Chapter 17 - Prioritization, Delegation, and Assignment
A client with toxic shock syndrome is to receive clindamycin 900 mg IV over 60 minutes. The clindamycin is diluted in 100 mL of normal saline. The nurse will infuse __________ mL/hr.
• 100 mL/hr •To infuse 100 mL over 60 minutes, the nurse will need to set the infusion pump to give 100 mL/hr.
A 68-year-old client who is ready for discharge from the emergency department has a new prescription for nitroglycerin 0.4 mg sublingual as needed for angina. Which client information has the *most* immediate implications for teaching? •The client has prostatic hyperplasia with some urinary hesitancy •The client's father and two brothers all have had myocardial infarctions •The client uses sildenafil several times weekly for erectile dysfunction •The client is unable to remember when he first experienced chest pain
•The client uses sildenafil several times weekly for erectile dysfunction •Sildenafil is a potent vasodilator and has caused cardiac arrest in clients who were also taking nitrates such as nitroglycerin. The other client data indicate the need for further assessment or teaching, but it is essential for the client who uses nitrates to avoid concurrent use of sildenafil.
The day after a radical prostatectomy, a client has blood clots in the urinary catheter and reports bladder spasms. The client says that his right calf is sore and that he feels short of breath. Which action will the nurse take *first*? •Irrigate the catheter with 50 mL of sterile saline •Administer oxybutynin 5 mg orally •Apply warm packs to the right calf •Measure oxygen saturation using pulse oximetry
•Measure oxygen saturation using pulse oximetry •It is important to assess oxygenation because the client's calf tenderness and shortness of breath suggest a possible venous thromboembolism and pulmonary embolus, serious complications of transurethral resection of the prostate. The other activities are appropriate but are not as high a priority as ensuring that oxygenation is adequate.
After a radical prostatectomy, a client is ready to be discharged. Which nursing action included in the discharge plan should be assigned to an experienced LPN/LVN? •Reinforcing the client's need to check his temperature daily •Teaching the client how to care for his retention catheter •Documenting a discharge assessment in the client's chart •Instructing the client about the prescribed narcotic analgesic
•Reinforcing the client's need to check his temperature daily •Reinforcement of previous teaching is an expected role of the LPN/LVN. Planning and implementing client initial teaching and documentation of a client's discharge assessment should be performed by experienced RN staff members.
The nurse is interviewing a woman who is in the clinic for a well woman exam, and the woman requests a screening test for ovarian cancer. Which response by the nurse is best? •"Only a small number of ovarian cancers are diagnosed at an early stage." •"There is no effective screening test for ovarian cancer in low-risk women." •"Benefits of ovarian cancer screening will depend on your medical history." •"Ovarian cancer screening will probably not be covered by your insurance."
•"Benefits of ovarian cancer screening will depend on your medical history." •Current guidelines state that there is no effective screening tool for low-risk women, but women who are high risk because of family history or the BRCA genes may be screened with transvaginal ultrasonography and serum marker CA-125 levels. The other statements are accurate but do not respond as well to the client's concern.
While the nurse is working in the clinic, a healthy 32-year-old woman whose sister is a carrier of the BRCA gene asks which form of breast cancer screening is the most effective for her. Which response is *best*? •"An annual mammogram is usually sufficient screening for women your age." •"Monthly self-breast examination is recommended because of your higher risk." •"A yearly breast examination by a health care provider should be scheduled." •"Magnetic resonance imaging (MRI) is recommended in addition to annual mammography."
•"Magnetic resonance imaging (MRI) is recommended in addition to annual mammography." •The current guidelines, supported by nonrandomized screening trials and observational data, call for first-degree relatives of clients with the BRCA gene to be screened with both annual mammography and MRI. Although annual mammography, breast self-examination, and clinical breast examination by a health care provider may help to detect cancer, the best option for this client is annual mammography and MRI.
A client with benign prostatic hyperplasia has a new prescription for tamsulosin. Which statement about tamsulosin is *most* important to include when teaching this client? •"This medication will improve your symptoms by shrinking the prostate." •"The force of your urinary stream will probably increase." •"Your blood pressure might decrease as a result of taking this medication." •"You should avoid sitting up or standing up too quickly."
