HESI CASE STUDIES

The nurse is preparing to give Judy's medications. The cyclosporine (Sandimmune) comes in a vial with 50 mg/mL. Judy weighs 132 lbs (60 kg). How many milliliters of the medication should the nurse draw up? (Enter numeric value only. If rounding is necessary, round to the tenth.)

4.8 D/H x V = X 122lbs/2.2 kg = 60kg 60kg x 4mg/kg = 240 mg 240mg x 1 mL/50mg = 4.8mL

19. Which statement accurately explains the scientific rationale for the use of omeprazole (Prilosec)? A. Omeprazole (Prilosec) decreases gastric secretions. B. Omeprazole (Prilosec) decreases pancreatic enzyme secretion. C. Omeprazole (Prilosec) decreases the propulsion of food through the small intestine. D. Omeprazole (Prilosec) decreases the number of stools and steatorrhea.

A. Omeprazole (Prilosec) is a proton-pump inhibitor (PPI) that decreases gastric secretions. Proton-pump inhibitors, such as omeprazole (Prilosec), reduce the production of acid by blocking the enzyme in the wall of the stomach that produces acid. -PPIs dont decrease the population of food thru the small intestine - they are enzymes prescribed to reduce steatorrhea (steatorrhea is an increase in fat excretion in the stools) - Octreotide (Sandostatin), A synthetic hormone that suppresses pancreatic enzyme secretion and maybe used to relieve pain and chronic pancreatitis

Based on the healthcare provider's (HCP) prescription, the pharmacy dispenses morphine 4mg per 1mL. How many mL should the nurse administer to the client? (numerical value only. If required, round to nearest hundredth)

0.25

Which is the primary cause of respiratory alkalosis? -Hypoxemia r/t acute lung disorders -Hypoxia r/t renal calculi -Lactic acidosis secondary to diabetes -Hypoventilation due to increas CO2

Hypoxemia r/t acute lung disorders = The primary cause of respiratory alkalosis is hypoxemia related to acute pulmonary disorders including atelectasis, pneumonia, and pulmonary embolism - the others don't contribute to the development of respiratory alkalosis

What is the maximum amount of weight that Judy should gain between each dialysis treatment? - 2 kg - 2.5 kg - 3 kg - 1.5 kg

1.5 kg The goal for hemodialysis clients is to keep their intradialytic (between dialysis treatments) weight gain under 1.5 kg

Referral to Alcoholics Anonymous (A.A.) The clinic nurse is concerned that Jeremy continues to smoke cigarettes, but his inability to abstain from drinking alcohol is a greater priority. The nurse encourages Jeremy to attend an AA meeting. Jeremy asks the nurse, "How will this meeting help me quit drinking?" 24. How should the nurse respond? A. "It is a support group that uses a 12-step recovery program to quit drinking." B. "If you go to these meetings instead of bars, you won't be able to drink." C. "A person cannot quit drinking on their own without some kind of help." D. "They discuss medications that can curb your desire to drink alcohol."

A. AA is a program of total abstinence. According to AA, sobriety is maintained through sharing experience, strength and hope at group meetings and through the suggested 12 Steps for recovery from alcoholism. -If you go to these meetings instead of bars, you won't be able to drink = Attending AA meetings does not ensure the client will not go to the bar and continue to drink -A person cannot quit drinking on their own without some kind of help = this response is not explained how a will help him quit drinking -They discuss medications that can curb your desire to drink alcohol = AA does not encourage medication use to quit drinking alcohol

Which risk factors relate to the use of hemodialysis? A) Noncompliant because treatments require more time B) bowel or bladder perforation C) orthostatic hypotension D) ascites E) hemorrhage

C + E orthostatic hypotension = hypotension can occur in up to 50% of HD treatments - hemorrhage = the heparin required during HD increases the risk for extensive bleeding. all invasive procedures must be avoided for four to six hours after dialysis. continually monitor the client for hemorrhage during and for at least one hour after dialysis - Noncompliant because treatments require more time = peritoneal dialysis typically requires a longer period of time for the exchange of fluid than does hemodialysis - bowel or bladder perforation = this is a serious complication associated with peritoneal dialysis. observe four and document any change in the color of the outflow. brown colored effluent occurs with a bowel perforation. if the outflow is the same color as urine and has the same glucose level a bladder perforation is probable - ascites = ascites is not a potential complication of hemodialysis

Which question is most important for the RN to ask Mrs. Tanner? "Have you smoked cigarettes in the last 24 hours?" "Have you had anything to eat or drink since midnight?" "Are you taking any medications?" "When was the last time you drank any alcohol?"

"Have you had anything to eat or drink since midnight?" Eating and/or drinking places the patient at risk for vomiting and aspiration during the procedure. If Mrs. Tanner has had anything to eat or drink, the biopsy will be canceled.

The nurse admits Raymond to a private room at the end of the hall. According to hospital protocol, the nurse put on a mask before starting the admission process. Raymond tells the nurse that his significant other is downstairs and that he would like for him to stay in the room with him.1. How should the nurse respond? Your HCP wants you to get some rest He may stay but only if he wears a mask He may stay but only after we have the TB skin test results You don't want to risk your significant other from getting TB do you?

"He may stay but only if he wears a mask" Raymond's significant other may stay in the room, but he should wear a mask to help decrease the possibility of contracting the TB organism. -The partner has already been exposed so should be allowed to stay so long as they wear the appropriate PPE

The ONS has given written and verbal info to the pt, has answered their questions and preformed a physical assessment Which question is important for the ONS to ask Mrs. Tanner? "How much alcohol do you drink a week?" "How long have you been signing?" "When did you first notice any hoarseness in your voice?" "What foods are difficult for you to swallow?"

"How much alcohol do you drink a week?" Heavy drinking is a risk factor for laryngeal cancer, but more importantly to ask d/t potential for alcohol withdrawal

Mrs. Tanner is being discharged home after 5 days in hospital and her husband stops the RN to say he is scared about taking her home What is the best response by the RN? -I know that this must be very scary, but you and your wife are strong -It sounds like you cant care for her - Have you discussed your fears with your wife -Let's sit down and discuss what you are worried about.

"Let's sit down and discuss what you are worried about." The RN should attempt to find out what he is scared about and provide factual info as well as support

Mr. Tanner shares with the RN that he is afraid to touch his wife How should the RN respond? -You are worried about touching your wife, but she needs your support right now -Would you like to talk to your wife's doctor? I can call him for you -You can touch your wife all you want. You will not hurt her -Tell me more about what you mean by touching your wife

"Tell me more about what you mean by touching your wife." The RN needs to clarify exactly what his fears are. If the RN doesn't address his sexual concerns, it is unlikely that they will be address by anther healthcare professional

How should the ONS respond to help Mrs. Tanner in her attempt to stop smoking? "What steps are you going to take to stop smoking?" "I know it will be hard and I am very proud of you" "Does anyone else in your household smoke?" "You will not be able to smoke after your surgery"

"What steps are you going to take to stop smoking?" The ONS should determine what steps Mrs. Tanner is planning to take to stop smoking and provide smoking cessation info, if needed.

The next time the RN enters Mrs. Tanner's room, Mrs. T writes on the whiteboard to ask if something is wrong since she heard staff talking about the med error How should the RN respond? -You are concerned that you might have received the wrong medication -"You were supposed to receive gentamicin, but you received ampicillin." -Please don't worry about anything, I am sorry you overheard that -No you did not receive the wrong med

"You were supposed to receive gentamicin, but you received ampicillin." The best response by the RN is to tell the truth

Upon completing the clients assessment, the nurse determines that the client has which surgical risk factors? (select all that apply) -Metoprolol -Poor appetite -Diabetes Mellitus -Albumin 3.0 g/dL -Marital status

- Metoprolol = has the potential to increase the risk of bradycardia when used in conjunction with anesthetics - Poor appetite = places the pt at risk for surgical complications d/t inadequate nutrition - Diabetes Mellitus = preexisting conditions, such as diabetes increase the client's risk for surgical complications Albumin 3.0 g/dL = low albumin places the client at risk for surgical complications

9. The TPN is prescribed to run at 75 mL per hour and is available in a 1000 mL bag. The nurse should anticipate that the TPN bag will be empty in how many hours?___________________(Enter numerical value only. If rounding is necessary, round to the whole number.)

13 Volume divided by rate = X 1000 divided by 75 = 13.33, round to 13 hours

The admission RN completes the admission assessment and starts an IV of 1000 mL normal saline prescribed to run over 10 hours. The drop factor on the tubing is 10 drops/mL (gtts/mL). At how many drops per minute (gtts/min) should the tubing be regulated to deliver the prescribed solution?

17 1000mL/600min x 10 gtts = 16.6 = rounded up to 17

Raymond's stool cultures are negative. After treatment with fluids and diet modification, his diarrhea resolves in 24 hours. Raymond's fluid balance is restored, and his oral candidiasis is resolving. The HCP is notified of Raymond's physical exam findings indicating possible dehydration and vital signs, including a blood pressure of 100/50. It is determined that Raymond could use a bolus of IV fluids. The HCP prescribes 1000 mL of normal saline to run over 6 hours. The drop factor tubing set is 15 drops/mL. How many drops/minute will the IV run? (Enter the numeric value only. If rounding is required, round to the whole number.)

42 1000/360 X 15 = 41.66 = 42 gtts/minute or 42 1000mL/6hr=166.67 166.67x15gtt=2499.99 2499.99/60min=41.67 ~ 42gtt/min

Raymond Malone is 5' 11" (180.3 cm) tall. He has a large frame and weighs 152 lbs (68.9 kg). His current body mass index (BMI) is 17.4. Raymond says he realizes he should eat, but he does not have the energy or the appetite, even when he has no oral pain. The nurse identifies the nursing diagnosis of, "Imbalanced Nutrition: less than body requirements." To achieve the goal of improving Raymond's nutrition the RN should preform which nursing interventions? A. Request a dietary consultation for Raymond to better assess Raymond's nutritional status and food preferences B. Monitor for oral thrush and diarrhea C. Weigh daily and record signs of wasting syndrome D. Request a prescription for TPN E. Instruct Raymond to focus on breakfast, the most important meal of the day

A + B + C Request a dietary consultation for Raymond to better assess Raymond's nutritional status and food preferences - Determining Raymond's food preferences is a good first step. It is essential that Raymond be an active participant in his care so he has some control. If a favorite food is not on the menu, it can be requested Monitor for oral thrush and diarrhea - HIV can cause profuse diarrhea, night sweats and decreased appetite due to yeast Weigh daily and record signs of wasting syndrome - Clients with HIV/AIDS or TB can lose weight. Wasting syndrome or cachexia can include redistribution of fat (lipodystrophy), hollow cheeks, or buffalo hump. -- While TPN may be needed, it is not the first intervention

Raymond develops severe diarrhea with occasional incontinence that could be caused by an opportunistic gastrointestinal infection or by one of his medications. While stool cultures are pending, other interventions can be initiated Which tasks should be delegated to the UAP? Select all that apply A. Weigh Raymond each morning before breakfast B. Measure the urine output C. Count and record the number of watery stools D. Assess Raymond's peri-rectal skin during incontinent care E. Check Raymond's skin turgor to determine if he is dehydrated.

A + B + C Weigh Raymond each morning before breakfast. - Weights can be obtained by the UAP Measure the urine output - Measurement of the urine output can be delegated to the UAP, who can then report to the nurse Count and record the number of watery stools -The UAP can legally count and record the number of watery stools. However, it is the nurse's responsibility to be aware of the client's condition and promptly report any significant changes to the HCP.

