet seat dirty dishes sharing a bath towel swimming handshaking
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first? 1. Stand as far away as possible and call for help. 2. Pick up the implant with a long-handled forceps and place it in a lead-lined container. 3. Leave the room and notify the radiation therapy department immediately 4. Put the implant back in place using forceps and a shield for self-protection, and call for help.
If a radioactive implant becomes dislodged, the nurse should pick it up with long-handled forceps and place it in a lead-lined container, then notify the radiation therapy department immediately. The highest priority is to minimize radiation exposure for the client and for the nurse; therefore, the nurse must not take any action that delays implant removal. Standing as far away from the implant as possible, leaving the room with the implant still exposed, or attempting to put it back in place can greatly increase the risk of harm to the client and the nurse from excessive radiation therapy.
A male client is receiving external radiation to the neck for cancer of the larynx. The most likely side effect to be expected is: Dyspnea Diarrhea Sore throat Constipation
In general, only the area in the treatment field is affected by the radiation. Skin reactions, fatigue, nausea, and anorexia may occur with radiation to any site, whereas other side effects occur only when specific areas are involved in treatment. A client receiving radiation to the larynx is most likely to experience a sore throat. Options B and D may occur with radiation to the gastrointestinal tract. Dyspnea may occur with lung involvement.
What is the priority nursing diagnosis for a patient with cystic fibrosis (CF)?
Ineffective Breathing Pattern related to presence of excessive thick mucus Patients with CF produce copious amounts of secretions. Breathing pattern will be compromised due to the secretions. CF patients produce copious amounts of secretions which affects their breathing patterns. Chapter 23
Inflammation and Infection: Pathophysiology
Inflammation caused by: Mechanical injuries Physical damage Chemical injury Microorganisms Extreme temperatures Immune response Ischemia Inflammatory response involves 3 steps: 1. Vascular response 2. Cellular response 3. Healing and tissue repair Inflammation Acute inflammation: Immediate/ lasts 1-2 weeks Local Manifestions: Systemic Manifestations: Elderly: infection→ delirium or mental status Δ Chronic Inflammation: Slow onset, lasts weeks to years
Inflammation: Interdisciplinary Care
Interventions: ---Medications: -Antibiotics -Acetaminophen (Tylenol) -Anti-inflammatory medications -Rest and fluids -Eat well-balanced diet -Wound care -Fluid and Diet treatment -Complimentary therapy -Prioritize Nursing care, Health Promotion and Assess -Potential Complications -Evaluate, Document and Continuity of Care
When caring for a child with nephrotic syndrome, the nurse would include which of the following in the plan of care? Select all that apply.
Monitor for increased urine protein Monitor for low serum albumin levels. Assess for periorbital and dependent edema Teach parents to watch for manifestations of thromboemboli. Patients with nephrotic syndrome will have proteinuria, low albumin levels, show edema around the eyes and lower body, prone to emboli.
The right forearm of a patient who had a purified protein derivative (PPD) test for TB is reddened and raised about 3mm where the test was given. The TB skin test would be read as having which of the following results?
Negative TB skin test that reads <5mm is considered normal or a negative response in all people. Chapter 23
Pediatric Differences in the Immune System
The organs of the immune system mature during infancy and childhood. Immaturity of the immunologic system places the infant and young child at greater risk for infection. Disorders of the immune system present differently in children then in adults (HIV infection passed to an infant through the mother).
A nurse is assessing a patient with left sided heart failure. The patient states that they need to use three pillows under the head and chest at night to be able to breathe comfortably while sleeping. The nurse documents that the patient is experiencing:
Orthopnea Orthopnea is shortness of breath while laying flat, causing the patient to prop themselves up. Chapter 17
The patient is being discharged with warfarin (Coumadin). What labs should be routinely monitored for this patient?
PT and INR Therapeutic levels of warfarin are measured via INR.
A patient comes to the outpatient clinic and tells the nurse that he has had leg pains that began when he walks but ceases when he stops walking. Which of the following conditions would the nurse assess for?
Peripheral vascular problems of the legs This is called intermittent claudication and the primary symptom of peripheral vascular disease.
Describe possible side effects with chemotherapy.