•"You should avoid sitting up or standing up too quickly." •Because tamsulosin blocks alpha receptors in the peripheral arterial system, the most significant side effects are orthostatic hypotension and dizziness. To avoid falls, it is important that the client change positions slowly. The other information is also accurate and may be included in client teaching but is not as important as decreasing the risk for falls.
A client has had a needle biopsy of the prostate gland using the transrectal approach. Which statement is most important to include in the client teaching plan? •"The health care provider (HCP) will call you about the test results." •"Serious infections may occur as a complication of this test." •"You will need to call the HCP if you develop a fever or chills." •"It is normal to have a small amount of rectal bleeding after the test."
•"You will need to call the HCP if you develop a fever or chills." •Although infection occurs only rarely as a complication of transrectal prostate biopsy, it is important that the client receive teaching about checking his temperature and calling the HCP if there is any fever or other signs of systemic infection. The client should understand that the test results will not be available immediately but that he will be notified about the results. Transient rectal bleeding may occur after the biopsy, but bleeding that lasts for more than a few hours indicates that there may have been rectal trauma.
The emergency department nurse receives change-of-shift report about four clients. Which one should be assessed *first*? •A 19-year-old client with scrotal swelling and severe pain that has not decreased with elevation of the scrotum •A 25-year-old client who has a painless indurated lesion on the glans penis •A 44-year-old client with an elevated temperature, chills, and back pain associated with recurrent prostatitis •A 77-year-old client with abdominal pain and acute bladder distention
•A 19-year-old client with scrotal swelling and severe pain that has not decreased with elevation of the scrotum •This client has symptoms of testicular torsion, an emergency that needs immediate assessment and intervention because it can lead to testicular ischemia and necrosis within a few hours. The other clients also have symptoms of acute problems (primary syphilis, acute bacterial prostatitis, and prostatic hyperplasia with urinary retention), which need rapid assessment and intervention, but these are not as urgent as the possible testicular torsion.
The clinic nurse reviews information about four clients who are requesting Pap testing. Which client needs to be scheduled *first*? •A 19-year-old client who first had intercourse at age 13 years •A 25-year-old client who has never had a pelvic examination •A 33-year-old client who had a normal Pap test 2 years previously •A 67-year-old client who says her previous Pap test results have been normal
•A 25-year-old client who has never had a pelvic examination •Current guidelines indicate that Pap testing should be started at age 21 years, regardless of when a woman has become sexually active. The 19-year-old client should be counseled that there is an increased risk for cervical cancer associated with sexual activity before age 17 years and encouraged to schedule Pap testing, human papillomavirus testing, or both at age 21 years. The 33-year-old client will need screening every 3 years, and the 67-year-old will not need further Pap screening if she has had several normal Pap test results within the past 2 to 3 years.
After receiving the change-of-shift report, in which order will the nurse assess these assigned clients? •A 22-year-old client who has questions about how to care for the drains placed in her breast reconstruction incision •An anxious 44-year-old client who is scheduled to be discharged today after undergoing a total vaginal hysterectomy •A 69-year-old client who reports level 5 pain (on a scale of 0 to 10) after undergoing perineal prostatectomy 2 days ago •A usually oriented 78-year-old client who has new-onset confusion after having a bilateral orchiectomy the previous day
•A usually oriented 78-year-old client who has new-onset confusion after having a bilateral orchiectomy the previous day •A 69-year-old client who reports level 5 pain (on a scale of 0 to 10) after undergoing perineal prostatectomy 2 days ago •An anxious 44-year-old client who is scheduled to be discharged today after undergoing a total vaginal hysterectomy •A 22-year-old client who has questions about how to care for the drains placed in her breast reconstruction incision •The bilateral orchiectomy client needs immediate assessment because confusion may be an indicator of serious postoperative complications such as hemorrhage, infection, or pulmonary embolism. The client who had a perineal prostatectomy should be assessed next because pain medication may be needed to allow him to perform essential postoperative activities such as deep breathing, coughing, and ambulating. The vaginal hysterectomy client's anxiety needs further assessment next. Although the breast implant client has questions about care of the drains at the surgical site, there is nothing in the report indicating that these need to be addressed immediately.