The nurse creates a plan of care for Raymond. The nursing diagnosis of Knowledge Deficit is used to describe what is needed during client education sessions with Raymond. Which statements by Raymond indicate that he understands why he is at risk for TB? (SATA) A. I realize my helper T cells are diminished from HIV. Those are the cells I need to fight TB B. I am at risk for developing TB bc I was born with a low # of helper T cells C. I guess living at a homeless shelter increased my chances of getting TB D. I realize I am at risk for developing TB bc I used IV drugs in the past E. I may get TB bc my viral load count is diminished

A + C I realize my helper T cells are diminished from HIV. Those are the cells I need to fight TB - HIV attacks the CD4 receptors on the helper T cells that help the body fight off diseases such as TB I guess living at a homeless shelter increased my chances of getting TB - The risks of acquiring the infection and of developing clinical disease depends on the infection's existence in the population, especially among persons residing in high-risk environments for the transmission of TB, such as correctional facilities, homeless shelters, hospitals, and nursing homes - Raymond may have been exposed to HIV and hepatitis virus from a contaminated needle, however the mode of transportation of the Myobacterium tuberculosis bacilli is thru respiratory secretions not blood-borne routes

Raymond's HCP has also prescribed the anti-tuberculosis regimen of rifabutin/isoniazid/pyrazinamide/ethambutol. What information is important to teach Raymond about the use of rifabutin/isoniazid/pyrazinamide/ethambutol? (SATA) A. Rifabutin stains urine, stool, saliva, sweat, and tears reddish-orange. B. Rifabutin/isoniazid/pyrazinamide/ethambutol have been known to cure HIV within months of taking it C. There's no need to wear sunscreen while taking these medications D. Liver function tests should be routinely conducted and monitored. E. Visual disturbances related to ethambutol therapy may develop during therapy, but may resolve once treatment is discontinued

A + D + E Rifabutin stains urine, stool, saliva, sweat, and tears reddish-orange - This teaching can help Raymond prepare for this side effect without anxiety Liver function tests should be routinely conducted and monitored - The major side effect of isoniazid, rifabutin, and pyrazinamide is drug-induced hepatitis. Therefore, Raymond must be taught the importance of having blood samples drawn to monitor his liver function Visual disturbances related to ethambutol therapy may develop during therapy, but may resolve once treatment is discontinued -Ethambutol is generally well tolerated. The most significant adverse effect is optic neuritis.

The nurse notices the UAP about to enter Raymond's room to deliver a meal tray without wearing any protective apparel. What information should the nurse provide the UAP? - Wearing a mask, gown, and gloves is required for healthcare workers entering Raymond's room for any reason - A mask is required for healthcare workers entering the room of someone suspected of having active TB - The UAP will only be in the room for a brief moment so no intervention is needed - Non-sterile gloves are necessary to deliver the meal and prevent the spread of TB

A mask is required for healthcare workers entering the room of someone suspected of having active TB TB is spread by airborne transmission of droplet nuclei. A specific fit tested, high-efficiency particulate air (HEPA) mask is necessary to filter the mycobacterium tuberculosis bacillus.

The ED nurse prepares to transfer Jeremy to the medical floor. 5. Which intervention should the nurse implement prior to transferring Jeremy to the floor? A. Insert a nasogastric tube and connect to low, intermittent suction. B. Assist with the insertion of an esophageal balloon tamponade tube. C. Attach a urometer to a drainage bag and insert a 16-gauge Foley catheter. D. Schedule Jeremy for endoscopic retrograde cholangiopancreatography (ERCP).

A. Nasogastric suction is used to relieve nausea and vomiting, to decrease painful abdominal distention and paralytic ileus, and to remove hydrochloric acid so that it does not enter the duodenum and stimulate the pancreas. -Schedule Jeremy for endoscopic retrograde cholangiopancreatography (ERCP). = This diagnostic test is not scheduled when the client has an acute exacerbation of pancreatitis it is performed to rule out chronic pancreatitis after recovery from an acute attack and plays a role in the management of clients with acute or chronic pancreatitis - Assist with the insertion of an esophageal balloon tamponade tube = this procedure is used to treat esophageal bleeding secondary to liver failure -since he is able to urinate on his own there is no reason to put him through the trauma of inserting a large bore Foley catheter

The nurse continues teaching Jeremy about administration of the enteric-coated pancreatic enzyme. 21. Which additional instruction regarding the use of pancrelipase (Cotazym) is important for the nurse to include? A. Take the medication with meals or snacks. B. Chew the medication 30 minutes before eating. C. Spread the capsule crystals over food and chew thoroughly. D. Swallow the capsule twice a day in the morning and at bedtime.

A. Pancrelipase (Cotazym) enhances the digestion of starches and fats in the GI tract by supplying an exogenous source of the pancreatic enzyme. This medication promotes nutrition and decreases the number of bowel movements. -Chew the medication 30 minutes before eating = Enteric coated medication should not be crushed chewed or mixed with alkaline foods such as milk and ice cream -Spread the capsule crystals over food and chew thoroughly = if the pancreatic enzymes are not enteric coated they may be spread over the food however if the capsules contain enteric coated Spears they should be taken with liquids or small amounts of soft foods such as applesauce or jello that do not require chewing - Swallow the capsule twice a day in the morning and at bedtime = the medication should be taken before or with meals to be most effective

After receiving further explanation by the HCP, Jeremy signs the procedure permit form; and the nurse then completes the pre-procedure assessment. After the nurse completes the assessment, Jeremy undergoes the ERCP without any problems. 16. Which question should the nurse ask Jeremy prior to the ERCP? A. When was the last time you had anything to eat or drink? B. When was the last time you had a bowel movement? C. Have you consumed any alcohol in the last 48 hours? D. Do you have any difficulty swallowing or chewing?

A. To reduce the risk of aspiration, clients should not have anything to eat or drink for at least 8 hours prior to the procedure. -The others are not pertinent to having an ERCP

Judy is at increased risk for the development of which problem if she chooses peritoneal dialysis as a course of treatment? - hepatitis B&C - hypertension - abdominal infection - osteoarthritis

Abdominal infection = peritoneal dialysis places the client at high risk for peritonitis since the catheter and fluid entered the peritoneal cavity. the client must be heparinized during hemodialysis therefore bleeding is a more likely potential complication than thrombosis - hepatitis B&C = clients on hemodialysis are at a greater risk for contracting hepatitis B&C then clients on peritoneal dialysis because of the equipment used in hemodialysis. hepatitis B vaccine is encouraged for clients with CKD - hypertension = the client is at risk for developing hypotension during treatment due to the fluid being removed. nausea vomiting diaphoresis, tachycardia and dizziness are common signs of hypotension - osteoarthritis = osteoarthritis is not a potential complication of hemodialysis

Raymond assures the nurse that he will use a condom with each sexual encounter. He also expresses concern that he may become dehydrated again - Access to a nurse on a hospital unit - Meals on Wheels - Access to the services of a registered dietitian - HIV/AIDS support group

Access to the services of a registered dietitian It is essential that the nurse arrange a consult for Raymond with a registered dietitian before Raymond is discharged home. The dietitian will give Raymond specific information on suggested foods and liquids to include in his diet to help prevent dehydration if diarrhea occurs at home. The registered dietitian will provide Raymond with resources, such as a phone number, that will give him access to the dietitian on an outpatient basis.

The nurse assessing the client's carotid artery reports no pulse is found. What is the nurse's priority action? -Hug the client's spouse -Activate a code -Begin compressions -Shock the client's chest

Activate a code -Begin compressions = will begin after a code is activated

Which explanation best describes the pathology resulting in her hypertension? -An increase in the excretion of sodium and water from the kidneys causes hypertension -activation of the renin angiotensin cycle and excretion of aldosterone causes hypertension -the increase of uremic waste products in the bloodstream increase the blood pressure -irritation of the pericardial lining of the heart due to uremic toxins increases the blood pressure

Activation of the renin-angiotensin cycle and excretion of aldosterone causes hypertension = the renin angiotensin cycle causes vasoconstriction of the periphery which increases the blood pressure. in addition the excretion of aldosterone causes the retention of sodium and water further increasing the fluid volume which increases the blood pressure - An increase in the excretion of sodium and water from the kidneys causes hypertension = hypertension would be caused by an increase in the retention of sodium and water rather than an increase in the excretion - the increase of uremic waste products in the bloodstream increase the blood pressure = this is the probable cause for gastrointestinal manifestations such as anorexia, nausea and vomiting -irritation of the pericardial lining of the heart due to uremic toxins increases the blood pressure = explains the cause of pericarditis

Thirty minutes after ending the code, Mr. Azizi succumbs to his illness. His spouse is crying uncontrollably. She begins to talk about how she is going to have a hard time without her husband of 30 years. What is the nurse's most therapeutic response? -Begin postmortem care -Inquire about the couple's children -Actively listen as she speaks -Contact the hospital chaplain

Actively listen as she speaks -Begin postmortem care = In the Muslim religion, post mortem care is performed in a ritualistic manner, and by a person of the same sex as the deceased individual

Which action should the nurse implement first? - Convert the IV to a saline lock - remove the indwelling catheter - administer an analgesic - change the surgical dressing

Administer an analgesic = this intervention will reduce the clients pain and anxiety it will also reduce discomfort when other procedures such as addressing change are performed - Convert the IV to a saline lock = converting the IV to saline lock is a low priority at this time - remove the indwelling catheter = this action is a low priority and one that can increase the clients discomfort temporarily as the catheter is pulled from the bladder it should be deferred until the client's higher priority need has been addressed - change the surgical dressing = since only the tape is loose this is not the highest priority intervention

Based on the nurse's assessment, which is the priority nursing action? -Give acetaminophen -Administer morphine -Monitor urine output -Assess mental status

Administer morphine = the priority is to administer pain medication for severe pain - acetaminophen = Administered for mild pain - UO is currently sufficient for the time frame (shown as 400mL) - Mental status has already been assessed there's no indication to reassess (drowsy but AOx3)

The nurse is caring for the client who has just been extubated. What should the nurse do first, after the client is extubated? -Administer supplemental oxygen -Auscultate bilateral lung sounds -Encourage cough and deep breathing -Notify the spouse of extubation

Administer supplemental oxygen - allows for adequate perfusion -Encourage cough and deep breathing = are important to prevent atelectasis but another action takes priority

Which instructions should the nurse give Judy? - take her prescribed diuretic and analgesic and record when she voids - increase her fluid intake and report any increase in her weight - advise her to come to the clinic right away for further evaluation - monitor her temperature and report a fever over 101 degrees F

Advise her to come to the clinic right away for further evaluation = she is experiencing symptoms consistent with organ rejection she needs immediate assessment and evaluation for this potentially fatal complication. the nurse should assess for kidney pain oliguria and anuria hypertension lethargy fever and fluid retention as well as an increased serum BUN creatinine and potassium - for the others = she is experiencing symptoms that require a different intervention - temperature and report a fever over 101 degrees F = the presence of a fever requires further investigation by the nurse because it can be a symptom of both infection and rejection which are treated very differently

Which nursing intervention is most helpful to Mrs. Tanner? Refer to a psychologist to discuss fears about surgery Tell pt its okay to be scared and hold their hand Ask Mrs. Tanner if she would like to talk to someone who has had this surgery. Give literature provided by the American Cancer Society

Ask Mrs. Tanner if she would like to talk to someone who has had this surgery. Pt may feel more comfortable talking to someone who has undergone the same procedure - can ask them questions and express their fears

What intervention should the nurse implement? -administer the prescribed tablet -request a faxed copy of the prescription -obtain the name of the office nurse - ask to speak directly to the HCP

Ask to speak directly with the HCP = the medication prescription is unsafe and requires direct communication with the prescribing HCP -administer the prescribed tablet = this is an unsafe intervention since the client's serum potassium is elevated -request a faxed copy of the prescription = requesting a written copy of a prescription is always desirable but in this case will only confirm an unsafe prescription -obtain the name of the office nurse = this is an appropriate action but it is not the most important action at this time

Using the American Heart Association's Basic Cardiac Life Support (BCLS) algorithm, what is the nurse's priority action? -Assess carotid artery -Monitor mental status -Check blood pressure -Determine heart rhythm

Assess carotid artery -Determine heart rhythm = its already known to be VTach

before the nurse can notify the HCP of the ABG results, that are telemetry monitor starts to alarm indicating ventricular tachycardia What is the nurse's first action? -Call the rapid response team -Activate a code -Assess the client -Monitor telemetry

Assess the client

Which interventions are important to include in Judy's plan of care while she is receiving multiple immunosuppressants? A. reinforce but do not routinely change any dressings B. educate patient to avoid consumption of grapefruit or grapefruit juice C. instruct visitors that fresh flowers should not be taken into the room D. change the IV site daily E. restrict patients activity to bed rest with the use of the bedside commode

B + C Educate Judy to avoid consumption of grapefruit or grapefruit juice = grapefruit/grapefruit juice potentially increase the blood concentration of cyclosporine Instruct visitors that fresh flowers should not be taken into the room = fresh flowers plants and fruits or source of bacteria and should be restricted from the client's room in addition visitors should be restricted to healthy adults and extra precautions should be taken to avoid sharing hospital equipment and to ensure a clean room environment - reinforce but do not routinely change any dressings = dressing should be changed regularly which allows inspection of the wounds for signs of infection strict aseptic technique should be used to reduce the risk of infection - change the IV site daily = although the IV site should be monitored frequently for signs of phlebitis and infection site changes should be performed following CDC guidelines excessive IV starts can be a source of infection - restrict patients activity to bed rest with the use of the bedside commode = since the patient is at high risk for infection activity and mobility should be encouraged to prevent the complications of immobility such as atelectasis and pneumonia the patient should be assisted with mobility as needed since they are also at risk for injury

An acid-fast-bacilli (AFB) stain is part of the initial admission prescriptions. Early morning sputum specimens will be collected for three consecutive days and sent onto the lab. Which tasks may the nurse delegate to the UAP? (SATA) A. Allow the UAP to teach the pt how to cough to obtain the sputum from deep in the bronchi B. Have the UAP tell Raymond that the specimen must be collected in the early morning C. Provide Raymond with three sterile specimen cups at his bedside D. Ask the UAP to assess the pt's ability to expectorate a sputum specimen E. Document the time and date that each sputum specimen was collected

B + C + E Have the UAP tell Raymond that the specimen must be collected in the early morning Provide Raymond with three sterile specimen cups at his bedside Document the time and date that each sputum specimen was collected - This task may be safely delegated. However, it is the nurse's responsibility to ensure that the documentation is completed and sent with the specimen to the lab.

