ELEVATE ME Three
A nurse is planning care for a client admitted to the unit after application of a halo apparatus to immobilize the cervical spine. What interventions should the nurse include?
1. Clean around pins once daily with a small brush. 2. Use the log roll technique when turning client in bed. 3. Assist client with daily shower. 4. Have client sit up slowly with assistance. 5. Inspect for skin breakdown under halo vest 2., 4., & 5. Correct: Turn the client in bed every 2 hours by means of a triple log roll technique, in which 3 nurses roll the client. 1st nurse stands behind the head of the bed and places hands firmly on the client's head and neck, turning them as 1 unit. 2nd nurse stands at the client's side and moves the shoulders. 3rd nurse stand at the client's side and moves the client's hips and legs. All 3 nurses turn the client at the same time into desired position and onto previously positioned pillow. Administer mild analgesics to control headache and discomfort around the pin site. Begin sitting and ambulating by assessing the client's tolerance to upright position, accompany the client when ambulating, and consider the client's use of a walker. Inspect skin under halo vest looking for skin breakdown. 1. Incorrect: Clean around pins at least twice daily with sterile q-tips. A brush may cause abrasions on the skin. 3. Incorrect. Assist client with a sponge bath to help keep the vest dry. Showers will cause the vest to become wet and should not be taken. This can lead to skin breakdown.
The nurse recognizes that Rho(D) immune globulin would be indicated for which Rh negative client?
1. Miscarriage at 12 weeks gestation 2. Abdominal trauma 3. Undergoes chorionic villus sampling (CVS) 4. Diagnosed with an ectopic pregnancy 5. Seventy-two hours post delivery of term Rh negative baby 6. Twenty-eight weeks gestation 1., 2., 3., & 4. Correct: All of these clients may need to receive the Rho(D) immune globulin because they could have some bleeding and therefore develop antibodies against a Rh positive fetus. An optional Rho(D) immune globulin dose may have been given during pregnancy by the practitioner at 28 weeks. 5. Incorrect: An Rh negative newborn does not need the Rho(D) immune globulin because the Rh negative mom does not have antibodies against the Rh factor.
A nurse auscultates for bowel sounds in a client suspected of having a bowel obstruction in the transverse colon. What would the nurse expect to hear in the right lower abdominal quadrant?
1. Hyperactive bowel sounds 2. Absent bowel sounds 3. Hypoactive bowel sounds 4. Normal bowel sounds 1. Correct: Peristalsis should increase in the ascending colon (RLQ) in an attempt to clear the blockage resulting in hyperactive bowel sounds. There will be little or no peristalsis distal to the obstruction (LLQ) resulting in decreased or absent bowel sounds. 2. Incorrect: Bowel sounds should be present proximal to the blockage (RLQ). 3. Incorrect: Peristalsis will increase proximal (RLQ) to the obstruction. 4. Incorrect: Peristalsis will increase proximal (RLQ) to the obstruction.
What sign and symptom should the nurse expect to find during the physical assessment of a client who has a history of rheumatoid arthritis?
1. Nodules over bony prominences 2. Reports of bedtime stiffness lasting over 1 hour 3. Reports of weight loss 4. Cool, swollen joints 5. Joint deformity 6. Low grade fever 1., 3., 5., & 6. Correct: Firm bumps of tissue (nodules) over bony prominences, such as on elbows, are called rheumatoid nodules, and are a sign of rheumatoid arthritis. Over time, rheumatoid arthritis can cause joints to deform and shift out of place. Weight loss is a common symptom of rheumatoid arthritis. Inflammation is a normal part of the immune response. However, inflammation from RA is part of the problem. The same substances that cause inflammation of the joints can also cause a fever. RA also causes an increase in metabolic rate, which can also result in a fever. 2. Incorrect: Morning stiffness that can last for hours is a symptom of rheumatoid arthritis. 4. Incorrect: Affected joints will be tender, red, warm, and swollen.
The nurse has a prescription to calculate a client's body mass index (BMI). The client weighs 140 kgs and is 2 m tall. Determine the BMI to the whole number.
35 The client has a BMI of 35 BMI = weight in kilograms / height in meters squared First we multiply the client's height by itself: 2 x 2 = 4 Next we divide the client's weight by the height in meters ²: 140 / 4 = 35 The client's BMI is 35
A client is seeing the obstetrician for a monthly checkup at 35 weeks. Vital signs are within normal limits but the nurse notes bilateral pedal edema. What statement by the nurse provides the most appropriate information to the client?
1. "Do not use any salt for your food." 2. "Cut your daily fluid intake in half." 3. "Sit and elevate feet above your heart." 4. "Request a prescription for a diuretic." 3. Correct: In the third trimester of pregnancy, it is common for clients to complain about edema of hands and feet, usually at the end of the day. The client should sit for short periods of time, with feet elevated above the level of the heart, to decrease the edema. 1. Incorrect: The type of edema the nurse has noted is not caused by salt intake, but rather is caused by walking or standing too long during the day. Removing sodium from the diet will not affect the amount of edema the client develops. 2. Incorrect: Pregnant females need to stay well hydrated, particularly in the third trimester, to avoid complications such as Braxton Hicks contractions. Cutting daily fluid intake has no effect on the presence of edema, but may cause other problems. 4. Incorrect: Staying well hydrated is important in all stages of pregnancy, particularly the third trimester. Unless the mother has cardiac issues, a diuretic would be contraindicated.
