Reduction of Risk/Physiological Adaptation (Week 3)

1st, 2nd, and 3rd line treatment for cholelithiasis

- 1st line- meds that dissolve gall stones: chenodeoxycholic acid / orsodeoxycholic acid - 2nd line- lithotripsy - 3rd line- cholecystectomy

Priority assessment before administering magnesium sulfate

- Deep tendon reflexes (normal is +2) - if DTR is low, give calcium gluconate instead of magnesium sulfate

Medications for decreasing ICP

- Mannitol - Dexamethasone - 3% NaCl

#1 complication of a liver biopsy and prevention

- bleeding - prevent by instructing client to lay on right side to apply pressure

normal color of peritoneal dialysis fluid

- clear - cloudy fluid indicates infection

signs and symptoms of peritonitis

- discolored drainage - abdominal pain - fever - rigid, board like abdomen

Pain in RUQ

- gallbladder (osmotic pain) - liver (dull pain)

Signs and symptoms of PAD

- intermittent claudication - cold extremities - pale/cyanotic extremities - no hair growth on distal extremities

Decreasing ICP

- keep HOB at 30 degrees - maintain head midline/neutral - minimize suctioning (when suctioning is needed, humidify oxygen and suction for < 10-15 seconds) - avoid coughing/blowing nose - insert indwelling catheter - give stool softeners - avoid fever (fever can increase ICP)

Pain in LUQ

- pancreas - stomach

Assessments when administering mannitol

- urine output - LOC

3 priority assessments for pregnancy-induced hypertension

1. BP 2. Edema 3. Proteinuria

stages of peritoneal dialysis

1. instillation 2. dwelling time

Normal fetal heart rate

120-160 bpm

When should you expect stool output following a bowel resection and colostomy placement

2-4 days

max amount of time to deliver PRBC

4 hours

Treatment for hypoglycemia if alert

4 oz of juice

A client with hypertrophic cardiomyopathy undergoes surgical placement of a dual chamber implantable cardioverter defibrillator (ICD). Prior to discharge, the nurse conducts teaching with the client. What client statement best indicates an understanding of their ICD? 1. "It is important to sit or to lay down if my ICD fires." 2. "I can lift objects as long as they are less than 20 pounds." 3. "I will avoid using the microwave to heat my food." 4. "I should leave the ICD identification card in my safe at home."

ANSWER: 1 - ICD delivers shock - Only lift objects 5 pounds or less - Microwaves are safe - Keep ICD card with you

The nurse is caring for a client with a Blakemore tube inserted for balloon tamponade of bleeding esophageal varices. What item does the nurse determine is most important to have available at the bedside? 1. Scissors 2. Atropine sulfate 3. Defibrillator 4. Arterial blood gas kit

ANSWER: 1 - risk for aspiration

The nurse on a medical-surgical unit is caring for a client who just returned from having an esophagogastroduodenoscopy (EGD) under moderate sedation. What client data is most essential for the nurse to obtain during the client's initial post-procedure assessment? 1. Check gag reflex 2. Monitor gastric pH 3. Auscultate bowel sounds 4. Assess stool characteristics

ANSWER: 1 Checking the gag reflex prevents aspiration

A client with bladder cancer has lost an estimated 500 mL blood in the urine. The client's hemoglobin is 8.0 g/dL, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should: 1. Attach the packed cells to the existing 19G I.V. of normal saline solution using Y tubing 2. Start an additional 22G I.V. site because the packed blood cells must be given in a separate line. 3. Attach the packed blood cells to the existing 18G I.V. of 5% dextrose using Y tubing. 4. Start an additional I.V. access device with a 21G Intracath.

ANSWER: 1 only use normal saline when giving blood products

A female client is diagnosed with cervical cancer and will undergo inpatient temporary internal radiation over the next 3 days. What interventions should the nurse include when planning this client's care? Select all that apply. 1. Assign the client to a private room. 2. Insert an indwelling urinary catheter. 3. Minimize staff contact with the client. 4. Utilize proper shielding equipment. 5. Provide client with a high-fiber diet

ANSWER: 1, 2, 3, 4 - Aim is to keep client in bed to prevent dislodging and minimize radioactive contact with others - Minimizing contact: private room, minimizing staff contact with the client, proper shielding equipment - Keep client in bed: urinary catheter, low fiber to prevent needing bathroom for bowel movement

The nurse is caring for a client receiving external radiation for breast cancer. The nurse is teaching the client about preventing skin complications from the radiation. What instructions are important for the nurse to review with the client? 1. Wear loose-fitting and soft clothing over the treatment area. 2. Use swimming pools to avoid exposure to stagnant water in lakes. 3. Apply skin products immediately after radiation treatments. 4. Wash area with lukewarm water and avoid washing off markings. 5. Apply an occlusive dressing over the treatment site every 3 days.

ANSWER: 1, 4

A client with suspected bacterial meningitis undergoes a lumbar puncture. What post-procedure prescriptions does the nurse anticipate the healthcare provider to prescribe? 1. Administer dexamethasone 4mg intravenously every four hours. 2. Place client in side-lying position for 3 hours after the lumbar puncture 3. Institute droplet precautions after cerebrospinal fluid culture results confirm diagnosis 4. Implement seizure precautions by padding side rails and having suction available 5. Monitor client's body temperature every hour for 4 hours, then once per shift

ANSWER: 1, 4 - dexamethasone treats inflammation - supine position - increased risk for seizures - VS should be monitored more frequently

The nurse is caring for a client using patient-controlled analgesia following an invasive procedure. The nurse enters the client's room and finds the client unresponsive with shallow respirations at a rate of four breaths/minute. What is the priority initial action of the nurse? 1. Apply oxygen using a face mask. 2. Begin bag-valve-mask ventilation. 3. Check respiratory rate for a full minute. 4. Turn the client on their left side.