Which intervention should the nurse include in Judy's plan of care? A. empty and record the drainage from the graph tubing regularly B. perform sterile dressing changes at the dual lumen catheter site C. instruct lab personnel to obtain blood specimens from the dual lumen catheter D. regularly rotate IV insertion sites above and below the graph site E. assess patients distal pulses in circulation in the arm with the access

B + E Perform sterile dressing changes at the dual-lumen catheter site = central vein insertion sites are major sources of nosocomial infection, and they should be cleaned weekly using a strict aseptic technique Assess pt's distal pulses and circulation in the arm with the access = ischema occurs in a few patients with vascular access when the fistula decreases arterial blood flow to areas below the fistula (steal syndrome). manifestations vary from cold or numb fingers to gangrene. if the collateral circulation is poor the fistula may need to be surgically tied off and a new one created in another area to preserve extremity circulation - empty and record the drainage from the graph tubing regularly = the graft tubing is internal and there is no attached external drainage device. the surgical site should be assessed for bleeding - instruct lab personnel to obtain blood specimens from the dual lumen catheter = this is not a safe intervention hemodialysis catheters are heparinized following dialysis treatments to prevent catheter thrombosis and they require the removal of this heparinized solution using a strict aseptic technique. use of these catheters between treatments for medication administration or blood samples is not advised due to the high risk for complications - regularly rotate IV insertion sites above and below the graph site = the extremity with the graft should not be used for venipuncture (starting IVs or drawing blood) or for blood pressure assessment

Jeremy, 47-years-old, is admitted to the emergency department (ED) reporting severe abdominal and back pain. He has been vomiting for the last 24 hours. Jeremy was diagnosed with chronic pancreatitis 2 years ago, and this is his fourth admission for an acute exacerbation of pancreatitis. He is the owner of a construction company, which is a highly stressful job. He has been married for 25 years and has two grown children.

Background for Chronic Pancreatitis HESI Case Study

Which additional assessment finding is consistent with ESRD? A) Clay colored stool b) tall tented T waves on c) electrocardiogram d) decrease attention span e) stridor f) yellow Gray pallor

B, D, F Tall tented T waves on electrocardiogram = potassium excretion occurs mainly through the kidney. any increase in potassium load during the later stages of CKD can lead to hyperkalemia (high serum potassium levels) Decreased attention span = problems ranging from lethargy to seizures or coma which may indicate uremic encephalopathy Yellow-gray pallor = the client with ESRD often exhibits a yellow Gray pallor as the result of anemia and uremia. in addition the client with ESRD may exhibit other skin manifestations such as bruising and uremic frost (a very late manifestation) - Stridor is a crowing respiratory noise due to bronchoconstriction it is not an expected finding in ESRD - Clay-colored stools = not a manifestation seen in ESRD

Discharge Teaching After Jeremy receives TPN for 3 days, his nasogastric tube is removed. He is started on a clear liquid diet, which he tolerates without pain. The HCP plans to remove Jeremy's diet restrictions gradually, decrease the TPN, and discharge Jeremy within the next 2 days. 13. Which nursing intervention has the highest priority when preparing Jeremy for discharge? A. Discuss the need to avoid spicy foods. B. Explain the importance of alcohol abstinence. C. Refer Jeremy to Alcoholics Anonymous (A.A.). D. Instruct Jeremy to eat a high-carbohydrate, low-fat diet.

B. Alcohol intake is the number one cause of an attack of acute pancreatitis, and continued use will do further damage to the pancreas. Since Jeremy was consuming alcohol daily, this intervention has the highest priority. -Discuss the need to avoid spicy foods = Spicy foods increase pancreatic and gastric juices but a discussion about spicy foods is not the most important intervention to help prevent another acute pancreatic attack -Refer Jeremy to Alcoholics Anonymous (A.A.) = a support group to help him quit drinking is an appropriate intervention but a referral is not the most important intervention -Instruct Jeremy to eat a high-carbohydrate, low-fat diet = this is an appropriate diet for him because these foods increase caloric intake without stimulating pancreatic secretions however instruction regarding his diet does not have the highest priority

17. What intervention has the highest priority when caring for Jeremy after the procedure? A. Monitor the client's IV fluids. B. Assess the client's pulse and blood pressure. C. Check the client's abdomen for pain and tenderness. D. Evaluate the client's hemoglobin and hematocrit. Jeremy does not experience any complications secondary to the ERCP and is discharged home with his wife. He has a follow-up appointment in 2 days with his HCP to discuss the results of the ERCP and the treatment plan.

B. Because esophageal and/or duodenal perforation can occur during the procedure, monitoring the client for manifestations of hypovolemia has the highest priority. -Monitor the client's IV fluids = He will be receiving IV fluids but monitoring fluids does not have the highest priority when providing post procedure nursing care -Check the client's abdomen for pain and tenderness = assessing the abdomen is an appropriate intervention but it does not have the highest priority -Evaluate the client's hemoglobin and hematocrit = evaluating his Hbg and HCT is an appropriate intervention but does not have the highest priority

Therapeutic Communication The nurse is concluding the teaching session when Jeremy asks, "Am I going to die if I keep drinking?" 26. How should the nurse respond to Jeremy's question? A. "You sound as if you are afraid you may die from this disease." B. "Jeremy, if you don't stop drinking, this disease may kill you." C. "I can't answer that question; no one can answer it." D. "Why are you concerned about that now?"

B. Chronic pancreatitis is a serious disease that can lead to disability and death. Since the risk of premature death may be reduced if abstinence from alcohol is maintained, the nurse should give Jeremy a straightforward answer in response to his question. -I can't answer that question; no one can answer it = the RN can answer and should do so in a caring and straightforward manner - You sound as if you are afraid you may die from this disease = Although this is a reflection of the clients statement and is a therapeutic technique the nurse is assuming that he is afraid so this is not the best response to his question -Jeremy, if you don't stop drinking, this disease may kill you = this response is likely to make him defensive and could be a block to further teaching or discussion

Assessment The nurse is completing Jeremy's ED admission assessment. 1. To support the admitting diagnosis of acute pancreatitis, which question should the nurse ask Jeremy? A. "Do you currently, or have you ever, smoked cigarettes?" B. "How often do you drink alcohol, and when was your last drink?" C. "What medications have you taken in the last 24 hours?" D. "Have you had any weight loss or gain in the last 6 months?"

B. Long-term use of alcohol is commonly associated with the development of chronic pancreatitis, and alcohol ingestion is the primary cause of an acute exacerbation of pancreatitis. - Have you had any weight loss or gain in the last 6 months? = weight loss is important but not a significant factor in the onset of an acute exacerbation - Do you currently, or have you ever, smoked cigarettes? = not a cause of an acute exacerbation of pancreatitis - What medications have you taken in the last 24 hours? = Corticosteriods, thiazide diuretics and oral contraceptive are associated with an increased indigence of the development of chronic pancreatitis, but taking one dose of the med in the last 24 hrs will not cause an acute exacerbation

Mr. Aaron Azizi is a 68-year-old Muslim male who is admitted to the medical-surgical unit with acute cholecystitis and is scheduled for a laparoscopic cholecystectomy in the morning. He is ambulatory without the use of an assistive device. His medical history includes hypertension (HTN) and type 2 diabetes mellitus (DM). His surgical history consists of an appendectomy in childhood and he reports no complications. He is independent and lives with his wife in a retirement community. Mrs. Azizi reports that Mr. Azizi has not eaten in the last two days due to nausea, vomiting, and abdominal pain.

Background for Advanced Cardiac Life Support (ACLS): Sepsis HESI Case Study

The nurse develops a plan of care for Jeremy. 7. Which intervention should the nurse include in the plan of care? A. Encourage the client to ambulate in the hall. B. Administer oxygen via nasal cannula. C. Irrigate the nasogastic tube every 4 hours. D. Keep the client's room humidified and warm.

B. Oxygen will help decrease the workload of the respiratory system and the tissue's utilization of oxygen. -Keep the client's room humidified and warm = The client should be placed in a cool comfortable room with air conditioning to help decrease the workload of the respiratory system and the tissues utilization of oxygen -Irrigate the nasogastic tube every 4 hours = the Ng tube should only be irrigated if it is clogged -Encourage the client to ambulate in the hall = the client should remain on bed rest to decrease body metabolism and reduce pancreatic and gastric secretions

The nurse continues to discuss strategies to prevent further attacks with Jeremy and his wife. 14. Which action should the nurse include when providing discharge teaching? A. Provide the client with a written list of high-protein snack foods. B. Discuss ways to deal with stressful situations and avoid stress if possible. C. Encourage daily exercise and teach the proper way to perform isotonic exercises. D. Teach Jeremy to limit coffee, tea, and colas to no more than 2 a day.

B. Stress stimulates the pancreas to secrete pancreatic enzymes. Effective management of highly stressful situations can help decrease inflammation of the pancreas. -Provide the client with a written list of high-protein snack foods = The client should be on a high carbohydrate low protein and low fat diet because these foods increase caloric intake without stimulating pancreatic secretions beyond the ability of the pancreas to respond - Encourage daily exercise and teach the proper way to perform isotonic exercises = daily exercise will not help prevent acute pancreatic attacks - Teach Jeremy to limit coffee, tea, and colas to no more than 2 a day = because coffee tea and cola is stimulate gastric and pancreatic secretions which may precipitate pain these drinks should be avoided altogether

Since Jeremy is asking questions and seems very interested in the discussion concerning complications of chronic pancreatitis, the nurse continues to talk about interventions that Jeremy can implement at home. 23. Which action should the nurse encourage Jeremy to take? A. Rest in bed as much as possible. B. Weigh weekly and report any significant weight loss. C. Increase fluid intake to 3-4 liters of water a day. D. Decrease the amount of dietary fiber.

B. Weight loss is a major problem for clients with chronic pancreatitis. It is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. -Increase fluid intake to 3-4 liters of water a day = Increasing fluids will not help prevent complications of chronic pancreatitis -Rest in bed as much as possible = since his last acute attack was more than three weeks ago he should be progressing to normal activity level -Decrease the amount of dietary fiber = decreasing the amount of fiber in the diet will not prevent complications and may lead to Constipation

Management The nurse, with the assistance of an unlicensed assistive personnel (UAP), is assigned to care for five clients, including Jeremy. 11. Which task can the nurse delegate to the UAP when caring for Jeremy? A. Change the subclavian site dressing. B. Obtain a blood glucose reading. C. Check placement of the nasogastric tube. D. Evaluate the 24-hour intake and output.

