UWORLD Fund #1
The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the best determinant that the goal has been met? 1. Chart audits found clients' self-reported pain scores improved by 10% 2. Number of narcotics used on the unit increased by 20% 3. Positive comments on returned client satisfaction surveys increased by 30% 4. Survey found that 90% of the nurses believed clients had better pain control
Explanation 1 Measurements should be objective, rather than subjective. Evidence-based criteria should be used, if applicable. These survey results are objective, retrospective measurements of a positive change. (Option 2) This increase in use could be attributed to many other factors, including difference in the number or type of clients on the unit and theft of the narcotics. In addition, clients may obtain pain relief by alternate means. (Option 3) These are subjective criteria. It is possible to consider satisfaction as an outcome, but there is no indication in the option that the percentage of returned surveys is a satisfactory amount. There is no indication whether the positive comments are about pain relief or other aspects of care. There is no indication if these clients had pain relief as part of their nursing needs. (Option 4) This is a subjective perception on the part of the nurses that may or may not be accurate. Educational objective: The outcomes of a quality improvement program should be objective and measureable.
The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? 1. Continue teaching the client and verify understanding by return demonstration 2. Discuss how important it is for the client to pay attention during the teaching 3. Maintain eye contact during the teaching by following the client's movements 4. Provide written instructions and a private place for the client to learn independently
Explanation 1 Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration. (Option 2) Lecturing the client about the importance of listening to the instructions for insulin self-injection would most likely be interpreted as degrading and disrespectful. (Option 3) In the American Indian culture, it is disrespectful to maintain eye contact during a conversation. (Option 4) A client learning the process of self-administration of insulin requires guidance and evaluation from the registered nurse before, during, and after the teaching session. The client should not be sent to a quiet place to learn the procedure independently. Educational objective: Individuals of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away during conversations in an attempt to prevent it. The nurse demonstrates culturally competent care by respecting and accepting this cultural communication pattern.
The nurse is caring for a client with end-stage liver disease who was admitted for bleeding esophageal varices. The bleeding varices were banded successfully, but the client declined having a transjugular intrahepatic portal-systemic shunt (TIPS) procedure and opted for do not resuscitate (DNR) status. Which topic is most important for the nurse to discuss with the client and family at discharge? 1. Complete abstinence from alcohol 2. Proper use of medications including lactulose 3. The importance of calling the healthcare provider (HCP) immediately if bleeding recurs 4. The purpose and use of the DNR bracelet
Explanation 4 A client with end-stage liver disease is at high risk for life-threatening events such as bleeding esophageal varices and hepatic encephalopathy. This client continues to be at risk for bleeding varices due to the declined TIPS procedure, which could have prevented further esophageal varices by treating the portal hypertension. This client who is DNR in the hospital should be discharged with a DNR bracelet or an active Physician Orders for Life-Sustaining Treatment (POLST) form in the community setting. This should be done to ensure that the client's wishes for emergency care will be carried out by first responders. (Option 1) Abstinence from alcohol will help delay the progression of end-stage liver disease and its complications. However, this is not always realistic for a client with long-term alcohol addiction. In addition, this client with end-stage liver disease who has chosen to be DNR may also choose to continue drinking if this is deemed important to quality of life. Even though the nurse may not approve of this choice, the client is the one who ultimately makes personal lifestyle and health management decisions. (Option 2) Lactulose and other medications are necessary for managing end-stage liver disease. However, this topic is less important than emergency response and advance care planning issues, particularly in a client with a new DNR order and recent history of bleeding esophageal varices. (Option 3) Although the client and family should know what to do if bleeding recurs, it would be more appropriate to call 911 than the HCP in this emergency situation. In addition, this topic is not as important as the discussion on DNR bracelet use which already covers emergency care for any type of situation. Educational objective: Discharge planning and teaching for the client with a new DNR order should include a method of ensuring that the DNR order will be carried out in the community and home. DNR bracelets and POLST forms are community-based systems that provide emergency responders with the legal documentation needed to withhold resuscitation.