The nurse is caring for a 21-year-old client who had a left orchiectomy for testicular cancer on the previous day. Which nursing activity will be best to assign to an LPN/LVN? •Educating the client about post-orchiectomy chemotherapy and radiation •Administering the prescribed "as needed" (PRN) oxycodone to the client •Teaching the client how to do testicular self-examination on the remaining testicle •Assessing the client's knowledge level about post-orchiectomy fertility
•Administering the prescribed "as needed" (PRN) oxycodone to the client •Administration of narcotics and the associated client monitoring are included in LPN/LVN education and scope of practice. Assessments and teaching are more complex skills that require RN-level education and are best accomplished by an RN with experience in caring for clients with this diagnosis.
While performing a breast examination on a 22-year-old client, the nurse obtains these data. Which finding is of *most* concern? •Both breasts have many nodules in the upper outer quadrants •The client reports bilateral breast tenderness with palpation •The breast on the right side is slightly larger than the left breast •An irregularly shaped, nontender lump is palpable in the left breast
•An irregularly shaped, nontender lump is palpable in the left breast •Irregularly shaped and nontender lumps are consistent with a diagnosis of breast cancer, so this client needs immediate referral for diagnostic tests such as mammography or ultrasonography. The other information is not unusual and does not indicate the need for immediate action.
A new nurse who is assigned to care for a transgender client who has been admitted with pneumonia tells the charge nurse, "I do not feel comfortable caring for this client." Which action should the charge nurse take *first*? •Teach the new nurse that culturally sensitive care for all clients is an expectation for staff members •Change the new nurse's assignment for the day and arrange for more training about transgender health •Ask the new nurse to clarify the specific concerns about providing treatment for a transgender client •Explain to the new nurse that the treatment for pneumonia will not be affected by the client's transgender status
•Ask the new nurse to clarify the specific concerns about providing treatment for a transgender client •The initial response by the charge nurse should be assessment of the new nurse's concerns about caring for this client. Acknowledging the new nurse's concerns will be more effective than mandating culturally sensitive care. Changing the assignment and arranging training may be appropriate, but more information about the new nurse's anxieties is needed first. Treatment for pneumonia will not be different for a transgender client, but it is important that the client's care is provided in a nonjudgmental manner.
The nurse is supervising a student nurse who is caring for a client who has an intracavitary radioactive implant in place to treat cervical cancer. Which action by the student requires that the nurse intervene *immediately*? •Standing next to the client for 5 minutes while assisting with her bath •Asking the client how she feels about losing her childbearing ability •Assisting the client to the bedside commode for a bowel movement •Offering to get the client whatever she would like to eat or drink
•Assisting the client to the bedside commode for a bowel movement •Clients with intracavitary implants are kept in bed during the treatment to avoid dislodgement of the implant. The other actions may also require the nurse to intervene by providing guidance to the student. Minimal time should be spent close to clients who are receiving internal irradiation. Asking the client about her reaction to losing childbearing abilities may be inappropriate at this time. Clients are frequently placed on low-residue diets to decrease bowel distention while implants are in place.
The nurse is caring for a client who has just returned to the surgical unit after a transurethral resection of the prostate (TURP). Which assessment finding will require the *most* immediate action? •Blood pressure reading of 153/88 mm Hg •Catheter that is draining deep red blood •Client not wearing antiembolism hose •Client report of abdominal cramping
•Catheter that is draining deep red blood •Hemorrhage is a major complication after TURP and should be reported to the surgeon immediately. The other assessment data also indicate a need for nursing action but not as urgently.
The nurse obtains the health history of a 37-year-old woman who is requesting contraceptive therapy. Which information about the client will have the *most* impact on the choice of contraceptive? •History of uterine fibroids •Blood pressure of 136/80 mm Hg •Cigarette smoking of a pack/day •Planning outpatient oral surgery
•Cigarette smoking of a pack/day •The most commonly prescribed oral contraceptives are combination estrogen-progestin medications, but estrogen-containing oral contraceptives are contraindicated for women who are older than 35 years and who smoke because of the increased risk for thromboembolism. A progestin-only oral contraceptive or an intrauterine device (IUD) may be prescribed for this client. Estrogen-containing contraceptives may stimulate fibroid growth and elevate blood pressure, but these are relative contraindications. It is recommended that estrogen-containing contraceptives be discontinued a few weeks before surgeries that might impair mobility and increase venous thromboembolism risk, but oral surgery will not affect mobility.