B. Clients on TPN should have their blood glucose levels checked every 4-6 hours. The UAP can perform this task, but the nurse must analyze the findings to determine if any action should be taken based on the results. - Evaluate the 24-hour intake and output = UAP's can obtain and calculate the client intake and output but are requires the expertise of the nurse to evaluate the intake and output to determine if it is normal for the client

Judy Harrison is a 38-year-old African American female with a long history of diabetes mellitus type 2 and hypertension. She has experienced renal insufficiency for the last two years. Her current medications include an angiotensin converting enzyme inhibitor (ACEI), a diuretic, and an oral hypoglycemic agent. She reports to the nurse at the clinic that she has lost her appetite and is very fatigued. She adds that she has to get up to go to the bathroom several times during the night and has trouble catching her breath at times. Her current weight is 114 lbs (51.7 kg). She is scheduled for diagnostic studies to evaluate for the onset of end-stage renal disease (ESRD).

Background for Chronic Kidney Disease HESI Case Study

Diagnostic Tests Three weeks after Jeremy is discharged home, he is admitted to the day procedure area for an endoscopic retrograde cholangiopancreatography (ERCP). When the nurse asks Jeremy to sign the procedure permit, he hesitates and states, "I don't understand why I need this procedure. I am not hurting anymore, so I think I want to cancel the test." 15. Which statement by the nurse provides the best response to Jeremy's comment? A. "The test will allow the HCP to visualize your pancreas." B. "I will contact your HCP to discuss this with you." C. "You are not sure you want to have this procedure." D. "The procedure is not done when you are hurting."

B. The procedure cannot be performed unless the client has been fully informed. Jeremy's comments indicate that he does not fully understand the need for the procedure, and it is the HCP's responsibility to explain the procedure to the client. -The test will allow the HCP to visualize your pancreas = It is correct that an ERCP permits direct visualization of the pancreas but this is not the best response by the nurse -The procedure is not done when you are hurting = although the nurse provides him with accurate information regarding the test not being performed when the client is experiencing an acute exacerbation this statement is not the best response to this situation -You are not sure you want to have this procedure = this is a therapeutic response but it is not the best response by the nurse in this situation

Raymond Malone, age 45 years admitted from his healthcare provider's office (HCP) to the acute care facility. Jeff was diagnosed HIV positive 2 years ago. His history includes fatigue, a productive cough, and weight loss. A tuberculosis(TB) test was administered in the healthcare provider's office. Admission prescriptions include "isolation precautions for suspected pulmonary tuberculosis."

Background for HIV + TB HESI Case Study

Mrs. Maureen Tanner is a 57-year-old housewife who has been happily married for 40 years and who has two grown children. She is active in her community, has sung in a local country and western club for 15 years, and has smoked approximately 1 pack of cigarettes a day for the last 35 years.

Background for Laryngeal Cancer HESI Case Study

After shocking the client's chest, what is the nurse's next action? -Administer another shock -Begin chest compressions -Initiate rescue breathing -Monitor heart rhythm

Begin chest compressions -Administer another shock = should be reassessed in 2 mins to determine if another shock is indicated -Initiate rescue breathing = not indicated during code for pulseless VTach -Monitor heart rhythm = should be reassessed in 2 mins to determine heart rhythm

Which assessment should the nurse perform to determine if the desired outcome of the captopril (Capoten) has been achieved? Blood pressure Intake and output apical pulse finger stick glucose

Blood pressure = captopril (Capoten) is an ACE inhibitor used as an antihypertensive agent -Intake and output = this would be an approximate assessment measure for a diuretic such as furosemide (lasix) but not for captopril - Apical pulse = this does not provide data as to the desired outcome of the captopril -finger stick glucose = this would be an appropriate assessment measure for a hypoglycemic agent such as glipizide (Glucotrol) but not for captopril

After listening to the nurse explain AA, Jeremy asks, "How much does it cost to go to these meetings?" 25. How should the nurse respond? A. "A nominal fee is charged for attending the meetings." B. "AA meetings are supported by nonmember contributions." C. "There are no dues or fees to attend the meetings." D. "Monthly dues encourage members to attend the meetings."

C. Although AA has a long-held tradition of being fully self-supporting, there are no dues or fees to attend the meetings. -there is no charge for AA meetings -AA meetings are supported by nonmember contributions = they dont take contributions from members or nonmembers

Nutritional Needs Four days after admission, Jeremy is still unable to tolerate any foods or fluids, so the HCP prescribes total parenteral nutrition (TPN). 8. Which intervention should the nurse implement prior to administering TPN? A. Assess the patency of the nasogastric tube. B. Restart Jeremy's IV with an 18-gauge angiocath. C. Assist the HCP with a subclavian line insertion. D. Consult with a registered dietician about the formula.

C. Because TPN has a high glucose content which exerts osmotic pressure that is injurious to the intimal lining of peripheral veins, it is administered into the vascular system through a central venous catheter, often inserted into the subclavian vein. -Consult with a registered dietician about the formula = The nurse does not need to consult with a registered dietitian regarding the TPN solution sent the TPN was prescribed by the HCP -Assess the patency of the nasogastric tube = TPN isn't administered thru an NG tube -Restart Jeremy's IV with an 18-gauge angiocath = TPN is not administered through a peripheral IV

Medication Teaching Jeremy's HCP has prescribed pancrelipase (Cotazym), a pancreatic enzyme, to help reduce the fatty, frothy, foul-smelling stools. Jeremy's HCP explains that his chronic pancreatitis is getting worse and that he needs to comply with the previous teaching as well as take additional medications. Along with pancreatic enzymes, Jeremy's HCP prescribes omeprazole (Prilosec). The nurse discusses the new prescriptions with Jeremy. 20. How should the nurse proceed when teaching Jeremy about this medication? A. Instruct Jeremy to let the tablet dissolve in his mouth. B. Advise Jeremy to check his stool daily for occult blood. C. Determine if Jeremy is allergic to any type of pork. D. Explain that joint pain may occur, but will resolve over time

C. Because pancrelipase (Cotazym) is made from the pancreas gland of a hog, the nurse should determine if Jeremy is allergic to pork products. - tablet should be swallowed not dissolved in mouth - There is no indication that he ever had blood in his stool and pancrelipase (cotazym) does not cause bleeding - although side effects are rare when pancrelipase (cotazym) is taken as directed if joint pain rash hives respiratory difficulty or hematuria occurs client should notify their HCP

Follow-Up Appointment At Jeremy's follow-up visit after the ERCP, the clinic nurse asks Jeremy if he is complying with his discharge teaching. He tells the nurse that he doesn't drink much alcohol and that he is trying to cut down on his smoking. He adds that he has quit drinking tea and cola, but he has to have his morning coffee. He tells the nurse his stomach hasn't been hurting too much, but he reports that his stools look fatty, appear bubbly and frothy, float on top of the water, and are extremely malodorous. 18. How should the nurse respond? A. "We need to get a stool specimen and send it to the lab." B. "Have you been eating any fatty foods in the last few days?" C. "This is common in persons with chronic pancreatitis." D. "This happens when you drink too much alcohol."

C. Clients with chronic pancreatitis have steatorrhea (fatty, frothy, foul-smelling stools) due to a decrease in pancreatic enzyme production. -We need to get a stool specimen and send it to the lab = There is no reason for the nurse to send a stool specimen to the lab -Have you been eating any fatty foods in the last few days? = fatty foods do not cause this type of stool -This happens when you drink too much alcohol = alcohol intake does not cause an abnormal appearance of the stools

Jeremy states, "I just don't know if I will be able to stop drinking. I have been drinking every day for the last 20 years of my life." 27. Which nursing intervention will be most beneficial in helping Jeremy and his wife plan for the future if he is unable to modify his lifestyle? A. Encourage Jeremy's wife to admit him to a substance abuse unit. B. Refer Jeremy for care to a home health care agency. C. Discuss the need to complete an Advance Directive. D. Suggest that Jeremy's wife attend Al-Anon meetings.

C. If Jeremy does not quit drinking, he will likely die from complications of chronic pancreatitis and alcohol abuse. Completing an Advance Directive will help Jeremy's wife so she won't be forced to make difficult decisions later on if Jeremy becomes unconscious or is dying and unable to speak for himself. -Encourage Jeremy's wife to admit him to a substance abuse unit = If he does not want to quit drinking admission to a substance abuse unit will likely not be very helpful -Suggest that Jeremy's wife attend Al-Anon meetings = attendance at AI-Anon meetings may be helpful to his wife but another intervention is of greater importance -Refer Jeremy for care to a home health care agency = he will not benefit from the services of a home health care agency at this time although home health care may be beneficial in the future

Emergency Department Nursing Interventions The ED nurse starts an intravenous (IV) infusion of D5 0.45 NS (normal saline) at 125 mL/hour with a 20 gauge angiocatheter in Jeremy's left forearm. Jeremy complains of severe abdominal pain rated "9" on a 0-10 numerical pain scale. Jeremy's abdomen is soft and tender in the upper quadrants, and there are bowel sounds in all 4 quadrants. 3. Which medication should the nurse expect to administer to relieve Jeremy's pain? A. Ondansetron (Zofran) 0.15 mg IV push diluted and administered over 15 minutes. B. Ranitidine (Zantac) IV piggy back administered over 30 minutes. C. Morphine 5 mg IV push administered diluted over 5 minutes. D. Promethazine (Phenergan) 25 mg deep intramuscular injection (IM).

C. Morphine is considered a first line opioid analgesic and one of the most commonly prescribed opioids for moderate to severe pain. Others include fentanyl (Duragesic), hydromorphone (Dilaudid), methadone (Metadol), and oxycodone (Percocet). -Promethazine (Phenergan). is an antiemetic agent that is prescribed to treat nausea and vomiting and not used to relieve acute pain. Deep IM Is the preferred route for Promethazine (Phenergan). it is very toxic to the vein and can cause severe tissue damage if extravasation occurs when given in a peripheral vein -Ondansetron (Zofran) is an antiemetic used to prevent nausea and vomiting associated with cancer chemotherapy and in the prevention of postoperative nausea and vomiting and is not an opioid needed for pain control but may be used in association with the administration of pain medication -histamine-2 antagonists are prescribed to decrease pancreatic activity by inhibiting stomach acid secretion, but Ranitidine (Zantac) will not help alleviate acute pain

Jeremy shares with the nurse that he has been drinking alcohol every day for the last few years and that he drank a little more than usual last night at a poker party at a friend's house. He also tells the nurse that he has smoked 2 packs of cigarettes a day for the last 20 years. To further evaluate Jeremy's condition, the health care provider (HCP) prescribes several laboratory tests. 2. Which laboratory data indicate that Jeremy is experiencing acute pancreatitis? A. Hemoglobin (Hgb) 12.9 g/dL and hematocrit (HCT) 42%. B. White blood cell count of 10,000/mm3. C. Amylase of 982 U/L and lipase of 400 U/L. D. Blood alcohol level of 1.0 mg.

C. Serum amylase and lipase levels can increase to an excess of 3 times their normal upper limits within 24 hours of an acute exacerbation of pancreatitis. Normal levels are amylase 23-85 U/L and lipase 0-60 U/L. - The hemoglobin and hematocrit are monitored to assess for bleeding but they are not used to diagnose pancreatitis - an elevated blood alcohol level does not support the diagnosis of acute pancreatitis - The WBC count may be elevated in clients with pancreatitis, but this WBC count is within normal limits

10. Which independent nursing action regarding the client's nutritional status should the nurse include when caring for Jeremy? A. Monitor his abdominal girth. B. Offer high-protein snacks frequently. C. Obtain and record a daily weight. D. Change the TPN IV tubing every 72 hours.

C. Short-term weight changes (over hours or days) accurately reflect the client's fluid balance which can be influenced by the pancreatitis; weight changes over days or weeks reflects the client's nutritional status. -Monitor his abdominal girth = the abdominal girth does not need to be monitored when a client is receiving TPN -Change the TPN IV tubing every 72 hours = because the Ivy tubing used for TPN is an excellent medium for bacterial growth due to the high glucose content of the solution it is changed with every bag -Offer high-protein snacks frequently = he has an Ng tube any oral intake must be prescribed by the HCP in conjunction with clamping the NG tube

The nurse is preparing to hang Jeremy's second bag of TPN. TPN bag #1 has finished infusing at 75 mL/hour, but TPN bag #2 has not been delivered from the pharmacy. The unit clerk calls the pharmacy and is told that TPN bag #2 is not ready. 12. Which action should the nurse take? A. Notify the charge nurse that the TPN bag #2 is not on the unit. B. Instruct the pharmacy to bring the bag to the floor immediately. C. Administer D10W via the infusion pump at 75 mL/hr. D. Hang D5W via the infusion pump at a keep-vein-open rate.