The emergency department nurse would administer a prescribed isotonic crystalloid solution to which client? 1. 25-year-old with a closed-head injury and signs of increasing intracranial pressure (ICP) 2. 45-year-old with acute gastroenteritis and dehydration 3. 68-year-old with chronic renal failure and hypertensive crisis 4. 60-year-old with seizures and serum sodium of 112 mEq/L
Explanation 2 Acute gastroenteritis is associated with nausea, vomiting, diarrhea, and dehydration. An isotonic crystalloid intravenous (IV) solution (eg, 0.9% normal saline, lactated Ringer's) has the same tonicity as plasma and when infused remains in the vascular compartment, quickly increasing circulating volume. It is appropriate to correct the extracellular fluid volume deficit (dehydration) in this client. (Option 1) A hypertonic, rather than isotonic, solution would be infused in clients with ICP. Increasing circulating volume would only further increase ICP. (Option 3) Isotonic solutions can exacerbate fluid overload in chronic renal failure and increase blood pressure. (Option 4) Clients with severe hyponatremia and neurologic manifestations need rapid correction of hyponatremia with hypertonic saline (3% saline). Educational objective: Depending on the type/tonicity of intravenous (IV) solution infused, fluids can remain in the vascular compartment or can shift from the extracellular to intracellular compartments, and vice versa. The nurse must be able to assess which type of IV fluid is appropriate in relation to a client's diagnosis and condition.
A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? 1. Explain to the family that this is a normal physiological response to dying 2. Explore the family's thoughts and concerns about the client's refusal of food 3. Recommend a feeding tube 4. Tell the family that "force feeding" the client could cause the client to choke on the food
**PRIORITY** Explanation 2 When a terminally ill person refuses food, family members often become upset and frustrated in their roles of nurturers and caregivers; they may feel personally rejected. Refusal of food is associated with "giving up" and is a reminder that their loved one is dying. It is not uncommon for family members to believe that a client would get stronger by eating instead of refusing food. The registered nurse needs to explore family members' concerns and fears and listen as they express their feelings. The nurse can help them identify other ways to express how they care. The nurse should also provide education about the effects of food and water during all stages of the illness. (Option 1) Families and caregivers need to understand the effects of food and water in all stages of a terminal illness; however, it is more important to first explore the family's feelings and concerns. (Option 3) Although it is not unusual for a client to be admitted to hospice with a feeding tube already in place, tubes are generally not placed after a client begins receiving hospice services. (Option 4) This is a true statement, but it is not the priority nursing action. Educational objective: It is very common for family members to become distressed when a terminally ill loved one refuses food. The nurse needs to explore their fears and concerns and help them identify other ways to express how they care.
The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply. 1. Cervical cancer 2. Hypertension 3. Ischemic stroke 4. Osteoporosis 5. Skin melanoma
1,2,3 Explanation The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women (Option 1). African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among the women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women (Option 2). African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia (Option 3). (Option 4) White and Asian women have a higher incidence of osteoporosis than African Americans, but the disease affects all ethnic groups. (Option 5) Melanoma of the skin is more common in people who are of white ancestry, light-skinned, and over age 60 with frequent sun exposure. The incidence of melanoma is 10 times higher in white Americans than African Americans. Educational objective: African Americans have the highest incidence of hypertension in the world as well as increased incidence of stroke and cervical cancer. Whites have a high incidence of osteoporosis and skin cancer (melanoma).
The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply. 1. Conduct teaching sessions while a family member is present 2. Discourage the client from using the internet to look up health information 3. Have client watch a DVD about heart failure management 4. Print out pictures of a food label and review where to look for sodium content 5. Speak slowly and loudly so the client can understand you
1,3,4 Explanation The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows: Using pictures and simplified text is beneficial to the older adult with low literacy. Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person's language. (Option 2) Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It is important for the nurse to teach the client and possibly supply a list of reputable sites for the client to view. (Option 5) Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning. Educational objective: For a client with low literacy, the nurse should use multiple teaching strategies including professionally produced educational programs, pictures with simplified text, and inclusion of a family member during teaching sessions.