Which information obtained when taking a client's health history will be *most* important in determining whether the client should receive the human papillomavirus (HPV) immunization? •Client is 19 years old •Client is sexually active •Client has a positive pregnancy test result •Client has tested positive for HPV previously
•Client has a positive pregnancy test result •Centers for Disease Control and Prevention guidelines indicate that the HPV immunization should not be given during pregnancy. Ideally, the immunization series should start at age 11 or 12 years for girls and boys, but it may be started up through age 26 years. HPV immunization is most effective in preventing HPV infection and cervical cancer when it is started before the individual is sexually active and before any HPV infection, but these are not contraindications for vaccination.
Which client is *best* for the oncology unit charge nurse to assign to an RN who has floated from the emergency department? •Client who needs doxorubicin chemotherapy to treat metastatic breast cancer •Client who needs discharge teaching after surgery for stage II ovarian cancer •Client with metastatic prostate cancer who requires frequent assessment and treatment for breakthrough pain •Client with testicular cancer who requires preoperative teaching about orchiectomy and lymph node resection
•Client with metastatic prostate cancer who requires frequent assessment and treatment for breakthrough pain •An RN from the emergency department would be experienced in assessment and management of pain. Because of their diagnoses and treatments, the other clients should be assigned to RNs who are experienced in caring for clients with cancer.
A client who is being treated as an outpatient for pelvic inflammatory disease (PID) with oral antibiotics returns to the clinic after 3 days of treatment. Which finding by the nurse is of *highest* concern? •Client reports nausea after taking the antibiotics •Client's abdominal rebound pain is unchanged •Client says she feels ashamed to have the infection •Client's cervical culture report shows gonorrhea
•Client's abdominal rebound pain is unchanged •Because clinical manifestations of PID should be improving with 3 days of effective antibiotic treatment, the client's ongoing pain indicates a need for actions such as hospitalization for intravenous antibiotic therapy. Nausea is an adverse effect of many antibiotics, but the client will be instructed to continue the medications. The client's feeling of shame should be addressed by the nurse but is not the most important finding. Because Neisseria gonorrhoeae is a common cause of PID, all drug regimens that are used will be effective in treating gonorrhea (and Chlamydia trachomatis).
Three days after undergoing a pelvic exenteration procedure, a client reports dizziness after experiencing a sudden "giving" sensation along her abdominal incision. The nurse finds that the wound edges are open, and loops of intestine are protruding. Which action should the nurse take *first*? •Notify the surgeon that wound evisceration has occurred •Cover the wound with saline-soaked dressings •Use swabs to obtain aerobic and anaerobic wound cultures •Call for assistance from the Rapid Response Team (RRT)
•Cover the wound with saline-soaked dressings •The initial action should be to ensure that the abdominal contents remain moist by covering the wound and loops of intestine with dressings soaked with sterile normal saline. Because national guidelines addressing the use of RRTs indicate that the role of the RRT is immediate assessment and stabilization of the client, the nurse's next action should be to activate the RRT. The surgeon should be notified after further assessments of the client (e.g., pulse and blood pressure) are obtained. Wound cultures may be obtained, but protection of the wound, further assessment of the client, and then notification of the surgeon so that other actions can be taken are the priority.
Which action by the nurse will *best* meet the goal of providing culturally competent care for lesbian, gay, bisexual, and transgender clients? •Direct transgender clients to the unisex bathrooms •Assure clients that they will all be treated the same way •Ask all clients about sexual orientation and gender identification •Develop forms that use gender-neutral terms to collect client information
•Develop forms that use gender-neutral terms to collect client information •The Joint Commission suggests that forms should use inclusive and gender-neutral language to allow for client self-identification. Unisex or single-stall bathrooms should be provided, but transgender clients should also be able to use bathrooms consistent with their gender identity. Treating all clients the same fails to acknowledge that sexual orientation and gender identity may have an impact on health care needs. The nurse should be receptive of information about client sexual orientation and gender identity, but self-identification should be at the client's chosen time.
The nurse is working with an unlicensed assistive personnel (UAP) to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which nursing action can be delegated to the UAP? •Teaching the client why blood pressure measurements are taken on the left arm •Elevating the client's arm on two pillows to promote lymphatic drainage •Assessing the client's right arm for lymphedema •Reinforcing the dressing if it becomes saturated
•Elevating the client's arm on two pillows to promote lymphatic drainage •Positioning the client's arm is a task within the scope of practice for UAP working on a surgical unit. Client teaching and assessment are RN-level skills. The RN should reinforce dressings as necessary because this requires assessment of the surgical site and possible communication with the surgeon.