C. The TPN solution has high glucose content. If the solution is stopped abruptly, the client may experience rebound hypoglycemia. To prevent this, an available IV solution containing a high percentage of glucose should be infused at the same rate as the TPN solution until the next bag of TPN is ready. - Hang D5W via the infusion pump at a keep-vein-open rate = This will not prevent complications associated with abrupt removal of the TPM solution - Instruct the pharmacy to bring the bag to the floor immediately = TPN solutions are not premixed and they must be prepared carefully which requires adequate time and aseptic technique -Notify the charge nurse that the TPN bag #2 is not on the unit = the nurse can handle the situation without notifying the charge nurse

Nursing Interventions on the Medical Unit The nasogastric tube is draining green bile, and Jeremy reports that his pain is a "4" on the 0 to 10 pain scale. 6. Which intervention regarding positioning should the nurse implement to help alleviate Jeremy's pain? A. Ensure that Jeremy remains in a supine position. B. Place 6-inch blocks under the foot of the bed. C. Encourage side lying with legs drawn to chest. D. No specific position will help Jeremy's pain.

C. The pain from pancreatitis is caused by stretching of the peritoneum secondary to edema caused by the inflamed pancreas. Sitting up, leaning forward, or lying in a fetal position helps alleviate this pain. -Ensure that Jeremy remains in a supine position. = Should not lie flat in the bed because this position will increase pressure on the diaphragm due to the distended abdomen increasing the clients pain -No specific position will help Jeremy's pain =there are a number of different positions the client can try to help alleviate the pain -Place 6-inch blocks under the foot of the bed =elevating the foot of the bed will not help alleviate the pain experienced by the client with acute pancreatitis

The RN is discussing ADLs What instruction should the RN include? -Encourage the use of aerosol deodorants -Caution Mrs. Tanner to take only tub baths. -Explain the need to wear a plastic bib when showering -Advise not to wear any type of perfume

Caution Mrs. Tanner to take only tub baths. Because water could enter the stoma site and go directly into the lungs during showers, tub baths should be encouraged -Encourage the use of aerosol deodorants = should be discouraged since the spray could enter the stoma site -Explain the need to wear a plastic bib when showering = the stoma should be protected from water entering the site but a plastic bib could block the airway -- the client should wear a shower shield if showering -Advise not to wear any type of perfume = pt can wear perfume but she should not apply it near the stoma site

Which expected outcome should be included in the nurse's teaching plan? - Client will select foods high in iron and calcium from a menu - client will adhere to a low protein diet - client will identify the need to increase her sodium and fluid intake - client will identify the need to avoid fresh fruits and vegetables

Client will select foods high in iron and calcium from a menu = clients with CKD frequently suffer from anemia and hypocalcemia requiring dietary supplementation with iron and calcium - client will adhere to a low protein diet = generally clients on dialysis should not restrict protein in their diets they should consume as much high biological quality value (HQV) protein such as dairy eggs meats and fish as they can manage - client will identify the need to increase her sodium and fluid intake = the client receiving hemodialysis will more typically need to restrict sodium and fluid intake rather than increase the amounts consumed - client will identify the need to avoid fresh fruits and vegetables = because fresh fruits and vegetables provide much needed vitamins they do not need to be avoided however those fruits that are high in potassium should not be eaten in excessive amounts

The night RN is preparing to administer the midnight dose of antibiotic - an IV antibiotic that was started in the PACU is empty and labeled incorrectly and was not prescribed (med error) What action should the night RN implement? -Call the day RN to determine what occurred -Complete a medication error incident report. -Notify the pharmacist about the med error -Assess Mrs. Tanner's WBC count

Complete a medication error incident report. The night RN should complete a med error incident report to document this finding

Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa (Epogen) has been achieved? Conjunctival sac returns to a reddish-pink color Normo-active bowel sounds no evidence of edema consumed 100% of diet

Conjunctival sac returns to a reddish-pink color = this assessment finding reflects an improvement in the client's anemia. epogen stimulates the production of RBCs resulting in an increase in hematocrit it is used to treat the anemia common in clients with CKD -Normo-active bowel sounds = this is not an indicator for the desired outcome of epogen - no evidence of edema = this assessment finding is an indicator use to assess the effectiveness of a diuretic such as a furosemide (Lasix) but not epogen - consumed 100% of diet = this is not the best indicator that the desired outcome of a Epoetin has been achieved although an improvement in dietary intake may be a secondary benefit of a reduction in fatigue

Upon reviewing the remaining postoperative prescriptions and comparing with preoperative prescriptions, the nurse realizes that the metformin doses are different. What is the nurse's priority action? -Request medication from the pharmacy -Administer medication as prescribed -Contact the HCP for clarification -Add the new prescription to the medication administration record (MAR)

Contact the HCP for clarification = the nurse performs medication reconciliation to decrease medication errors. clarification when needed is a great way to advocate for patient safety and it is an important step to prevent errors -Request medication from the pharmacy = can lead to med error -Administer medication as prescribed = can lead to med error -Add the new prescription to the medication administration record (MAR) = can lead to med error

Long-Term Complications Jeremy and his wife did not realize how serious chronic pancreatitis can be even though they received some information when he was first diagnosed. 22. When the nurse is discussing the complications of chronic pancreatitis with Jeremy and his wife, which information should be included in the teaching? (Select all that apply.) A. The need to report any painful urinating or dribbling. B. The signs and symptoms of hypovolemic shock. C. The importance of checking bilirubin levels. D. The need to monitor blood glucose levels. E. That recurring attacks tend to become more severe in nature.

D, E Because diabetes mellitus can develop secondary to chronic pancreatitis, blood glucose levels should be monitored. Because recurring attacks tend to be more severe, it is important for the client to seek medical attention at the first signs of an attack. -The need to report any painful urinating or dribbling = Painful urination and dribbling urine or not signs of potential complications of pancreatitis these symptoms may indicate a UTI or prostate enlargement -The importance of checking bilirubin levels = altered bilirubin levels could indicate a complication from liver dysfunction rather than chronic pancreatitis -The signs and symptoms of hypovolemic shock = this is a complication that can occur with acute necrotic pancreatitis not chronic pancreatitis

The HCP writes admitting prescriptions for Jeremy. 4. Which diet should the nurse expect the HCP to prescribe for Jeremy? A. Regular diet. B. Low-fat diet. C. Clear-liquid diet. D. Nothing by mouth.

D. All oral intake is withheld to inhibit pancreatic stimulation and the secretion of pancreatic enzymes.

The nurse is aware that the older adult client is at an increased risk for surgical complications due to normal physiological functions and comobidities. Which risk factors place the older adult client at increased risk for surgical complications? -Decreased respiratory muscle strength -Increased glomerular filtration rate -Enhanced elasticity of the arterial walls -Rigidity of the arterial walls increases the clients risk for complications

Decreased respiratory muscle strength A decrease in respiratory muscle strength predisposes the order client to postoperative respiratory complications -Increased glomerular filtration rate = places the elderly client at increased risk for complications -Enhanced elasticity of the arterial walls = increases the client's risk for complications -Rigidity of the arterial walls increases the clients risk for complications = delayed gastric emptying ad motility increase post risk

When performing Raymond's morning physical assessment, the nurse discovers that he has a weak, rapid pulse, decreased skin turgor, and dry, sticky, oral mucous membranes. His weight is 2 lbs (0.91 kg) less than it was yesterday morning. What is the highest priority nursing diagnosis for Raymond? - Fatigue - Disturbed sleep pattern - Deficit fluid volume - Situational low self-esteem.

Deficit fluid volume A weak, rapid pulse; decreased skin turgor; dry, sticky, oral mucous membranes; and weight loss are signs of dehydration.

Which is the likely reason for the elevated serum creatinine in the absence of kidney disease? -Anemia -Hypertension -Increased pain -Dehydration

Dehydration Dehydration can temporarily increase creatinine - Anemia and pain have no effect on creatinine - HTN would be indicative of kidney disease

What is the best initial response by the nurse? - Going home often causes anxiety which can increase your pain - you have developed a tolerance to your pain medication - describe the location and type of pain you're having - the HCP will need to call you back later if you need more pain medication

Describe the location and type of pain you are having = the nurse must always assess first as complete data is needed to determine the nature of the problem and then to intervene appropriately - the others not the best responses since the nurse has not obtained adequate data to make this determination and the nurse first needs to obtain additional information before recommending contacting the HCP

Two days later, Mrs. Tanner is admitted to the hospital, accompanied by her husband and two grown children. She is in the preoperative holding area Which intervention will the RN implement? - Ask Mrs. Tanner if she has any concerns about the upcoming surgery - Determine if Mrs. Tanner has any problems hearing or writing. - Reassure Mrs. Tanner that her family can stay with her until surgery - Notify the surgeon that Mrs. Tanner has been admitted to the hosptial

Determine if Mrs. Tanner has any problems hearing or writing. A means of communication must be determined prior to surgery since Mrs. Tanner will not be able to speak following her total laryngectomy. An erasable communication board is usually used. if the client has trouble hearing or writing, this situation must be addressed and another means of communication should be determined. - Ask Mrs. Tanner if she has any concerns about the upcoming surgery = these concerns should have been addressed prior to admission - Reassure Mrs. Tanner that her family can stay with her until surgery = due to limited space and the need to prepare the client for surgery, usually only one person is allowed to stay in the holding area - Notify the surgeon that Mrs. Tanner has been admitted to the hospital = the surgeon is aware of the time that Mrs. Tanner is scheduled for surgery

The RN is completing the shift assessment and notes that Mrs. Tanner has white and dark brown patchy areas on her tongue and oral mucosa Which action should the nurse implement? -Determine when Mrs. Tanner received her last antibiotic - Assist Mrs. Tanner to gargle with warm, salty water -Notify the HCP during rounds -Document this finding and take no action

Document this finding and take no action. With cancer of the larynx, the inside of the mouth and the tongue may appear white, gray, or dark brown and may display a patchy pattern -Determine when Mrs. Tanner received her last antibiotic = in some situations, white patches in the mouth may indicate a superinfection, however even if this were the case, knowing the last dose of antibiotics isn't useful info - Assist Mrs. Tanner to gargle with warm, salty water = gurgling won't help treat the patchy areas -Notify the HCP during rounds = if the RN thinks that a medical intervention is needed, the HCP should be notified immediately - however this is a normal finding in a client w/ cancer of the larynx so no need to notify the HCP

What additional information in Judy's history may be related to the onset of ESRD? A) Hypertension B) Polycystic Kidney Disease C) Hysterectomy at age 35 D) Female gender E) African-American ethnicity F) Hypertension

E + F African American ethnicity = African American clients are more likely to develop ESKD and have hypertensive ESKD Hypertension Polycystic Kidney Disease = Polycystic kidney disease gene mutation will develop kidney cysts by age 30 half of these people develop CKD by age 50 -hysterectomy at age 35 = this is not a risk factor for CKD -Female gender = CKD does not seem to be more common in either gender -HTN = hypertension is one of the primary causes of CKD the vast majority of clients with CKD have hypertension which may be either the cause or the result of CKD

Which task should the RN delegate to the UAP? -Clean Mrs. Tanner's bathroom -Perform the routine trach care -Change the IV bad on the pump -Assist Mrs. Tanner with her bed bath -Empty the foley catheter and record the output

Empty the Foley catheter and record the output. Assist Mrs. Tanner with her bed bath.