A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply. 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting
Explanation 2,4,5 Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows: Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Tub baths should be avoided due to risk of introducing infection (Option 3). Do not apply powders or lotions on incisions as these trap the bacteria at the incision (Option 3). Report any redness, swelling, and increase in drainage or if the incision has opened (Option 2). Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling (Option 5). Educational objective: The nurse should instruct the client with chest and leg incisions from CABG to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply any powders or lotions to the incisions, to report any redness, swelling or increase in drainage, and to wear an elastic compression hose on the legs.
A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? 1. "Have you shared your concerns with your health care provider (HCP)?" 2. "If I were you, I would be more worried about whether the melanoma has spread." 3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications." 4. "There is special make-up you can use to hide any facial scars left from the surgery."
Explanation 3 Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and issues related to altered body image. The best response by the nurse uses 2 therapeutic approaches aimed at reducing the client's concerns and anxiety: The client is provided with factual information about facial surgery and the healing process. The client is given assurance and support that something can be done to minimize the complications of wound healing. This will provide the client with a plan of action and a sense of control over the condition and post-surgical course. It is impossible to predict the lasting effect of the surgery on the client's facial appearance; however, teaching on managing wound care will help lessen the client's anxiety. (Option 1) This is not the best or priority response. Although the HCP will be able to give the client more information and details about the surgery and potential outcomes, the response suggests that the nurse has little or no role in providing information or teaching the client about the upcoming procedure. The response is also a "yes" or "no" question; closed-ended questions tend to minimize nurse-client interactions. (Option 2) This is a non-therapeutic response; it gives advice to the client, suggests that the nurse "knows better," and minimizes the client's concerns. It also introduces a more serious issue about the diagnosis. (Option 4) This is a non-therapeutic response. Although it is true that there are methods to conceal scars and other skin discolorations, the response is dismissive and does not address the client's concerns. Educational objective: Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and altered body image. Providing information about the surgical procedure, healing process, and self-care activities, and giving support will lessen anxiety and give the client a sense of control.
A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond? 1. "Don't worry. You'll feel better in a few weeks." 2. "How well are you sleeping at night?" 3. "These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again." 4. "You may be experiencing depression. I'll call the health care provider and see if we can get a prescription for an antidepressant."
Explanation 3 Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder (Option 3). (Option 1) The client will most likely feel better in a few weeks, but this statement is not therapeutic and does not really provide any useful information. (Option 2) This is good information for the nurse to have, but it does not directly relate to the client's issues of forgetfulness and becoming teary often. (Option 4) Two weeks postoperative is most likely too early for a diagnosis of depression. Depression can occur after a major illness or surgery, but antidepressants would be considered only for persistent symptoms. Educational objective: The nurse should teach the client that possible memory impairment and problems with concentration, language comprehension, social integration, and emotional lability are common following major surgery. Symptoms typically resolve after 4-6 weeks or when healing is complete. Persistent problems should be reported to the health care provider.
For the past month, the registered nurse (RN) has been providing care to a 7-year-old client recently diagnosed with type 1 diabetes mellitus. Initially, the family seemed devastated over the diagnosis. The client's parent stated, "Our lives will never be the same." What statement now made by the parent best indicates that nursing interventions have been effective? 1. "Our child will not be able to participate in sporting events." 2. "Our whole family will have to make sacrifices to deal with this disease." 3. "We cannot let this disease control our child's life." 4. "We have set aside a place in the pantry for our child's special foods."
Explanation 3 It is not unusual for parents to feel devastated after learning that their child has a chronic illness, such as diabetes. Reactions include shock, denial, helplessness, anger, fear, and anxiety. They may question, "Why did this happen to my child?" or have feelings of guilt that they somehow contributed to or failed to prevent the development of the disease. The parents' emotional response, adaptation, and coping strategies will greatly impact the child's perception of self and the ability to self-manage the disease. In providing diabetes education to the family and the child, the RN needs to emphasize and reinforce that with planning and preparation, diabetes can be managed and controlled, regular day-to-day activities can be resumed, and the child can have a normal life. When the parents perceive themselves and their child as being in control rather than victimized and dependent, it increases the likelihood that they will be actively engaged in diabetes self-management activities. (Option 1) This is not a true statement. Clients with diabetes can participate in a wide variety of sports. (Option 2) The diagnosis and management of diabetes in a child will affect the whole family. However, parents and siblings should be able to lead a normal life. The use of the word "sacrifice" suggests that the parent is feeling victimized by the disease. (Option 4) Nutritional management of diabetes does not require special foods. Clients need to learn to balance food choices with medications and exercise for blood sugar control. Nutrition education should emphasize healthy food choices for the client and the family. Educational objective: The diagnosis of a chronic illness, such as diabetes, in a child will have an impact on the entire family. When the parents see themselves and their child as capable of being independent and in control of the condition, there is an increased likelihood that the disease will be better managed and controlled.