Possible side effects with chemotherapy are : Bone marrow suppression : reduced numbers of RBC (erythrocytes), WBC (leukocytes), and platelets (thrombocytes). As a result, patients often become anemic, experiencing fatigue and exercise intolerance. Low WBC (leukopenia) increase the risk for infection and impair the patient's ability to fight off infection that develop. Low platelet counts (thrombocytopenia) impair clotting and can result in serious bleeding or hemorrhage. GI toxic effects: stomatitis (inflammation of the oral cavity) interferes with the ability to eat and drink, potentially leading to malnutrition. Nausea and vomiting can be severe, resulting from direct effects of the drug on vomiting centers. Administering an antiemetic drug before chemotherpay administration can reduce nausea and vomiting. Diarrhea, which can lead to fluid volume deficit, often can be managed by including constipating food (ex. cheese) and foods high in fiber in the diet. reversible alopecia (hair loss) teratogenic (defect-producing) effects on a developing fetus irreversible sterility in male hyperuricemia (high uric acid levels in the blood) weight loss with unknown cause In the long term, increased risk for cancer (carcinogenesis) due to DNA damage by chemotherapy agents. (Burke, pg. 279-280) Some common side effects of chemotherapy are: stomatitis (inflammation of the oral cavity) nausea and vomiting diarrhea anemia as a result of bone marrow suppression (reduced WBC's, RBC's and platelets) fatigue thrombocytopenia (low platelet counts) impairs clotting and can result in serious bleeding alopecia (hair loss) irreversible sterility in men hyperuricemia (high uric acid levels in the blood) bone pain fevers chills anorexia muscle aches lethargy (Burke pg.279-280)
A patient just experienced a tonic clonic seizure. What is the nurse's priority in managing their condition?
Protecting the airway Protecting the airway is always a priority (think ABC) in a patient experiencing a seizure.
A patient taking warfarin (Coumadin) needs to have regular coaguaulation studies done. Which of the following laboratory tests needs to be evaluated? Select all that apply.
Prothrombin Time (PT) International Normalized Ratio (INR) Warfarin levels are measured by the INR and/or PT to check for therapeutic levels.
For the patient with cirrhosis, what nursing intervention would be most appropriate to control fluid accumulation in the abdominal cavity?
Providing a low sodium diet Patients with cirrhosis can also have ascites (fluid accumulation in the peritoneal cavity). Sodium should be reduced, if not it will cause further retention of fluids.
When educating the patient with a sprained ankle about home care, the nurse should teach the patient the acronym:
RICE A sprain can be treated with rest, ice, compression and elevation.
For a female client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care? A. Administering aspirin if the temperature exceeds 102° F (38.8° C) B. Inspecting the skin for petechiae once every shift C. Providing for frequent rest periods D. Placing the client in strict isolation
Rationale: Because thrombocytopenia impairs clotting it is important to check for bleeding frequently. Aspirin should not be given because it will increase bleeding.
The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy? 1 Hairdressers 2 The homeless 3 Children in day care centers 4 Individuals living in a group home.
Rationale: Individuals at risk for developing a latex allergy include health care workers, individuals who work in the rubber industry or those who have had multiple surgeries, have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.
Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. 1. Maintain the child in a semiprivate room. 2. Reduce exposure to environmental organisms. 3. Use strict aseptic technique for all procedures. 4. Ensure that anyone entering the child's room wears a mask. 5. Apply firm pressure to a needle-stick area for at least 10 minutes
Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). A common complication of treatment for leukemia is overwhelming infection secondary to neutropenia. Measures to prevent infection include the use of a private room, strict aseptic technique, restriction of visitors and health care personnel with active infection, strict hand washing, ensuring that anyone entering the child's room wears a mask, and reducing exposure to environmental organisms by eliminating raw fruits and vegetables from the diet and fresh flowers from the child's room and by not leaving standing water in the child's room. Applying firm pressure to a needle-stick area for at least 10 minutes is a measure to prevent bleeding.Test-Taking Strategy: Focus on the subject, preventing infection. Reading each intervention carefully and keeping this subject in mind will assist in answering the question. A semiprivate room places the child at risk for infection. Applying firm pressure to a needle-stick area is related to preventing bleeding.Level of Cognitive Ability: AnalyzingClient Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Pediatrics: OncologicalHealth Problem: Pediatric-Specific: CancersPriority Concepts: Infection; SafetyReference: McKinney et al. (2018), pp. 1151-1152.
A patient receiving external radiation for treatment of lung cancer. Patient teaching for care of the skin in the marked area includes: 1. applying antibacterial ointment daily 2. cleansing the skin with mild soap and water 3. avoiding rubbing or scratching treated skin areas 4. avoiding contact with others to eliminate radiation risk.