Based on the client's respiratory assessment, which is the priority nursing action? -Encourage coughing and deep breathing -Prepare the client for intubation -Diagnose the client with atelectasis -Delay the chest x-ray until the morning

Encourage coughing and deep breathing = Client is exhibiting signs of atelectasis and must cough and deep breathe -Prepare the client for intubation = The client displaying signs and symptoms of atelectasis will not require intubation -Diagnose the client with atelectasis = Only advance practice RNs and other HCPs are authorized to diagnose -Delay the chest x-ray until the morning = delaying the chest X-ray is contrary to the "stat" prescription

Based on these diagnoses, which nursing intervention should be included in Judy's plan of care? -Encourage oral fluid intake -avoid any substances and intramuscular injections -encourage patient to ask questions and discuss fears about diagnosis -offer high protein snacks frequently

Encourage pt to ask questions and discuss fears about diagnosis = an open atmosphere that allows for discussion can decrease anxiety. facilitate discussions with family members about the prognosis and the impact on lifestyle -Encourage oral fluid intake = fluid restrictions will be instituted -avoid any substances and intramuscular injections = although the client with CKD is likely to bruise easily due to a reduction in platelets avoidance of injections is not necessary -offer high protein snacks frequently = protein is restricted to reduce the accumulation of waste products associated with protein metabolism which causes the manifestations of uremia

The RN is completing discharge teaching Which intervention has the highest priority prior to discharge? -Ensure that Mrs. Tanner carries a special identification card. -Encourage pt to wear attractive coverings over the soma -Stress the importance of returning to as normal a lifestyle as possible -Discuss the importance of attending support group meeting

Ensure that Mrs. Tanner carries a special identification card. The card is available from the Internation Association of Laryngectomees and instruct the reader in providing an emergency airway or resuscitating someone with a stoma, Life-sustaining issues always have the highest priority

The client remains in pulseless ventricular tachycardia and is unresponsive. The team intubates him and administers the second schock. What medication does the nurse anticipate administering after the second shock? -Atropine -Lidocaine -Epinephrine -Amiodarone

Epinephrine = the primary med administer used to increase C.O.

Mrs. Tanner is concerned about singing again and asks how long until she will be able to - How should the ONS respond? - Request that the oncologist visit the pt and explain the procedure again - Reassure the patient that they'll be able to sign again but their once will be different - Ask the patient if they understand what a total laryngectomy means - Explain that pts vocal cords will be removed and that they will not be able to sing.

Explain that Mrs. Tanner's vocal cords will be removed and that she will not be able to sing.

Raymond's significant other, Brandon, arrives. Raymond wants to know why a mask is necessary for people entering his room. What teaching should the nurse implement? - Explain the use of a private room and mobile high-effective particle filters placed in the room - Explain that the Tuberculosis(TB) organism is most often spread through the air. - Tell Raymond that TB will not be spread to others and everything will be okay if the mask is worn - Tell Raymond that masks are required for those who do not agree to receive the BCG vaccine

Explain that the Tuberculosis(TB) organism is most often spread through the air. When an infected person coughs or sneezes, they produce infectious droplets that can be breathed in by another person. This answer provides Raymond with the scientific rationale for wearing a mask. - The BCG (Bacille Calmette-Guerin) vaccine is not generally given in the US -- only given to a select people who meet specific criteria

Mrs. Tanner uses her erasable board to communicate to the staff that foods taste funny and she cannot smell anything. She's worried something is wrong. Which action should the RN take regarding Mrs. Tanner's concern? -Have pt smell a variety of aromas to ensure that the pt cannot smell -Explain to the client that this is normal following this type of surgery. -Reassure the pt that these senses will return after post-op edema subsides -Notify the HCP about this finding when making rounds

Explain to the client that this is normal following this type of surgery. This is a common, expected occurrence in pt's with a total laryngectomy bc a laryngectomy alters airflow, decreasing taste and smell perception. This info should be included I the pre-op teaching, and it may need to be reinforced post-op as well. -Reassure the pt that these senses will return after post-op edema subsides = this offers false reassurance to the pt

Judy's hemoglobin level is 7.8. Which underlying pathology does the nurse recognize as the cause of this abnormal lab value? -Fewer red blood cells are being formed -hematuria results in blood loss -renal waste products destroy red blood cells -dehydration causes dilutional anemia

Fewer red blood cells are being formed = hemoglobin is decreased as the kidneys become less able to produce erythropoietin necessary for the formation of red blood cells -hematuria results in blood loss = CKD does not result in hematuria -renal waste products destroy red blood cells = this does not occur in CKD -dehydration causes dilutional anemia = if dehydration occurred it would be likely to result in a high hemoglobin level rather than a low level

Raymond has been diagnosed with the opportunistic disease TB. He has experienced weight loss and has a CD4 cell count of 240 cells/mm3. The HCP moves Raymond from the HIV asymptomatic stage (CDC HIV Infection Stage 1) to the HIV Infection Stage 3 (AIDS). A UAP says, "Now that Raymond's condition has worsened and he has been moved to the HIV Symptomatic stage, shouldn't added precautions be posted on Raymond's door to protect staff members?" What information should the nurse give the UAP? - Following Standard Precautions will minimize the exposure to blood and bodily fluids - Reverse isolation precautions should be implemented to protect the staff - Respiratory precautions are all that are needed and those are already posted on the door - Staff caring for Raymond should begin prophylaxis medications

Following standard precautions will minimize the exposure to blood and body fluids Standard precautions are designed to prevent contact with blood or body fluids, which are the mode of transmission for HIV, and are used regardless of the stage classification of the disease.

In which case is the laboratory result consistent with blood loss through hemorrhaging? - Erythrocyte sedimentation rate 8 mm/hr - Hematocrit 40% - Red blood cell count 5.2 million/mm3 - Hemoglobin 11.3 g/dl

Hemoglobin 11.3 g/dl Normal hemoglobin for a female is 12.0g/dl - 15.0 g/dl -- 11.3 is consistent with blood loss thru hemorrhaging - Erythrocyte sedimentation rate 8 mm/hr = normal erythrocyte sedimentation rate is 1-20 mm/hr - Red blood cell count 5.2 million/mm3 = normal RBC count for females is 4.0 - 5.3 million/mm3 (4.7 - 6/1 for males)

Which intervention is most important for the nurse to implement? -Hold the dose of Key Ciel and contact the HCP to report the serum potassium level -calculate the millimeters of medication needed in record the amount on the fluid intake record - administer the dose of Key Ciel and document the serum potassium level in the medical record -ask the pharmacist to supply a tablet rather than an elixir since the patient is on fluid restriction

Hold the dose of Kay Ciel and contact the HCP to report the serum potassium level = the serum potassium level is elevated and administering additional potassium in any form is potentially dangerous to the client -calculate the millimeters of medication needed in record the amount on the fluid intake record = if the potassium level was within normal limits and the medication was given this would be an appropriate intervention however since the potassium level is high this is not the correct intervention - administer the dose of Key Ciel and document the serum potassium level in the medical record = this is not an appropriate intervention considering the client's elevated serum potassium level -ask the pharmacist to supply a tablet rather than an elixir since the patient is on fluid restriction = the HCP must be contacted regarding this change since the administration of this prescription would be unsafe for the client in any form there is another intervention that should be implemented

The home health RN is discussing the plan of care with the Tanner's. She instructs them to keep the rooms humidified at all times. Mr. Tanner asks why this is important Which explanation should the RN provide? -Humidified air will keep the mucous membranes and secretions moist. -It will help decrease the amount of foreign material that enters the stoma -Humidified air decreased the need for oral fluids -The lower airway responsibility for humidification was removed during surgery

Humidified air will keep the mucous membranes and secretions moist. With a trach, humidification of inspired air in the upper airway is lost. Humidifying the air helps maintain most mucous membrane and secretions, which promotes secretion removal by coughing or suctioning.

After giving report, the nurse transfers Mr. Azizi back to the MICU. Which of the client's signs and symptoms cue the MICU nurse to determine if the client continues to have sepsis? (Select all that apply) -Hypothermia -Altered mental status -Tachycardia -Leukocytosis -Tachypnea

Hypothermia = Sepsis is defined as a constellation of symptoms in response to an infection. it is characterized by a dysregulated client response like hypothermia defined as a core temperature < 97 degrees F Altered mental status = one of the constellation of symptoms in response to an infection. Characterized by restlessness, apprehension, and confusion Tachycardia = one of the symptoms of sepsis characterized by a heart rate > 90 beats/min Leukocytosis = it is important for nurses to recognize cues associated with sepsis such as Leukocytosis characterized by WBC > 12,000 Tachypnea =abnormally rapid breathing or tachypnea as a response to sepsis and characterized by respiratory rate > or equal to 22/min

How should the supervisor respond to the staff LVN who does not want to care for Raymond? - I understand. I will assign you another pt and give Raymond to another LVN - I understand your fears, but do you realize this will cause hardship on your fellow staff members? - I understand you want to protect your children. Please tell me your concerns regarding caring for a client with HIV - I understand your concern, but I am concerned about you losing your job over this

I understand you want to protect your children. Please tell me your concerns regarding caring for a client with HIV This response by the nurse supervisor demonstrates compassion and provides an opportunity to discover if education of the staff LVN is needed.

Before Raymond is discharged home, it is important that he understands how to prevent the spread of HIV. When discussing infection control practices with the nurse, Raymond says, "I have heard that condoms don't always prevent HIV." - If used correctly and consistently, latex condoms are highly effective in preventing the transmission of HIV - I will have an AIDS educator discuss condom use with you - I know you feel terrible if you passed HIV to someone bc you didn't use a condom - What's your source of info for condom failure

If used correctly and consistently, latex condoms are highly effective in preventing the transmission of HIV Raymond's misinformation and misunderstanding is a common myth regarding the effectiveness of latex condoms. Studies prove that condoms work.

Which is the primary reason for administering epinephrine 1mg every 3-5 minutes during a cardiac arrest? -Increases cardiac output -Causes massive vasodilation -Protects the kidneys -Treats dysrhythmias

Increases cardiac output -Causes massive vasodilation = epi causes vasoconstriction

A home healthcare RN has been assigned to care for Mrs. Taner and is making the initial visit. After completing the admission assessment, the RN develops a nursing care plan Of the nursing diagnoses included in Mrs. Tanner's care plan, which one has the highest priority? -Deficient knowledge -Ineffective airway clearance -Impaired verbal communication -Risk of complicated grieving

Ineffective airway clearance One week following surgery, some local tissue edema may remain and may interfere with airway latency; therefore impaired airway clearance is the priority. In addition, secreations that may be difficult to remove may also affect airway patency. (remember Maslow's Hierarchy of Needs"

What is the priority preoperative nursing action to prevent postoperative atelectasis? -Administer pain medication as needed -Instruct on incentive spirometer use -Obtain baseline pulse saturation -Turn and position every 2 hours

Instruct on incentive spirometer use The RN should teach the pt how to use an incentive spirometer in the pre-op period to help decrease risk of atelectasis. The RN should also ensure that learning has occurred through the client verbalization and return demonstration

The charge RN notices the primary RN caring for Mrs. Tanner is cutting a 4x4 gauze to use as a trach dressing What action should the charge nurse implement? -Praise the RN for using a cost-effective technique -Determine why commercially prepared dressing aren't being used -Instruct the primary nurse not to cut gauze for the tracheostomy dressing. -Take no action since Mrs. Tanner's care is the primary RN's responsibility

Instruct the primary nurse not to cut gauze for the tracheostomy dressing. Small strings from the gauze can be aspirated thru the stoma into the lungs. Folding the gauze into a V-shape and placing it under the trash tube is an acceptable technique, but not cutting the gauze

The client's spouse asks why the antibiotic is being delayed to obtain lab tests. What is the nurse's best response? -It improves the chance of identifying the bacteria that is making your husband sick -This is the order that the healthcare provider wants it done -The hospital's protocol is to collect cultures before administering antibiotics -The order of events does not matter as long as your husband receives the antibiotic

It improves the chance of identifying the bacteria that is making your husband sick = Collecting the cultures before ministering the antibiotic increases the likelihood that the microorganism will be identified and the appropriate antiinfective can prescribed. this response allows for change and learning to occur - the other explanations dont provide the spouse the reason why the lab tests are performed before administering antibiotic

Which explanation by the nurse is an accurate description of CKD? -There are frequent exacerbations since half of all nephrons are damaged -It is a fatal disorder unless renal replacement therapy is received. -The condition has a rapid onset with frequent remissions -symptoms are reversible with lifelong medication

It is a fatal disorder unless renal replacement therapy is received. CKD is fatal unless some form of renal replacement therapy dialysis or organ transplant is done whereas acute renal failure has a good prognosis for the return of kidney function if appropriate supportive care is provided during the acute. -symptoms are reversible with lifelong medication = chronic kidney disease is progressive irreversible kidney injury acute renal failure may be reversible with adequate supportive care during the acute episode -The condition has a rapid onset with frequent remissions = acute renal failure has a rapid onset but chronic kidney disease has a gradual onset occurring over months or years neither form of renal failure has frequent periods of remission -There are frequent exacerbations since half of all nephrons are damaged = half of all nephrons are often damaged in acute renal failure in CKD about 90% of nephrons are typically involved

Which action can be delegated to the unlicensed assistive personnel (UAP)? - administer an analgesic - convert the IV to a saline lock - measure the client's urinary output - change the surgical dressing

Measure the client's urinary output.