A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed. 2. Client reports, "I'm in pain." Medication provided. 3. Inspiratory wheezes heard in bilateral lower lung fields 4. Voided x 1
Explanation 3 The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. "Inspiratory wheezes heard in bilateral lung fields" best fits these criteria. The nurse should avoid vague terms such as "appears," "seems," and "normal." These words suggest that the nurse is stating an opinion and do not accurately communicate facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements, establish accuracy, and not provide opinions or assumptions. (Option 1) The nurse should not use the word "appears" as it is too vague. "Eyes closed" is a factual observation. A more accurate entry would be, "Client lying in bed with eyes closed. Respirations even and unlabored." (Option 2) It is a good practice to document client quotes. However, in this case, the nurse should have elicited more information from the client, such as a pain scale, and then documented the analgesic the client was given. (Option 4) This documentation would be more descriptive if it listed how much urine, its color and clarity, and if an odor was present. Educational objective: Nursing documentation should be factual, descriptive, and contain objective information that the nurse sees, hears, feels, or smells. It must include direct observation and measurement.
A postoperative client is prescribed IV patient-controlled analgesia (PCA) with morphine. The client tells the nurse, "I am pushing the button, but I'm still having a lot of pain." What is the priority nursing action? 1. Administer a bolus dose 2. Notify the health care provider (HCP) to request a higher dose 3. Perform a thorough pain assessment 4. Reinforce the proper use of the IV PCA pump
Explanation 3 When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis. The client's self-report is considered to be the most reliable indicator of pain, so the priority nursing action is to perform a thorough pain assessment to determine the cause of worsening/continuous pain despite the medication. This includes location, quality, radiation, severity, and associated factors (eg, nausea, diaphoresis) for the severe pain. The assessment data will guide the nurse's subsequent interventions (Option 3). (Option 1) An IV PCA bolus is an extra, as-needed dose of analgesia (eg, 1-2 mg) for increased pain (eg, before a painful procedure) that is prescribed by the HCP when the PCA is initiated. If needed, the nurse programs the pump to deliver the bolus dose because no one but the client is permitted to push the button. However, this is not the priority action. (Option 2) If the client's attempts are twice the number of doses actually delivered and adequate pain relief is not achieved, the nurse would notify the HCP to request a dose increase or shorter dose interval. However, this is done after the pain assessment. (Option 4) The client learns how to use the IV PCA pump when it is initiated. The nurse should reassess the client's knowledge level regarding proper use and reinforce previous teaching. However, it is not the priority intervention. Educational objective: When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis, assesses the client's knowledge level regarding its use, and reinforces previous teaching.
The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication. What is the most appropriate action for the RN to take? 1. Administer the hydromorphone 2. Ask the licensed practical nurse to administer the medication 3. Ask the unlicensed assistive personnel to take repeat vital signs 4. Contact the health care provider
Explanation 4 A STAT order indicates that the medication should be given immediately and only one time. A new prescription for the medication must be acquired before the dose can be repeated. The most appropriate action is to contact the health care provider to request an as-needed prescription for pain medication. (Option 1) A STAT medication dose was administered and cannot be repeated without a new prescription. (Option 2) In most states, the registered nurse (RN) cannot delegate the administration of IV opioids to the licensed practical nurse, and it cannot be administered without a new prescription. (Option 3) The RN can delegate repeat vital sign checks to the unlicensed assistive personnel, but it is not the most appropriate action. Educational objective: A STAT order indicates that a medication is to be given immediately and only once.