Rationale: Rubbing or scratching increases irritation to the site and increases risk of infection. Skin should be cleaned with clear water; no ointments should be applied unless directed by the physician. Patients receiving external radiation are not radioactive, and therefore are not a risk to others.
The client reports to the nurse that when performing testicular self-examination he found a lump the size and shape of a pea. The most appropriate response to the client is which of the following? 1. "That's important to report even though it might not be serious." 2. "That could be cancer. I'll ask the doctor to examine you." 3. "Let me know if it gets bigger next month." 4. "Lumps like that are normal, don't worry."
Rationale: Testicular cancer almost always occurs in only one testicle and is usually a pea-sized painless lump. The cancer is highly curable when found early. The finding should be reported to the physician. (Saunders Comprehensive NCLEX-RN Review 3rd Edition)
The client who has human immunodeficiency virus seropositve has been taking stavudine (d4t, Zerit). Which should the nurse monitor closely while the client is taking this medication. 1. Gait 2. Appetite 3. Level of consciousness 4. Hemoglobin and hematocrit blood levels
Rationale: the medication can cause peripheral neuropathy and the nurse should monitor the clients gait closely and ask the client about paresthesia.
A patient with cirrhosis is prescribed lactulose, which causes diarrhea. What should the nurse explain about this medication?
Reduces serum ammonia levels By having the patient take lactulose and having diarrhea, the patient's ammonia will be excreted via the feces and serum ammonia levels will drop.
The nurse is preparing to make rounds after receiving shift report. Which patient should the nurse assess first?
The patient diagnosed with a deep vein thrombosis who is requesting an anti-anxiety medication Shortness of breath after ambulating is expected for a patient diagnosed with COPD; patients diagnosed with deep vein thrombosis are at risk for pulmonary embolism (PE). Anxiety is a symptom of PE. The nurse must determine if interventions are needed for PE, a life-threatening emergency; anyone can take a specimen to the laboratory; a patient with emphysema would have these vital signs
A nurse has a next-door neighbor who complains of having to stop and rest after walking one block because of muscle pain and leg cramping (intermittent claudication). The nurse advises the neighbor to see their HCP, understanding the cause is most likely related to:
peripheral arterial disease. Intermittent claudication is a classic manifestation of peripheral arterial disease and occurs with walking or exercise that feels like a cramping or aching sensation in the calves or arch of the foot. It subsides with rest. Chapter 18
Prevention of infection
Safe injection Practices -Use a single dose syringe and needle 1 time and discard -Do NOT recap a needle -Discard in sharps container -Do not force a syringe into a full sharps container Do NOT place a syringe and needle in yourpocket, on bedside table, on a meal tray Clean up spills of body fluids immediately, then cleanse area with germicidal solution Avoid contaminating the outside of specimen containers. Consider ALL body fluids to be contaminated Hand Hygience Protective Barriers: (as indicated) Gloves, Mask, Eye shield, Gown
Anti-Inflammatory Drugs
Salicylates Aspirin (acetylsalicylic acid) Give with food or milk Do not give to children with chickenpox or influenza Nonsteroidal Anti-Inflammatory Drugs (NSAID's) Ibuprofen (Motrin, Advil) Give with food or milk Avoid the use of alcohol Cyclooxygenase-2 Inhibitors (Cox-2 inhibitor) Celecoxib (Celebrex) Monitor for bleeding with long-term use Corticosteroids: suppress immune and inflammatory responses Delay healing Never stop abruptly—wean off
The nurse will provide preoperative teaching on deep breathing, coughing and turning exercises. When is the best time to provide the initial preoperative teachings?
Several days prior to surgery Teaching about post op complications and ways to minimize them before surgery is the best time to teach surgical patients. They have lower anxiety and pain which helps retain the information.
Inflammatory Changes in the Older Adult
Skin thinner, drier and more fragile Decreased blood flow Fewer macrophages Less phagocytic activity Slower wound healing Signs of inflammation: red, heat, swelling may be diminished or absent**
The nurse is caring for a patient with thrombocytopenia. The nurse expects that the patient might be treated with:
platelet transfusion. Thrombocytopenia are low platelets. Platelet transfusion can be administered.
Which of the following nursing actions would help the patient decrease anxiety during the preoperative period?
Spending time listening to the patient and answering questions Assessing and listening to your patient's concerns will minimize their fear/anxiety. Chapter 10
A nurse performs an admission assessment on a patient with a diagnosis of tuberculosis. The nurse reviews the result of which diagnostic test that will confirm this diagnosis?