What is the correct interpretation of these ABGs? Metabolic acidosis (compensated) respiratory alkalosis (compensated) metabolic alkalosis (compensated) respiratory acidosis (compensated)

Metabolic acidosis (compensated) = an excessive bicarbonate is excreted, the HCO3 level decreases causing metabolic acidosis (decreased pH). compensation occurs when an increased rate and depth of respirations reduce the CO2 levels returning the pH to low normal - alkalosis would be indicated by an increased pH rather than decreased pH -respiratory acidosis (compensated) = this is a compensated acidosis but if it were respiratory in nature the CO2, would be elevated rather than decreased

Since Raymond now has thrush, in addition to fatigue and anorexia, which food best contributes to improving Raymond's nutrition? - Broiled steak - Milk shake - Tomato soup - Lettuce salad with raw vegetables.

Milk shake A milk shake is a nutrient-dense food. It provides needed calories, calcium, and protein. Raymond can drink the nutritious snack without using the energy it would take to eat a full meal. Raymond may find that the cool liquid is soothing to his sore mouth -- Although liquid soup is not difficult to eat and the warmth may be soothing -- the acidity of the tomato soup may be irritating to Raymond's mouth

Which intervention should be included in the plan of care during the immediate postoperative period? - monitor patients urinary output hourly using a urimeter - monitor patients nasal gastric tube every four hours - encourage patient to use the incentive spirometer daily - assess patient surgical incision every shift

Monitor pt's urinary output hourly using an urimeter = a kidney from a living donor related to the client usually begins to function immediately after surgery and may produce large amounts of dilute urine therefore the UO should be closely monitored - monitor patients nasal gastric tube every four hours = the client usually does not have an NG2 in place after the surgery if one is present it should be monitored more frequently then every four hours - encourage patient to use the incentive spirometer daily = patient should use the incentive spirometer at least every two to four hours to prevent complications from immobility such as pneumonia - assess patient surgical incision every shift = the surgical incision should be assessed at least every two hours in the immediate postoperative.

One hour has passed since the client was extubated. Which nursing actions take priority at this time? (select all that apply) -Monitor respiratory rate -Assess cardiac rhythm -Measure blood pressure -Compare bilateral pulses -Instruct on mouth care

Monitor respiratory rate = Assessing the client's respiratory indicates a tolerance of extubation. Seeing changes in the respiratory rate or cardiac rhythm allows the nurse to advocate for measures to improve respiratory status. assessing cardiac rhythm = provides indicators to tolerance of extubation. changes in respiratory rate or cardiac rhythm allows the nurse to advocate for measures to improve respiratory status. -blood pressure, mouth care and comparing pulses are not an indicators of the tolerance of extubation.

After reviewing the client's assessment data, what is the nurse's priority action? -Reassure the client's spouse that these results are expected -Administer lispro insulin SQ as prescribed -Administer po metoprolol as prescribed -Notify the HCP of the findings

Notify the HCP of the findings = Changing mental status is of concern, and is indicative of oxygenation issues HCP should be notified -Reassure the client's spouse that these results are expected = they're not expected -Administer lispro insulin SQ as prescribed = Insulin will need to be started oxygenation is priority -Administer po metoprolol as prescribed = metoprolol is not indicated at this time

Which intervention will the PACU RN implement first? Obtain vital signs Monitor pulse ox Check HCP's prescriptions Assess gag reflex

Obtain Mrs. Tanner's vital signs VS should be assessed first to establish baseline for the post-anesthesia period

Raymond is scheduled for several activities the following morning. Which activity should Raymond perform first upon awakening? - Weigh to determine if weight loss from the disease is continuing - Eat a nutritionally dense, early morning snack sent from the cafeteria - Obtain the first of three sputum specimens for laboratory testing - Take a shower and get ready to go form a chest X-ray

Obtain the first of three sputum specimens for laboratory testing Secretions collecting during the night provide the opportunity for the client to cough and expectorate upon awakening before performing other morning activities.

The nurse notifies the HCP, who prescribes nystatin (Nyamyc) 6 mL PO 4 times per day.What instruction should the nurse give Raymond about the use of liquid nystatin (Nyamyc)? What instruction should the nurse give Raymond about the use of liquid nystatin (Nyamyc)? -Place all of the suspension in the mouth, then swish and swallow immediately - Sip the suspension over 5 minutes, swishing and swallowing after each sip - Place the suspension in the mouth, then swish for several minutes before swallowing -Use the applicator to paint the medication on the infected sites and swallow the remaining dose.

Place the suspension in the mouth, then swish for several minutes before swallowing. This "swish and swallow" technique is the proper way to take liquid nystatin (Nyamyc). HCPs also recommend gargling, as well as swishing, prior to swallowing.

Mrs. Tanner;s gag reflex has returned, and she is preparing to ear her first meal Which action should the RN implement first? -Provide Mrs. Tanner with soft foods when she is eating for the first time after surgery. - Place cold packs around the neck prior to eating - Remind pt to place the food on the front of the tongue and to flex head backward to swallow -Ensure the pt has a variety of thin liquids to drink

Provide Mrs. Tanner with soft foods when she is eating for the first time after surgery. Soft foods are easier to swallow initially - Place cold packs around neck prior to eating = cold packs can decrease edema and constrict blood flow, but they are not helpful with swallowing or eating - Remind pt to place the food on the front of the tongue and to flex head backward to swallow = food should be placed o the back of the tongue with the head flexed forward -Ensure the pt has a variety of thin liquids to drink = liquids often cause the pt to choke, all thing liquids should be thickened slightly

Mrs. Tanner shares with the RN that she is worried that no one will help her if she needs help and that she will not be able to talk to anyone Which intervention should the RN implement? - Reassure Mrs. Tanner that someone will be with her at all times - Provide a bell that Mrs. Tanner can ring as another means of communication. - Tell Mrs. Tanner that while her fears are justified, she should try not to worry - Show Mrs. Tanner how to work the nurse's call light and have her perform a return demonstration

Provide a bell that Mrs. Tanner can ring as another means of communication. A bell provides a means of empowerment for the client. It can be used to ring into the call light, or the phone or to ring in the room to inform someone she needs something. It can also be used to answer questions: 1 ring for no or 2 rings for yes. The RN. should remember to ask Mrs. Tanner "yes/no" questions (rather than open-ended) when she speaks to Mrs. Tanner over the call light intercom

Mrs. tanner has a tracheostomy that has an inner cannula. The RN is preforming routine tracheostomy care. Which action should the RN implement first? -Cleanse the inner cannula using a small pipe brush -Pour hydrogen peroxide and normal saline into separate containers -Remove the tracheostomy dressing with clean disposable gloves. -Wash the flange of the outer cannula with normal saline

Remove the tracheostomy dressing with clean disposable gloves. The RN should remove the dressing first, set up sterile supplies, clean the stoma site and out cannula, and then remove and clean the inner cannula before replacing it -Cleanse the inner cannula using a small pipe brush = although cleaning the inner cannula is part of the routine, its not the first step -Pour hydrogen peroxide and normal saline into separate containers = although these salutation are used to cleanse the inner cannula, pouring the into sep containers isnt the first step -Wash the flange of the outer cannula with normal saline = this can be done after the inner cannula is reinserted into the outer cannula (not the first step)

pH = 7.50 PaCO2 = 30 HCO3 = 24 The nurse knows that the client is in which acid base imblanace? -Metabolic Acidosis -Respiratory Acidosis -Metabolic Alkalosis -Respiratory Alkalosis

Respiratory Alkalosis = An elevated pH with a decreased PaCO2

Which nursing diagnosis has the greatest priority when caring for a client receiving immunosuppressive agents? - Risk for infection - Pain - Fatigue - Diarrhea

Risk for infection = suppression of the normal immune response causes leukopenia that can reduce the client's ability to fight infection resulting in the potential for life threatening sepsis - Pain = immunosuppressive agents such as Imuran can cause arthralgia, but this is not the highest priority - Fatigue = immunosuppressive agents can cause fatigue but this is not the highest priority - Diarrhea = immunosuppressive agents such as cyclosporine can cause diarrhea but this is not the highest priority

What is the priority nursing diagnosis for Raymond at this time? - Imbalanced nutrition, less than the body's requirements related to medications side effects - Risk for social isolation related to worsening of condition - Risk for new opportunistic infections related to decreased immune function - Fatigue related to altered body chemistry

Risk for new opportunistic infections related to decreased immune function Since Raymond's immune system is no longer competent, he is at risk for additional opportunistic infections. Immune problems start when the CD4 cell count drops below 500 cells/mm3. Preventing infections is a basic need and is a high priority in the immunocompromised client.

Which lab value is likely to be decreased in a client with chronic kidney disease? -Serum K+ -Serum BUN and Creatinine -Serum Ca+ -Serum Phosphorous

Serum calcium = Serum calcium is decreased in CKD in response to an increase in serum phosphorus -serum potassium levels are increased in CKD as the kidney loses the ability to remove potassium from the body clients with CKD should be assessed carefully for symptoms of hyperkalemia - serum creatinine and BUN are tests which evaluate the removal of nitrogenous wastes by the kidney. Both are increased in CKD although BUN levels are directly impacted by protein intake hydration status and other factors - serum phosphorus is increased as less phosphorus is excreted by the kidney

Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate (PhosLo) has been achieved? Serum hemoglobin of 12 g/dL serum glucose of 90 mg/dL serum phosphorus of 4.0 mg/dL Serum hematocrit of 32%

Serum phosphorous of 4.0 mg/dL = calcium acetate (PhosLo) acts as a phosphate binder reducing the high serum phosphorus levels commonly found in the client with CKD -hemoglobin and hematocrit are not affected by the use of PhosLo - serum glucose of 90 mg/dL = this normal glucose level is managed with the clients glipizide (Glucotrol)

Because of the cancer, Mrs. Tanner is at risk for potential complications, such as neck wound fistula and a carotid artery blowout When anticipating these possible complications, the RN should place which equipment at Mrs. Tanner's bedside? -The ICU crash cart - A syringe filled with calcium gluconate - Two non-sterile hemostats - Several packages of sterile 4x4 gauze

Several packages of sterile 4x4 gauze If a carotid artery blowout occurred, the RN would need to apply direct pressure to stem the bleeding -The ICU crash cart = should remain centrally located - A syringe filled with calcium gluconate = this med isn't indicated for any complication that routinely occurs w/ a total laryngectomy -- it used to manage hypocalcemia, cardiac arrest, and cardiotoxicity due to hyperkalemia or hypermagnesemia. - Two non-sterile hemostats = these are often kept at the bedside for a pt with chest tubes

The code team arrives with the crash cart. The carotid artery is reassessed and there is still no pulse. Cardiac leads are placed and pulseless ventricular tachycardia is confirmed. Which is the priority nursing action? -Shock the client's chest -Administer epinephrine -Continue compressions -Escort the client's spouse out

Shock the client's chest

While assessing Mrs. Tanner, the RN notices that her BP is 92/60 and her pulse is 112. Mrs. Tanner reports feeling very tired Which action should the RN implement first? -Slip a gloved hand under the client's neck - Administer oxygen via a nasal cannula - Suction Mrs. Tanner's tracheostomy - Check the previous VS

Slip a gloved hand under the client's neck. Since the VS indicate possible hemorrhage, the RN should assess for bleeding. A common site or blood to pool following any type of throat surgery is behind the client's neck - Administer oxygen via a nasal cannula = Mrs. Tanner doesn't breathe thru her nose anymore -- the mask would need to be placed over the stoma site Suction Mrs. Tanner's tracheostomy = this would the the first intervention if the client was exhibiting signs of ineffective airway clearance - Suction Mrs. Tanner's tracheostomy - Check the previous VS = since the client's VS reflect hypovolemic shock, another interferon has more immediacy

A referral to which member of the interdisciplinary team will be most important for Mrs. Tanner prior to surgery? Social Worker Physical Therapist Case Manager Speech therapist

Speech therapist Mrs. Tanner will need to learn a new method of speech, which is taught by the speech therapist

