Funds AQ Review

Human Tetanus Antitoxin (Tetanus immune globulin) provides antibodies against tetanus; Which patient presenting with an open, infected wound might receive this?

This is given to the pt who may be infected and has never received tetanus toxoid or has not received it for more than 10 years. It is PASSIVE immunity because antibodies are passed from humans and given to another human.

Tension along a suture line can precipitate what post-operative complication?

Wound Dehiscence

What nursing actions best promote communication when obtaining a nursing history?

-Establishing Eye Contact -Paraphrasing the client's message -Using broad, open-ended statements

What should be included in client teaching, before discharge home with indwelling urinary catheter, to best prevent infection?

-Once a day, the client should wash the first inches of the catheter starting at the insertion site and moving outward. -The foreskin should be pushed forward as soon as the foreskin has been cleaned and dried -The drainage bag should be cleaned with the one part vinegar and two parts water solution -It is recommended to change the drainage bag at least once a week

What are the best ways for a nurse to be protected legally?

-Provide care within the parameters of the state's nurse practice act -Document consistently and objectively -Clearly document a client's non-adherence to the medical regimen

Before administering IV potassium chloride, the nurse knows that is a priority to assess what?

-Urinary output (must be normal) -Last serum potassium level -Patency of the intravenous access

A client is receiving therapy that includes a radioactive sealed implant. What nursing intervention should be implemented to protect against exposure to radiation?

-Using long-handled forceps to retrieve a dislodged implant keeps it away from the nurse. It should be placed in a lead container kept in the client's room. -Know exposure should be limited to no more than 30 minutes daily -Visitors should maintain a minimum distance of 6 feet from the radiation source and visit only 30 minutes a day.

What causes infiltration of IV infusion?

Failure to secure catheter adequately, catheter displacement, or dislodgment

What is an example of an intentional tort?

False Imprisonment

Which blood protein is associated with the immune system?

Globulin

What is an example of an unintentional tort?

Negligence, Malpractice, Breach of duty

Does a dosimeter film badge offer protection for the nurse against radiation emitted from the client radioactive sealed implant?

No, it measures the amount of exposure but offers no protection.

To detect a distended bladder, the nurse should use what assessment skills?

Percussion and palpation should be performed over the hypogastric region of the abdomen. Percussion of a distended bladder will produce a dull sound and feel firm on palpation.

Detachment

A coping mechanism that the client needs, especially when faced with the inevitability of death; if a client seems detached from their environment, the nurse should accept this behavior.

The nurse is caring for a client that has an implanted port and is receiving IV fluids. To decrease the risk of infection, the nurse should change the non-coring needle every:

7 days.

Methyldopa is associated with what type of anemia?

Acquired hemolytic anemia and may cause symptoms such as fatigue, dyspnea and pale appearance

What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill?

Personal feelings about terminal illness and death

What causes a post-operative paralytic ileus?

Post-op paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery.

Hyperventilation can lead to what?

Carbonic acid deficit and respiratory alkalosis. (due to breathing off too much CO2)

What major life-threatening side effect should the nurse assess for when the client is receiving doxorubicin (Adriamycin)

Cardiotoxicity. This chemotherapy drug can cause CHF and dysrhythmias.

Why is it contraindicated to cleanse the arm with an alcohol swab before administering a smallpox vaccine?

Cleaning of the arm should not be done before this immunization unless the arm is dirty. If dirty, only water should be used to cleanse. Alcohol swabs will deactivate the vaccine

A client that is bitten by a large dog may have what type of trauma injury?

Crush injury

What are clinical indicators of hyperkalemia?

Diarrhea, Weakness, Dysrhythmias

The unlicensed assistive personnel (UAP) assigned to the 7 am shift has not been coming to work until 8 am. Nursing care is delayed and assignments are started late. What is the most appropriate action by the charge nurse/team leader?

Document the information before discussing it with the UAP -Documentation is the best initial response; documentation should include both the missed time and the effect on client care.

When taking the chemotherapy drug Vincristine (Oncovin), what does the nurse expect the dietary plan to include?

High in fluids! A common side effect of Oncovin is a paralytic ileus that results in constipation. Diet should be high in fiber and fluids that exceed minimum requirements.

Tetany is caused by what electrolyte imbalance?

Hypocalcemia

Seizures and other disturbances with the CNS can be caused by what electrolyte imbalances?

Hypocalcemia and Hyponatremia

No more than two tap water enemas should be given at one time to prevent the occurrence of what?

Hypokalemia and Hyponatremia. Repeated tap water enemas deplete cells and ECF of potassium and sodium resulting in hypokalemia, hyponatremia, and potential water intoxication.

What is the most important side effect to monitor for in a post-op client that has received epidural anesthesia?

Hypotension due to autonomic nervous system blockade

Symptoms of Hypokalemia

Leg cramps, Muscle weakness, Bradycardia

What is the main fx of albumin?

Maintenance of oncotic pressure

What is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury when filing a lawsuit against a nurse as malpractice?

Proximate cause

What is the purpose of applying a cooling blanket and administering antipyretic medication to a client with a temp of 104.5 degrees F?

Reduce brain metabolism and limit hypoxia

The spouse of a comatose client (who has not previously been deemed legal durable power of attorney for healthcare) may consent to treatment for the client, but has no legal authority to:

Refuse a treatment

When using the Problem-etiology-signs and symptoms format, the nurse knows that nursing interventions are derived from what?

The etiology statement