Which information will the nurse include when teaching a group of 20-year-old women about emergency contraception with levonorgestrel (the morning-after pill)? Select all that apply. •Heavier menstrual bleeding is a common side effect of this medication regimen •Emergency contraception requires a prescription from a licensed health care provider •Even if pregnancy occurs after using emergency contraception, risk for complications is low •Because nausea and vomiting may occur, an antiemetic may be used before levonorgestrel •The medication must be taken within the first 24 hours after unprotected intercourse to be effective
•Heavier menstrual bleeding is a common side effect of this medication regimen •Emergency contraception requires a prescription from a licensed health care provider •Because nausea and vomiting may occur, an antiemetic may be used before levonorgestrel •Emergency contraception with levonorgestrel (Plan B) may cause heavy menstrual bleeding and nausea with vomiting. Risk for pregnancy complications is not increased. The medication is most effective if taken within 72 hours, but it can be used up to 5 days after unprotected intercourse. Levonorgestrel does not need a prescription when used for emergency contraception by clients age 17 years or older.
When the nurse is developing the plan of care for a home health client who has been discharged after a radical prostatectomy, which activities will be delegated to the home health aide? *Select all that apply.* •Monitoring the client for symptoms of urinary tract infection •Helping the client to connect the catheter to the leg bag •Checking the client's incision for appropriate wound healing •Assisting the client in ambulating for increasing distances •Helping the client shower at least every other day
•Helping the client to connect the catheter to the leg bag •Assisting the client in ambulating for increasing distances •Helping the client shower at least every other day •Assisting with catheter care, ambulation, and hygiene are included in home health aide education and would be expected activities for this staff member. Client assessments are the responsibility of RN members of the home health care team.
An 86-year-old woman had an anterior and posterior colporrhaphy (A & P repair) several days ago. Her retention catheter was removed 8 hours ago. Which assessment finding requires that the nurse act *most* rapidly? •Her oral temperature is 100.7°F (38.2°C) •Her abdomen is firm and tender to palpation above the symphysis pubis •Her breath sounds are decreased, with fine crackles audible at both bases •Her apical pulse is 86 beats/min and slightly irregular
•Her abdomen is firm and tender to palpation above the symphysis pubis •After an A & P repair, it is essential that the bladder be empty to avoid putting pressure on the suture lines. The abdominal firmness and tenderness indicate that the client's bladder is distended. The health care provider should be notified and an order for catheterization obtained. The other data also indicate a need for further assessment of her cardiac status and actions such as having the client cough and deep breathe, but these are not such immediate concerns.
A client who had an abdominal hysterectomy 3 days ago reports burning with urination. Her urine output during the previous shift was 210 mL, and her temperature is 101.3°F (38.5°C). Which of these actions prescribed by the health care provider will the nurse implement *first*? •Insert a straight catheter as needed (PRN) for output of less than 300 mL/8 hr •Administer acetaminophen 650 mg now and every 6 hours PRN •Send a urine specimen to the laboratory for culture and sensitivity testing •Administer ceftizoxime 1 g IV now and every 12 hours
•Insert a straight catheter as needed (PRN) for output of less than 300 mL/8 hr •The client has symptoms of a urinary tract infection. Inserting a straight catheter will enable the nurse to obtain an uncontaminated urine specimen for culture and sensitivity testing before the antibiotic is started. In addition, the client is probably not emptying her bladder fully because of the painful urination. The antibiotic therapy should be initiated as rapidly as possible after the urine specimen is obtained. Administration of acetaminophen is the lowest priority because the client's temperature is not dangerously elevated.