Despite the team's efforts, Mr. Azizi remains unresponsive and the telemetry monitor shows asytole. Mrs. Azizi, who has been in the room the entire time, asks the team to stop. She can not bear to see her husband's chest "crushed" anymore. What is the nurse's next action? -Continue compressions -Escort the client's spouse out of the room -Stop coding the client -Document the spouse's remark

Stop coding the client

The client's spouse inquires about the client's blood sugar because she has never seen it that high, and she reports that the client isn't even eating. What is the nurse's best response? -I have sen higher. Do not worry -There are other things to worry about -Stress can increase blood sugars -The healthcare provider will discuss it with you

Stress can increase blood sugars = Stress and infection can cause hyperglycemia with or without food consumption. it is the nurses rresponsibility to teach the spouse and to ensure that the spouse learns the information via teach back

Which nursing intervention should the ICU RN implement? - Place Mrs. Tanner in the supine position with the bed flat - Remove the tracheostomy tube every shift to asses the stoma site - Discourage coughing for the first 24 hours - Support the client's head when moving the client in bed

Support the client's head when moving the client in bed. Head support reduces the strain on tissues in the operative area - Place Mrs. Tanner in the supine position with the bed flat = HOB should be elevated to promote effective breathing - Remove the tracheostomy tube every shift to asses the stoma site = trach must be left in place until the stoma site has healed - Discourage coughing for the first 24 hours = coughing should be encouraged to help remove secretions

Which statement describes esophageal speech? - Swallowed air is used to create sound and words in a controlled belch. - A handheld device delivers tone via a plastic tube that is inserted into the mouth - Vibration and sound are used to form words by occluding a valve over the stoma - A generator held to the neck creates vibrations that form words when the client speaks

Swallowed air is used to create sound and words in a controlled belch. The describes esophageal speech where clients "burp" swallowed air to form sounds into words using the palate, tongue, lips, and teeth. - Vibration and sound are used to form words by occluding a valve over the stoma = This is a description of TRACHEOESOPHAGEAL FISTUAL SPEECH for which a small one-way shunt is fitting into the fistula and occlusion of the valve forms words

What is the best description of an AV graft? - Synthetic tubing tunneled beneath the skin connecting an artery and a vein - central line tunneled catheter with a barrier cuff - external loop of synthetic tubing connecting an artery and a vein - internal surgical anastamosis between an artery and a vein

Synthetic tubing tunneled beneath the skin connecting an artery and a vein = these graphs can be placed in the arm or inner thigh and can be used within one to two weeks of surgery - central line tunneled catheter with a barrier cuff = this describes a soft flexible catheter that is tunneled under the skin and placed in the superior vena cava. this cuff keeps the catheter in place and serves as a barrier to infection - external loop of synthetic tubing connecting an artery and a vein = this describes an AV shunt which can be used immediately after insertion but since the advent of central line catheters shunts are no longer commonly used - internal surgical anastamosis between an artery and a vein = this describes an AV fistula typically located in the forearm which require prolonged healing (2-4 months) before use

Which action should the nurse take first? - Hold Raymond's breakfast tray to provide bowel rest - Perform oral care and moisten mucous membranes - Take Raymond's blood pressure to assess for postural hypotension - Notify the HCP of Raymond's weak, rapid pulse.

Take Raymond's blood pressure to assess for postural hypotension Postural hypotension can result from dehydration. Therefore, it is important for the nurse to obtain this vital information because it directly impacts Raymond's safety -- and this must be reformed prior to contacting the HCP

Mrs. Tanner writes on the white board that she is afraid of suffocating when she goes home since she has trouble coughing up the secretions from her lungs Which instructions should the RN provide to Mrs. Tanner? -Take a deep breath in through the nose, cough, and expel the secretions thru the trach -Take a deep breath, occlude the tracheostomy with your finger, cough, and remove your finger. -Insert a suction tube into the stoma while applying suction, then remove while twisting the tube -Inert a small amount of sterile normal saline into the stoma and cough in a normal manner

Take a deep breath, occlude the tracheostomy with your finger, cough, and remove your finger. This technique is called "glottal stop" which helps remove secretions -Take a deep breath in through the nose, cough and expel the secretions thru the trach = pt cant breath thru nose -Insert a suction tube into the stoma while applying suction, then remove while twisting the tube = suction shouldn't be applied when inserting the tube, only when removing -Inert a small amount of sterile normal saline into the stoma and cough in a normal manner = pt shouldn't insert liquid into the stoma since it goes directly into the lungs

What should the RN do before reinserting the inner cannula? -Remove the outer cannula, reinsert the inner cannula, and then place back into stoma -Tap or shake the inner cannula to remove excess moisture. -Clean it with hydrogen peroxide -Dry the outside of the inner cannula with non-sterile gauze

Tap or shake the inner cannula to remove excess moisture. This will help remove excess saline prior to inserting the cannula into the stoma in order to reduce the risk of fluid entering the lungs, Some sources recommend drying the inner cannula with sterile pipe cleaner, although this may damage the inner cannula - follow the organization's policy and procedure -Remove the outer cannula, reinsert the inner cannula, and then place back into stoma = the outer cannula should never be removed from the stoma site by the RN -Clean it with hydrogen peroxide = the inner cannula should be rinsed thoroughly with normal saline before reinserting into the outer cannula -Dry the outside of the inner cannula with non-sterile gauze = while cleaning the inner cannula sterility must be maintained

After 3 days, the nurse receives the results from Raymond's Tuberculin skin test that was administered at his HCP office. Even though Raymond's reaction to the TB skin test measures only 5mm in diameter, the HCP documents a positive test result. A new graduate nurse finds this confusing. The new graduate nurse thought a 10mm induration was the minimum size for a positive reading and asks the nurse preceptor for clarification. How should the nurse preceptor reply? - Let's ask the NP who specialises in caring for pt's who are positive for HIV - This confused me too, I think we should contact the HCP - That is not always true. A 5mm induration is considered positive for TB in a person with HIV - It may be that you are confusing induration with inflammation in skin testing results

That is not always true. A 5mm induration is considered positive for TB in a person with HIV The person with HIV has diminished T cell immunity, which compromises their ability to react to skin tests. Therefore, an induration of 5 mm is considered a positive reaction, rather than the standard of 10 to 15 mm for other groups.

A licensed vocational nurse (LVN) says to the nurse who is making assignments, " I do not want to be assigned to care for Raymond. I have never cared for a client with HIV and do not want to start now. I have a family at home that needs me." Which information should the nurse base a response about the LVN's right to refuse care for a client with HIV? - The LVN does not have enough experience to care for a pt who is on isolation and therefore may refuse to care for pt's with contangeous disease - Refusal to care or treat a person based on race, gender, or age is discrimination, which the federal government prohibits - The LVN may refuse to care for a client in circumstances in which risk to the nurse outweighs the nurse's responsibility to care for a client, or if the assignment conflicts with the nurse's ethical standards - The required staffing ratio of the licensed professional to client population does not allow for professional nurses to refuse care to a pt

The LVN may refuse to care for a client in circumstances in which risk to the nurse outweighs the nurse's responsibility to care for a client, or if the assignment conflicts with the nurse's ethical standards According to the ANA Code for Nurses, a nurse may morally refuse to participate in care, but only on the grounds of either client advocacy or moral objection to a specific type of intervention. Exceptions may be made when risk of harm outweighs the nurse's responsibility to care for a given client. For example, an immunosuppressed nurse may refuse to care for clients with certain infectious processes. The pregnant nurse may refuse to care for the client with HIV who has secondary infections such as toxoplasmosis or cytomegalovirus, both of which can cause severe damage or death to the fetus.

The unlicensed assistive personnel (UAP) asks why Raymond could not be in an empty semiprivate room closer to the nurses station so that the staff would not have to walk so far to provide care. What information should the nurse provide to the UAP on infection control services? - A private room is required to implement contact precautions for possible TB - The pt needs to be at the end of the hallway bc they require privacy - The pt needs to be at the end of the hallway for confidentiality - The implementation of airborne precautions for possible TB requires a private, negative pressure room assignment

The implementation of airborne precautions for possible TB requires a private, negative pressure room assignment. According to the Centers for Disease Control (CDC), in addition to isolating Raymond by using a private room, engineering controls can help to prevent the spread of TB. Controlling the direction of the airflow can prevent contamination of air in adjacent areas.

Raymond responds by agreeing to take his medications as prescribed. He then states, " However, I don't what good they will do. Do you?" The nurse should respond? - I honestly don't know, but I would give it a try. What's to lose? - Tell me about the experiences your friends had with these medications - You should talk to your HCP about your medications - The main purpose of these medications is to block the replication of the HIV virus

The main purpose of these medications is to block the replication of the HIV virus The purpose of the antiretroviral and inhibitor medicines is to block the replication of the HIV virus and prevent opportunistic diseases.

Which statement should serve as the basis for the nurse's reply? - state nurse practice acts indicate that the professional nurse should only administer legally prescribed medications - the nurses job description in most hospital policy manuals clearly states that adhering to the HCP's prescriptions is required - only the prescribing HCP is legally liable for the administration of a prescribed but unsafe medication - the professional nurse can be held accountable for the administration of any unsafe medication

The professional nurse can be held accountable for the administration of any unsafe medication. - state nurse practice acts indicate that the professional nurse should only administer legally prescribed medications = the nurse practice act in each state does establish the legal regulation of the practice of nursing however the issue in question is not the legality of the prescription but rather the safety - the nurses job description in most hospital policy manuals clearly states that adhering to the HCP's prescriptions is required = the nurse must use sound professional judgment to determine if a prescribed medication or treatment is safe and should collaborate with the prescribing HCP. in addition the nurse must be careful to act within the limits of the state nurse practice act and may not administer a Med or medical treatment without a prescription - only the prescribing HCP is legally liable for the administration of a prescribed but unsafe medication = this is an inaccurate statement liability extends beyond the HCP

What is the best response by the nurse? - This is a very difficult time for you and your family - don't blame the HCP's they're doing everything possible - your obvious anger will not help her now - why do you think the HCP's are at fault

This is a very difficult time for you and your family

Which documentation should the nurse enter into the nurses' notes? - health care provider notified of graft occlusion - bruit intact and palpated - +4 bounding pulse palpated - thrill present and palpated

Thrill present and palpated = this buzzing sensation indicates that the graph is patent in addition to palpating for a thrill the nurse should auscultate for a bruit which is the sound heard at a Peyton graph site as well As for intact pulses distal to the graph site - health care provider notified of graft occlusion = a palpable thrill in audible with stethoscope bruit over the graph site indicate that the graph is patent the nurse should also assess the pulse distilled to the gravesite to ensure adequate circulation - bruit intact and palpated = a bruit is the swishing sound heard when the graph site is auscultated this should also be assessed when the graph is palpated - +4 bounding pulse palpated = this sensation does not reflect the client's pulse although it is important for the nurse to assess the pulse distal to the graph

Before breakfast, the nurse brings Raymond the HIV medicines that are due. Raymond inquires about his other medications,stating, "I take all my HIV medications all at once before breakfast. I don't want to bother with taking medications all day long!" How should the nurse reply? - Okay I will give the rest to the UAP to bring in later - Were just trying to help you with the best care possible on this unit - To be most effective, HIV medications are prescribed on different schedules - We need your cooperation to help fight this disease

To be most effective, HIV medications are prescribed on different schedules Some HIV inhibitors need to be given on an empty stomach and some need to be given with food for best effectiveness. Many need to be taken around the clock, even if sleep is disrupted, to ensure drug efficacy."

Which nursing assessment has the highest priority during the first 24-hour postoperative period? - Range of motion - bowel sounds - pedal pulses - vital signs

Vital signs = vital signs should be monitored frequently to assess for post operative bleeding infection and organ rejection - the others are an important assessment but not the highest priorities, bowel sound should return w/in 24 hours, but again not highest priority

The nurse notices that Raymond has left most of his dinner untouched. The nurse offers to order something different for Raymond, but he replies that his mouth is sore and he just doesn't feel like eating. Which assessment finding by the nurse would be indicative of oral candidiasis, a common secondary infection in persons with compromised immune systems? - Blisters on the tongue or oral mucosa - Inflammation of the gums - Painless white lesions on the lateral surface of the tongue - White-yellow patches on the tongue or oral mucosa.

White-yellow patches on the tongue or oral mucosa.This sign is indicative of a Candida albicans infection. It is a common finding in people with HIV, and it frequently occurs with a falling CD4 cell count