ANSWER: 2

At 1200, the nurse assesses a client who experienced a myocardial infarction three days ago and notes the client is unusually fatigued and dyspneic. In caring for this client, what is the nurse's priority initial action? 1. Administer 0.4mg nitroglycerin sublingually. 2. Compare client's prior weight with current weight. 3. Continue to monitor client's vital signs every 4 hours. 4. Instruct client to take more frequent rest periods.

ANSWER: 2 - Common complication of an MI is heart failure. Check for fluid retention and changes in BNP.

A client with a pituitary tumor is scheduled to undergo surgery by a transsphenoidal approach for tumor removal. The nurse reviews postoperative instructions with the client. What postoperative instruction is most essential for the nurse emphasize? 1. "You must stay in bed and lie flat for 24 hours after your surgery." 2. "You must avoid coughing, sneezing, and blowing your nose." 3. "You must restrict your fluid intake following this surgery." 4. "You must report any ringing in your ears immediately."

ANSWER: 2 - can cause bleeding, increased ICP, CSF leak

A client receiving chemotherapy for metastatic colon cancer is admitted to the oncology unit due to several days of vomiting. Assessment findings include: irregular pulse of 120 per minute blood pressure 88/48 mmHg, respiratory rate of 14, serum potassium of 2.9 mEq/L, and arterial blood gas—pH 7.46, PCO2 45, PO2 95, bicarbonate level 29 mEq/L. Which of the following interventions is appropriate for the nurse to administer to the client? 1. Oxygen at 4L per nasal cannula. 2. Potassium 40 mEq PO now 3. 5% Dextrose in 0.45% Normal Saline with KCl 40 mEq/L at 125 mL/hour. 4. NaHCO3 75 mEq IV. Alkaline

ANSWER: 3 - Need to replace potassium - 02 is WDL - Nothing PO b/c pt is vomiting - Nothing alkaline b/c pt is in metabolic acidosis

A client is receiving an intravenous (IV) infusion of doxorubicin through a peripheral line at the outpatient center. The client reports pain at the peripheral IV site. What action is most important for the nurse to do first? 1. Apply a cold compress to the IV site. 2. Elevate the affected arm on a pillow. 3. Stop the doxorubicin infusion. 4. Flush the IV with normal saline.

ANSWER: 3 - never flush the line if pt is complaining of pain during chemo

The medical-surgical nurse is caring for a client who performs their own peritoneal dialysis. What assessment is most important for the nurse to make while the dialysis solution is dwelling in the client's abdomen? 1. Monitor client's electrolyte levels. 2. Assess for presence of urticaria. 3. Monitor for drainage at catheter site. 4. Observe client's respiratory status.

ANSWER: 4 - PD can cause compression of diaphragm and can lead to difficulty breathing

The nurse is caring for a client with a chest drainage system. The nurse notes that the chest tube has fallen out of the client's chest wall. What is the nurse's priority of care? 1. Notify the provider immediately. 2. Assess lung sounds and oxygenation. 3. Ask the client how the tube fell out. 4. Apply a dressing to the chest wall site.

ANSWER: 4 open hole will cause air to go into chest wall and lung will collapse

Priority action with evisceration

Apply gauze moistened with saline to the site

Treatment for hypoglycemia with decreased LOC

IV dextrose

Treatment for DKA

IV insulin and fluids

Grey colostomy stoma indicates:

Infection

Drug of choice for pregnancy-induced hypertension

Magnesium sulfate

diet with pancreatitis

NPO or low fat

Blue colostomy stoma indicates:

Poor perfusion

Colostomy diet

Resume regular diet gradually

Would a colostomy be more watery on the left or right abdomen

Right. Right sided colostomies are in the ascending colon whereas left sided colostomies are in the descending colostomy which has had more water removed.

positioning for pancreatitis

Semi Fowler to reduce risk of bleeding and promote lung expansion

Positioning with prolapsed umbilical cord

Trendelenburg (relieves pressure)

aplastic anemia

all blood cells are low

Pain in RLQ

appendix

Pain in LLQ

colon

Warning sign of seizures in eclampsia

epigastric pain

S/S of a perforated bowel after EGD

epigastric pain and dark, tarry stools

Positioning patients with PAD

extremities should be in dependent position to promote distal blood flow

Priority action with a boggy uterus

fundal massage

electrolyte imbalance in pancreatitis

hypocalcemia

vital signs in hypovolemic shock

hypotension, tachycardia

signs and symptoms of biliary obstruction

jaundice, pale/fatty stool, dark urine

Positioning for pregnancy-induced hypertension

left lateral position to promote uteroplacental circulation

diet with cholecystitis/cholelithiasis

low fat

Why is hydration important post lumbar puncture

must replace the fluid that was lost

early sign of hypocalcemia

numbness and tingling around the lips and fingers

Nursing priority in cholecystitis/cholelithiasis

pain

intermittent claudication

pain in the leg muscles that occurs during exercise and is relieved by rest

Biggest complication of peritoneal dialysis

peritonitis

Why is supine position indicated post-lumbar puncture

prevents CSF leak which causes spinal headache

If a chest tube is disconnect, what should the nurse do with the tube?

put the tip of the tube in water

teletherapy

radiation therapy administered at a distance from the body

Biggest risk factor for PAD

smoking

brachytherapy

the use of radioactive materials in contact with or implanted into the tissues to be treated

Blakemore tube

tube used in the management of upper gastrointestinal hemorrhage due to bleeding from esophageal varices

primary assessment before giving potassium

urine output

Causes of postpartum hemorrhage

uterine atony, lacerations, retained placental fragments,