A client who has just returned to the surgical unit after a transurethral resection of the prostate (TURP) reports acute bladder spasms. In which order will the nurse perform these prescribed actions? •Administer acetaminophen/oxycodone 325 mg/ 5 mg. •Irrigate the rentention catheter with 30 to 50 mL of sterile normal saline •Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours •Offer the client oral fluids to at least 2500 to 3000 mL/day
•Irrigate the rentention catheter with 30 to 50 mL of sterile normal saline •Administer acetaminophen/oxycodone 325 mg/ 5 mg. •Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours •Offer the client oral fluids to at least 2500 to 3000 mL/day •Bladder spasms after a TURP are usually caused by the presence of clots that obstruct the catheter, so irrigation should be the first action taken. Administration of analgesics may help to reduce spasm. Administration of a bolus of IV fluids is commonly used in the immediate postoperative period to help maintain fluid intake and increase urinary flow. Oral fluid intake should be encouraged when the nurse is sure that the client is not nauseated and has adequate bowel tone.
The nurse is working on a medical unit staffed with LPNs/LVNs and unlicensed assistive personnel (UAP) when a client with stage IV ovarian cancer and recurrent ascites is admitted for paracentesis. Which activity is *best* to assign to an experienced LPN/LVN? •Obtaining a paracentesis tray from the central supply area •Completing the short-stay client admission form •Measuring vital signs every 15 minutes after the procedure •Providing discharge instructions after the procedure
•Measuring vital signs every 15 minutes after the procedure •LPN/LVN education includes vital sign monitoring after procedures such as paracentesis; an experienced LPN/LVN would recognize and report significant changes in vital signs to the RN. The paracentesis tray could be obtained by a UAP. Client admission assessment and teaching require RN-level education and experience, although part of the data gathering may be done by an LPN/LVN.
After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit. Which nursing action is *best* to assign to an experienced LPN/LVN? •Monitoring the client's dressing for any signs of bleeding •Documenting the initial assessment on the client's chart •Communicating the client's status report to the charge nurse on the surgical unit •Teaching the client about the importance of using pain medication as needed
•Monitoring the client's dressing for any signs of bleeding •An LPN/LVN working in a postanesthesia care unit would be expected to check dressings for bleeding and alert RN staff members if bleeding occurs. The other tasks are more appropriate for nursing staff with RN-level education and licensure.
A postmenopausal woman who is taking raloxifene for osteoporosis calls the clinic nurse with these concerns. Which information indicates a need for *immediate* further evaluation? •Experiences hot flashes several times weekly •Describes family history of coronary artery disease •Reports nasal stuffiness and runny nose •Notices swelling and tenderness in left calf
•Notices swelling and tenderness in left calf •Raloxifene increases the risk for deep vein thrombosis and pulmonary embolism, and the client should be evaluated further with an examination, possible venous ultrasonography, and coagulation studies. Hot flashes and nasal congestion are common side effects of raloxifene but are not reasons to discontinue the medication. Raloxifene lowers myocardial infarction risk in women at high risk.
The nurse obtains this information when taking the health history of a 56-year-old postmenopausal woman. Which information is *most* important to report to the health care provider (HCP)? •Sagging of breasts bilaterally •Vaginal dryness and painful intercourse •Hot flashes occurring during the night •Occasional painless vaginal bleeding
•Occasional painless vaginal bleeding •Painless vaginal bleeding in postmenopausal women may indicate endometrial or cervical cancer and will require diagnostic testing such as endometrial biopsy. Breast atrophy, vaginal dryness and painful intercourse, and hot flashes are common after menopause, although these symptoms should also be discussed with the HCP and may need treatment.
The nurse is providing orientation for a new RN on the medical-surgical unit who is caring for a client with severe pelvic inflammatory disease (PID). Which action by the new RN is *most* important to correct quickly? •Telling the client that she should avoid using tampons in the future •Offering the client an ice pack to decrease her abdominal pain •Positioning the client flat in bed while helping her take a bath •Teaching the client that she should not have intercourse for 2 months
•Positioning the client flat in bed while helping her take a bath •The client should be positioned in a semi-Fowler position to decrease pain and minimize the risk of abscess development higher in the abdomen. The other actions also require correction but not as rapidly. Tampon use is not contraindicated after an episode of PID, although some sources recommend not using tampons during the acute infection. Heat application to the abdomen and pelvis is used for pain relief. Intercourse is safe a few weeks after effective treatment for PID.