The nurse is performing an admission assessment on an elderly client with Alzheimer disease (AD). The nurse should do which of the following when communicating with the client? 1. Ask open-ended questions 2. Speak in a loud voice 3. Touch the client prior to speaking 4. Use simple sentences
Explanation 4 AD is a progressive neurodegenerative disease that causes dementia (reduced cognitive function) in older individuals (age >60). Conversation becomes progressively more difficult and word-finding difficulties occur. The best way for the nurse to obtain information is to offer a calm environment and use clear and simple explanations. (Option 1) Asking open-ended questions is often a good way to collect information from clients, but in this case it could confuse the client with AD. This is not the best answer option. (Option 2) AD results in reduction in cognitive function and is not associated with hearing loss. There would be no need to speak loudly. (Option 3) Touching the client before speaking would be more appropriate for a client who has hearing loss, not one with AD. Educational objective: When speaking with AD clients, use clear and simple explanations. When communicating with clients who have hearing loss, speak loudly, stand close to the person, and touch the person before speaking.
The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate? 1. Administer the prescribed as-needed milk of magnesia 2. Ask dietary services to add more fruits and vegetables to the client's tray 3. Notify the health care provider (HCP) 4. Perform a focused abdominal assessment
Explanation 4 Constipation may develop as a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client. The nurse can administer the as-needed laxative once it has been determined to be safe. The HCP is contacted if the focused abdominal assessment indicates a potential complication, such as postoperative ileus. (Option 1) The nurse's first priority is assessment. A laxative would not help if this client had intestinal obstruction (from adhesions). (Option 2) The client is taught to eat a high-fiber diet and increase fluid intake to promote normal bowel function. The nurse would not change the diet until further assessment of the client is accomplished and the HCP has prescribed a new diet. (Option 3) The nurse should further assess the client before contacting the HCP. Educational objective: Constipation may be a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client and then use measures that promote normal bowel function (eg, as-needed laxatives, stool softeners, bulk agents, high-fiber diet, increased fluids).
A client of the Jewish Orthodox faith with a history of type 2 diabetes mellitus is hospitalized, recovering from a total right hip arthroplasty. At noon, the client consumed the following meal: lean roast beef sandwich with lettuce and low-fat mayonnaise, carrot and celery sticks, and fresh fruit. What would be the most appropriate 2:00 PM snack for this client? 1. Angel food cake with fresh strawberries 2. Crackers and low-fat cheese 3. Nonfat plain yogurt 4. Pita chips and hummus
Explanation 4 Individuals who practice Orthodox Judaism follow Kosher laws. These regulations are strict regarding the use of certain animal products (eg, no pork, shellfish, fish without scales) and the separation of meat/poultry from dairy. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product can be consumed. Certain foods, including fresh fruits and vegetables, grains, tea, and coffee, are considered neutral and can be consumed at any time. Pita chips and hummus are non-dairy foods and would be an appropriate snack. This choice also provides a combination of carbohydrates and protein, which will help in regulating blood glucose. (Option 1) This choice would be allowable under Kosher rules; however, it is not the best choice for a client with diabetes due to the high carbohydrate content. (Option 2) Low-fat cheese is a dairy product and cannot be consumed within 3-6 hours of a meat/poultry meal. (Option 3) Yogurt is a dairy food and would not be an appropriate choice for a 2:00 PM snack. Educational objective: Clients of the Orthodox Jewish faith follow Kosher rules. These include no pork, shellfish, or fish without scales. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product can be consumed.
