Reduction of risk potential cards

Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. What should the nurse do first?

Determine whether the tube is obstructing the airway. If the gastric balloon should rupture or deflate, the esophageal balloon can move and partially or totally obstruct the airway, causing respiratory distress. The client must be observed closely. No direct action should be taken until the condition is accurately diagnosed.

The nurse is triaging trauma clients in an emergency room. Which clients are at risk for developing shock? Select all that apply.

a 16-year-old female with a large burn a 33-year-old male with spinal injuries

The nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed?

petrolatum gauze

The nurse caring for a multigravida in active labor observes a variable fetal heart rate deceleration pattern. What should the nurse do first?

Change the client's position.

Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. What should the nurse do first?

Determine whether the tube is obstructing the airway.

Three weeks after an infant receives a spica cast, the mother calls the nurse because the infant's toes are swollen and cool to the touch. What should the nurse instruct the mother to do? Place the child's legs in a lowered position. Have the child fitted for a larger cast. Inspect the area for an infection. Put more cotton wadding to line the casting.

Have the child fitted for a larger cast.

A nurse, who witnesses an accident involving an adolescent being thrown from a motorcycle, stops to help. The adolescent reports that he is now unable to move his legs. While waiting for the emergency medical service to arrive, what should the nurse do?

Leave the adolescent as he is, staying close by. The adolescent's signs and symptoms suggest a spinal cord injury. A client with suspected spinal cord injury should not be moved until the spine has been immobilized. Removing the helmet could further aggravate a spinal cord injury. The nurse could assess for abdominal trauma, but only if it can be done without moving the adolescent.

The nurse is caring for a dysphagic client who is receiving intermittent enteral feedings via a gastrostomy tube (G-tube). What action for the prevention of aspiration pneumonia will the nurse include in the plan of care?

Perform oral care every 4 to 6 hours.

The nurse is receiving a client in the operating room for an incision and drainage of the right thumb. What will the nurse do during the timeout procedure? Select all that apply. Obtain the client's medication history. Confirm the client's name band. Assess the client's dominant hand. Identify the correct surgical procedure. Review the surgical site marking of the right thumb.

Review the surgical site marking of the right thumb Identify the correct surgical procedure. Confirm the client's name band.

The nurse is performing client teaching about a percutaneous feeding tube to the caregiver of a 6-month-old client. The child's caregiver expresses concern about the child pulling on the tube. What would be an age-appropriate suggestion for the nurse to provide to the caregiver?

Suggest dressing the child in a one-piece bodysuit that snaps between the child's legs.

After a nasogastric (NG) tube has been inserted, which finding helps the nurse determine that the tube is in the proper place? A whooshing sound is auscultated when 10 mL of air is inserted. Thirty milliliters of normal saline can be injected without difficulty. The pH of the aspirated fluid is measured. The client is no longer gagging or coughing.

The pH of the aspirated fluid is measured.

A nurse is providing postprocedure instructions for a client who is to undergo a esophagogastroduodenoscopy. The nurse should begin this process

before the procedure.

A client has been diagnosed with septic shock. The nurse would anticipate implementing which order? intravenous dextrose in water at 75 mL/hour vital signs every 4 hours blood chemistry of serum lactate blood chemistry of AST, alkaline phosphates

blood chemistry of serum lactate

The nurse assesses a 6-month-old infant who is lethargic and suspected to be severely dehydrated. Which additional information is a priority for the nurse to determine?

blood pressure and capillary refill time

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should assess the client for which changes? hypothermia seizure cardiac arrhythmias hypertension

cardiac arrhythmias

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to:

instruct the client to rise slowly from a supine position.

A client with schizoaffective disorder is brought to the hospital by a family member. The family member states that the client is having an increase in auditory hallucinations and is becoming significantly more withdrawn. The nurse reviewing the admission blood work expects which blood level to be subtherapeutic?

lithium carbonate

A nurse assesses a client who has manifestations of peripheral intravenous extravasation. List the actions to take in order of priority. All options must be used.

Discontinue the intravenous tubing as close to the hub as possible. Notify the healthcare provider. Elevate the affected arm on pillows. Apply ice in short intervals to the affected site. Photograph the site with the client's written permission.

When administering a tube feeding to a client through a percutaneous feeding tube, how should the nurse position the client? Head of bed elevated 30 to 45 degrees Head of bed elevated 90 degrees Supine Left lateral decubitus position

Head of bed elevated 30 to 45 degrees The client should be positioned with the head of the bed raised 30 to 45 degrees to help prevent aspiration and promote gastric emptying. Having the head of the bed raised to 90 degrees would also help prevent aspiration, but is uncomfortable and not feasible for many clients being tube fed, particularly those that are critically ill or who receive continuous feedings. Lying a client supine while tube feeding should be avoided, because it increases the risk for aspiration and can lead to many negative outcomes. Side lying on the left side with the top leg bent at the knee would be the proper positioning for an enema or rectal examination, not a tube feeding, because it would also increase the risk of aspiration and should be avoided.

A nurse is caring for a client following transsphenoidal hypophysectomy and notes a watery discharge from the client's nose. Which action is appropriate for the nurse to take?

Test the drainage for a yellow "halo." Following transsphenoidal adenohypophysectomy, the client should avoid blowing the nose. The meninges require time to heal without the pressure of blowing the nose. If a cerebral spinal fluid leak develops, the client will experience persistent watery nasal drainage. Bruising, incisional pain, and swelling are all common events following surgery.

The nurse cares for a 4-year-old male client brought to the clinic with a rash. History The parent reports the client has not been feeling well for 2 days. This morning, the client developed itchy blisters over their trunk and in their mouth. The client now does not want to drink. The client has a history of a systolic murmur and atrial septal defect (ASD) repair with closure at 2 years of age. The client has done well since and is not on any routine medications. The other parent was deployed overseas 6 months ago, and the client goes to a babysitter full-time. There are three other children in the family, all under the age of 10. The parent is unsure of their immunization status. Vital signs are temperature 103°F (39.5°C); heart rate 120 bpm; respiration rate 30 breaths/min; and blood pressure 100/50 mm Hg. The client weighs 36 lb (16.3 kg). What finding(s) are most important for the nurse to follow up on? Select all that apply.

Temperature Rash Fluid intake Immunization status