The nurse is working in the emergency department when a client with possible toxic shock syndrome is admitted. Which prescribed intervention will the nurse implement *first*? •Remove the client's tampon •Obtain blood specimens for culture •Give acetaminophen 650 mg •Infuse nafcillin 1000 mg IV
•Remove the client's tampon •Because the most likely source of the bacteria causing the toxic shock syndrome is the client's tampon, it is essential to remove it first. The other actions should be implemented in the following order: obtain blood culture samples (best done before initiating antibiotic therapy to ensure accurate culture and sensitivity results), infuse nafcillin (rapid initiation of antibiotic therapy will decrease bacterial release of toxins), and administer acetaminophen (fever reduction may be necessary, but treating the infection has the highest priority).
The nurse is working in the postanesthesia care unit caring for a 32-year-old client who has just arrived after undergoing dilation and curettage to evaluate infertility. Which assessment finding should be *immediately* communicated to the surgeon? •Blood pressure of 162/90 mm Hg •Saturation of the perineal pad after the first 30 minutes •Oxygen saturation of 91% to 95% •Sharp, continuous, level 8 abdominal pain (on a scale of 0 to 10)
•Sharp, continuous, level 8 abdominal pain (on a scale of 0 to 10) •Cramping or aching abdominal pain is common after dilation and curettage; however, sharp, continuous pain may indicate uterine perforation, which would require rapid intervention by the surgeon. The other data indicate a need for ongoing assessment or interventions. Transient blood pressure elevation may occur because of the stress response after surgery. Bleeding after the procedure is expected but should decrease over the first 2 hours. Although the oxygen saturation is not at an unsafe level, interventions to improve the saturation should be carried out.
The nurse is reviewing medication lists for several clients. Which medication is *most* important for the nurse to question? •Testosterone transdermal gel for a client who has prostate cancer •Metformin for a client whose only diagnosis is polycystic ovary syndrome •Sildenafil for a client who is also taking hydrochlorothiazide for hypertension •Methoprogesterone for a client who has infertility associated with endometriosis
•Testosterone transdermal gel for a client who has prostate cancer •Testosterone is contraindicated in clients who have prostate cancer because it can promote growth of prostate cancer. Although metformin is most commonly prescribed for type 2 diabetes, it can be helpful in restoring ovulation in clients with polycystic ovary syndrome. Sildenafil lowers blood pressure and should not be used by clients who are taking nitrates or alpha-adrenergic blockers but may be used in clients taking other antihypertensives. Progestin therapy alone will not treat infertility caused by endometriosis but may be used to shrink endometrial tissue.
The nurse is assessing a long-term-care client with a history of benign prostatic hyperplasia. Which information will require the *most* immediate action? •The client states that he always has trouble starting his urinary stream •The chart shows an elevated level of prostate-specific antigen •The bladder is palpable above the symphysis pubis, and the client is restless •The client says he has not voided since having a glass of juice 4 hours ago
•The bladder is palpable above the symphysis pubis, and the client is restless •A palpable bladder and restlessness are indicators of urinary retention, which would require action (e.g., insertion of a catheter) to empty the bladder. The other data would be consistent with the client's diagnosis of benign prostatic hyperplasia. More detailed assessment may be indicated, but no immediate action is required.
The nurse obtains the following assessment data about a client who has had a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. Which finding indicates the *most* immediate need for nursing intervention? •The client states that he feels a continuous urge to void •The catheter drainage is light pink with occasional clots •The catheter is taped to the client's thigh •The client reports painful bladder spasms
•The client reports painful bladder spasms •The bladder spasms may indicate that blood clots are obstructing the catheter, which would indicate the need for irrigation of the catheter with 30 to 50 mL of normal saline using a piston syringe. The other data would all be normal after a TURP, but the client may need some teaching about the usual post-TURP symptoms and care.
When assessing a client with cervical cancer who had a total abdominal hysterectomy yesterday, the nurse obtains the following data. Which information has the *most* immediate implications for planning of the client's care? •Fine crackles are audible at the lung bases •The client's right calf is swollen, and she reports mild calf tenderness •The client uses the patient-controlled analgesia device every 30 minutes •Urine in the collection bag is amber and clear
•The client's right calf is swollen, and she reports mild calf tenderness •Right calf swelling and tenderness indicate the possible presence of deep vein thrombosis. This will change the plan of care because the client may be placed on bed rest and will require diagnostic testing and possible anticoagulant therapy. The other data indicate the need for common postoperative nursing actions such as having the client cough, assessing her pain, and increasing her fluid intake.