Sputum culture Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.
What type of diet would you offer to a patient who has stomatitis as a result of chemotherapy?
Stomatitis (inflammation of the oral cavity) is a common toxic effect caused by chemotherapy on the GI tract. Other toxic effects from chemotherapy on the GI tract include: nausea, vomiting and diarrhea. Administering an antiemetic before chemotherapy can help reduce nausea and vomiting. Including constipating foods such as cheese or foods high in fiber can help with diarrhea. Ensuring adequate fluid intake and small meals helps. Extremely hot foods may be more difficult to eat than cold foods. Client should avoid spicy, irritating foods. The diet should consist of cold, bland, semi soft/liquid foods. Using a anesthetic mouthwash before eating may reduce discomfort of chewing and swallowing. Generally, the American Cancer Society recommends a diet comprised of mainly plant sources and healthy grains, with limited red meat and processed meat for cancer prevention. (Burke, pg 289)
Older patient experiencing anginal pain with complaints of fatigue or weakness usually are medicated with which of the following types of medication?
Sublingual nitroglycerin Angina frequently is managed with sublingual nitroglycerin, which causes vasodilation and increases blood flow to the coronary arteries. Cardiac glycosides are used to treat heart failure, and morphine is used to treat myocardial infarction. The HMG-CoA reductase inhibitors are used for patients with type 2 diabetes mellitus.
Which of the following signs and symptoms would the nurse expect to find when assessing a patient with symptomatic deep vein thrombosis?
Sudden onset of unilateral swelling of the affected leg Swelling, warmth and redness of the affected limb are characteristic of DVT. Chapter 18
A patient complains of sudden loss of vision in their right eye. The nurse notices that as the patient speaks, their words are slurred and mouth is drooping at the corner. After 5 minutes, all of their symptoms disappear. The nurse informs the HCP that the patient had experienced symptoms of a
TIA A short episode of stroke like symptoms is referred to a TIA (transient ischemic attack). These are usually precursor to a stroke.
Why does the CD4 T cell count drop in HIV infection?
The CD4 T cell count drops in HIV infection because the virus enter the bloodstream and sheds its protein coat leading to viral RNA converted with reverse trancripstase to viral DNA. Viral DNA then integrates with host cell DNA, leading to the virus remaining latent, virus infecting daughter cells during host replication or virus actively replicating causing lysis of host cell as virus seeks to invade other cells. (Burke Chapter 11 p.253)
HIV (human immunodeficiency virus)
Transmission: -Unprotected Sexual Intercourse -Contact with blood and blood products -Perinatal-during pregnancy, delivery, or breastfeeding Screening: -Enzyme immunoassay (EIA) at 3 weeks, 6 weeks, 3 months after exposure - Rapid HIV Antibody testing- tests for antigens, not antibodies, if positive, need follow up with EIA and/ or Antibody/Antigen test. Seroconversion development of HIV specific antibodies. - Window Period- may be 2 months between infection and detection of antibodies (HIV positive) Acquired Immunodeficiency Disease Syndrome- (AIDS) Presence of at least one or more: - CD4 Tcell count DOWN 200 cells/uL (compromised immune system) -Opportunistic infections- Fungal- Candidiasis, pneumocystis jiroveci pneumonia (PCP) -Viral- Cytomegalorirus (CMV) -Bacterial- Mycobacterium tuberculosis, pneumonia -Protozoal- Toxoplasmosis of brain, intestine Cancer -Invasive cervical -Kaposis sarcoma -Lymphoma Wasting Syndrome Aids Dementia Complex Early Chronic Infection -HIV infection to development of AIDS- average 11 years -Symptoms- fatigue, headache, lymphadenopathy, low grade fever. -Normal CD4- T-cell count -Increased infections Intermediate Chronic Infection -CD4 * T-cell count DOWN 200-500 cells/uL -Increased viral load -Increased infections, earlier symptoms more severe Late Chronic infection -Diagnosis of AIDS Treatment -Antiretroviral therapy (ART) begins with confirmation of HIV Goals: -Decrease viral load -Maintain or Increase CD4 * Tcell count -Delay onset of HIV related symptoms -Prevent or delay opportunistic infections
Explain the difference between staging and grading of tumors.