The nurse reviews the laboratory results for an adult male client admitted with septic shock. Which value requires the most immediate action? Click on the exhibit button for additional information. 1. Blood urea nitrogen 2. Creatinine 3. Hematocrit 4. Potassium
Explanation: 4 Serum potassium may increase in clients in progressive shock as a result of metabolic acidosis, which can cause a shift of potassium from the intracellular to extracellular compartments. Because the most significant manifestation of hyperkalemia is a disturbance in cardiac conduction and the development of cardiac dysrhythmias, correction of the imbalance requires immediate action. (Option 1) Although a blood urea nitrogen level of 44.4 mg/dL (15.9 mmol/L) is elevated, it does not require immediate action. It can increase in clients in a shock state as the result of decreased perfusion to the kidneys (pre-renal azotemia) or extra-renal factors such as dehydration, fever, or gastrointestinal bleed. (Option 2) Normal creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). (Option 3) Normal hematocrit level is 39%-50% (0.39-0.50). Educational objective: The most significant manifestations of hyperkalemia are disturbances in cardiac conduction and the development of potentially life-threatening cardiac dysrhythmias. Copyright © UWorld. All rights reserved.
The client screams at the nurse, "You are all incompetent here! I have been waiting for 2 hours!" How should the nurse respond initially? 1. "I know you are upset, but I will have to call security if you continue to scream." 2. "I see that you are upset. Let's focus on how I can help you." 3. "I want you to know that the health care providers (HCPs) are all well-qualified professionals." 4. "It is frustrating to wait so long, and I am sorry for the delay."
Explanation: 4 Therapeutic communication is used to establish trust, encourage communication, and display respect for the client. Empathizing with the client's feelings conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue. It can be helpful to offer a "blameless apology," in which the nurse apologizes for the problem (eg, long wait) without taking personal responsibility for causing it. This technique can be helpful for diffusing negative emotions as clients feel acknowledged for the "wrong" they believe they have endured (Option 4). (Option 1) Security may be called if the client appears to be losing control or is a risk to self or others. However, initially calling security or using an authoritative approach may further escalate the situation and does not address the client's concern. The nurse should initially try to diffuse the situation and the client's anger. (Option 2) Although sharing an observation is therapeutic, attempting to change the subject will only further infuriate the client. Clients want their feelings to be recognized and validated. (Option 3) A defensive response may communicate that the client's feelings are wrong or lack importance. In this example, the client knows that the HCPs are qualified; stating this information is defensive and ignores the client's concern. Educational objective: When a client is angry and upset, therapeutic communication skills such as acknowledging the feeling, empathy, active listening, and offering a blameless apology may help deescalate the situation. The nurse should not initially ignore the client or use threats, authoritative rules, or aggressive behaviors.
Which client is at greatest risk for the development of hospital-acquired pressure ulcers (HAPUs)? 1. 25-year-old quadriplegic client with urosepsis, temperature of 101 F (38.3 C), and white blood cell (WBC) count of 18,000 µL 2. 50-year-old client with AIDS, weight loss of 20 lb (9 kg) in a month, prealbumin level <10 mg/dL, mean arterial blood pressure of 50 mm Hg, and receiving Levophed infusion 3. 80-year-old client 2 days postoperative from hip replacement, with dementia, two Jackson-Pratt drains, and hemoglobin level of 14 g/dL 4. 85-year-old client 2 days postoperative from open cholecystectomy
Explanation:2 Pressure ulcers are areas of localized injury of skin and underlying tissue caused by external pressure with or without friction and/or shearing. They result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and fractured hips, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, and infection are also at increased risk. Client 2 has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 g/dL indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving Levophed (norepinephrine), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and ability to provide adequate nutrition to the cells. (Option 1) This client has 4 risk factors: a deficit in independent mobility and activity, spinal cord injury with quadriplegia, decreased sensation, and fever and infection. (Option 3) This client has 3 risk factors: advanced age, surgery, and dementia. Hemoglobin is within the normal range. (Option 4) This client has 2 risk factors: advanced age and surgery. Surgery can be associated with deep-tissue injury (DTI) ulcers. Positioning and immobility during the surgical procedures (>2½ hours) and receiving anesthetic and vasoactive drugs (to treat hypotension) present a special risk for the development of DTI in postoperative clients. Educational objective: Although pressure ulcers can develop in any client with limited mobility and activity, those at most risk include older adults; those with quadriplegia; the critically ill; and those with fracture of a long bone (hip, femur), anemia, nutritional deficits, incontinence, chronic illness, renal failure, problems with oxygenation and circulation, infection, or fever.