Tumor grading evaluates the cell differentiation and estimates the rate of growth. It is graded from 1-4 with 1 being the least malignant where the cells still resemble normal healthy cells and 4 being the most aggressive malignant cells (looks very different from normal healthy cells; mutated). Tumor staging evaluates the size of the tumor and extent of the disease if it is treatable or not will lead to treatment options. The TNM classification is used to stage tumors. T - tumor size and invasiveness N - presence and lymph node involvement M - denotes distant metastases
An patient is admitted with acute glomerulonephritis with symptoms of fatigue, anorexia, and blood pressure of 140/94. The nurse identifies the priority goal of treatment is to
reduce the hypertension. Excess fluid in this patient will ensure HTN. The goal of care is to bring the BP down.
Inflammation and Infection
Two Major Defense Mechanisms Inflammation/ Infection Immunity Inflammation: Response to an injury Purpose is to destroy the harmful agent, limit spread and begin healing process Pathophysiology Body's defense: Skin and mucous membranes Cilia Body fluids
Which type of surgery is most likely to predispose a patient to postoperative atelectasis, pneumonia or respiratory failure?
Upper abdominal surgery on an obese patient with long history of smoking Smoking and obesity poses a great risk for pulmonary compromise. Chapter 10
Age-Related Infections
Urinary tract infections (UTI's)→ Pneumonia and Influenza→ Tuberculosis → Skin infections → Herpes zoster or shingles→ Decubitus ulcers→ Monitor s/s UTI Increase Fluids, Antibiotics Vaccines: Antibiotics Monitor Anti-TB meds Wash hands for 15 seconds Antibiotics or antifungals Analgesics, steroids, antivirals (vaccine) Topical ointments Maintain skin integrity: Wound care
Which of the following post operative findings should be the nurse report to the health care provider?
Urine output is 20 ml/hr for the past two hours
A nurse is assessing a patient who is at risk for developing acute kidney injury. The nurse would become most concerned if which of the following assessments was made?
Urine output of 20 mL/hr for the last 3 hours, serum BUN elevated and serum creatinine elevated Low urine output and elevated serum creatinine and BUN will make people at risk for AKI.
The nurse assesses a patient's respiratory status. Which observation indicates that the patient is experiencing difficulty breathing?
Use of accessory muscles The use of accessory muscles for respiration indicates the patient is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the patient conserve energy. Nasal flaring is typically seen in infants.
Which nursing action best promotes adequate gas exchange for a patient with advanced chronic obstructive pulmonary disease (COPD)?
Using a high-flow venturi mask to deliver oxygen as prescribed The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.
Diagnostic Tests: Inflammation
WBC count with differential -Neutrophils -Eosinophils -Basophils -Monocytes -Lymphocytes -Leukocytosis -Leukopenia -Erythrocyte sedimentation rate (ESR): -C-reactive protein (CRP): -Cultures of wound, blood, or other infected body fluids:
A patient who has a Type I-immediate hypersensitivity reaction is brought to the emergency room with symptoms. Which symptom seen in an anaphylactic reaction is most severe?
Wheezing Consider ABC in any type of reaction. Wheezing would affect breathing.
The major rationale for the use of aspirin in the treatment of rheumatoid arthritis is to:
reduce the inflammation of the joints. Aspirin acts as an anti inflammatory for RA patients. Ensure there is no bleeding history.
A patient is admitted to the emergency department with possible fractures of the bones of the lower extremity. Prior to initiating treatment for the patient, it is most important for the nurse to first:
assess the neurovascular status of the lower leg. Always assess first and in this case neurovascular assessment is required for suspected fractures. Chapter 42 With a suspected fracture, assessing is the priority nursing intervention. Perform CMS of the affected extremity.
An older adult patient had a right hip replacement 1 day ago. The nurse notes that the patient is now slightly confused and disoriented. The most important action by the nurse at this time would be to:
assist the patient to put on their glasses and hearing aids. Older adults can be dependent on sensory devices. If they are missing these devices, they can appear confused and disoriented. Infections usually do not occur until 2-3 days after surgery. Bedrest is not indicated for a post surgical patient as they can develop many post surgical complications. Chapter 10
A nurse is teaching a patient with COPD how to purse-lip breathe. The nurse tells the patient to:
breathe so that expiration is twice as long as inspiration. The benefit of purse lip breathing is it slows your breathing down allowing for CO2 to be released. Should be taught to COPD patients as they have CO2 retention. Chapter 23
The nurse is admitting a patient who fell at home and now is complaining of right hip pain and an inability to put weight on the right leg. When conducting a focused admission, the nurse appropriately:
compares pulses on the affected leg with those with those on the unaffected leg. Assessing the neurovascular status of both extremities prior to any other intervention is the priority. Movement is only assessed distal to the fracture site. Chapter 42
If wound evisceration occurs, the immediate nursing action is:
cover the wound with sterile gauze moistened with sterile normal saline. Keeping the area sterile is important and applying a moist gauze will prevent anything adhering to the wound bed. Chapter 10
Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. To promote optimum absorption, the nurse instructs the mother to administer the iron with:
orange juice. Vitamin C helps with absorption of iron.
The nurse is caring for a patient who has just had surgery to repair a fracture of the tibia. The patient's leg is in a cast and the patient is receiving morphine for pain. The patient continues to complain of severe pain and paresthesias in the foot. The nurse should:
immediately notify the health care provider. After having a cast placed, pain should not be increasing. Assessing for CMS in the casted area is needed and findings should be reported to the HCP.
Following a bronchoscopy, the nurse should have the patient:
maintain NPO status until gag reflex returns. The back of the throat is anesthetized during a bronchoscopy. Refraining from food and fluids until the gag reflex returns is a priority or aspiration will occur. Chapter 21
A patient with type 1 diabetes mellitus has a glycosylated hemoglobin level of 8%. The nurse recognizes that this indicates the patient:
needs adjustment in diet and/or medication. A HgbA1C of 8% is high indicating the patient has poor management of their blood sugars. Diet and/or medications will have to be readjusted. Chapter 36
The health care provider prescribes albuterol sulfate (Albuterol) for a patient with newly diagnosed asthma. When teaching the patient about this drug, the nurse should explain that it may cause:
nervousness. Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Otther adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and muscle cramps.
A patient has just returned from surgery after having his left leg amputated below the knee. The health care provider's orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under the patient's amputated limb. The nursing action is to:
remove the pillow and elevate the foot of the bed. Placing a pillow under the stump can lead to a flexion contraction. The stump should lay flat on the bed with the foot or bottom of the bed raised.
A patient who is being successfully treated for Cushing's syndrome, the nurse would expect a decline in:
serum glucose level. Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing's syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing's syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing's syndrome. With successful treatment, the patient experiences a return of menstrual flow, not a decline in it.
A patient with COPD is prescribed a bronchodilator, the short-acting Beta-2 agonist (Albuterol). The patient is instructed by the nurse to monitor for the side effect of:
tachycardia. This drug stimulates the sympathetic nervous system causing bronchodilation in the lungs. Increased heart rate, nervousness, irritability are common side effects. Chapter 23
A patient is admitted to the hospital experiencing respiratory distress. After assessment, the nurse concludes that the patient is in sickle cell crisis. The nurse plans care for the relief of pain because:
the sickled cells accumulate in tissue. The sickled cells accumulate in the blood vessels causing hypoxia.
The nurse is instructing a patient in preparation for a colonoscopy. The nurse explains that the patient:
will receive conscious sedation during the procedure. Patients who undergo a colonoscopy will have conscious sedation for the duration of the procedure. The enema is given the day before and patients are kept NPO prior to the procedure.
How would a latex allergy be enforced in the hospital?
▪ In health care workplaces, where wearing latex gloves is common, non latex products have been substituted to reduce exposure. A nonallergic contact dermatitis caused by the powder used in latex gloves may be mistaken for a true latex allergy and is much more common.The cornstarch contains latex parti-cles that can enter the body through the skin and mucous membranes or by inhalation. Also, chemicals used in man-ufacturing latex products may be irritating.Hospitals should use latex-free carts for patients with identified latex allergies and select products free of latex. Health care workers with latex allergies should use non latex gloves when handling noninfectious material. Hand hygiene should be performed after using latex products to limit exposure pg 244-245 ▪ Latex allergy is a problem for healthcare professionals. Repeated exposure to latex-containing equipment often causes delayed hypersensitivity. Pg 264 ▪Hospitals should use latex-free carts for patients with identified latex allergies and select products free of latex. Health care workers with latex allergies should use non latex gloves when handling noninfectious material. Hand hygiene should be performed after using latex products to limit exposure (NIOSH, 2012). ▪Collaborative Care Key aspects of care for patients with allergies are to wear a "allergy alert" bracelet, identify the allergen, minimize exposure, prevent the hyper-sensitivity response, and provide prompt interventions. A complete history of all of the patient's allergies is obtained, including medications, foods, animals, plants, and other materials. The type of hypersensitivity response is documented, as are onset, manifestations, and usual treatment. Several tests may be ordered: