Critical Thinking Final Review
Stop the magnesium sulfate infusion. Rationale: Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls, or if reflexes are diminished or absent, all of which are true for this client. The client also shows other signs of impending toxicity, such as flushing and feeling warm. Inaction will not resolve the client's suppressed DTRs, low respiratory rate, and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.
A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium sulfate I.V. for 3 hr. The latest assessment reveals deep tendon reflexes (DTR) of +1, flushing, blood pressure of 150/100 mm Hg, a pulse of 92 beats/min, a respiratory rate of 10 breaths/min, and urine output of 20 ml/hr. Which action would be most appropriate? Continue monitoring per standards of care. Stop the magnesium sulfate infusion. Increase the infusion rate by 5 gtts/min. Decrease the infusion rate by 5 gtts/min.
Vomiting, difficulty breathing, lack of vocalization Rationale: Severe abusive head trauma (AHT) manifests as seizures, shock, or severe respiratory distress leading to death. Many cases present with more subtle signs of increased intracranial pressure such as irritability, poor feeding, or vomiting. Failure to smile or vocalize indicates a change in level of consciousness. Increased tone is associated with AHT versus hypotonia. Head lag can still a be normal finding at 4 months.
A 4-month-old infant is brought the emergency department following a seizure. What findings would lead the nurse to suspect the infant has experienced abusive head trauma or shaken baby syndrome? Select all that apply. vomiting difficulty breathing head lag lack of vocalization hypotonia
bone marrow cells Rationale: The fast-growing, normal cells most likely to be affected by certain cancer treatments are blood-forming cells in the bone marrow, as well as cells in the digestive track, reproductive system, and hair follicles. Fortunately, most normal cells recover quickly when treatment is over. Bone marrow suppression (a decreased ability of the bone marrow to manufacture blood cells) is a common side effect of chemotherapy. A low white blood cell count (neutropenia) increases the risk of infection during chemotherapy, but other blood cells made in the bone marrow can be affected as well. Most cancer agents do not affect tissues and organs, such as heart, liver, and pancreas.
A client diagnosed with cancer is receiving chemotherapy. The nurses should assess which diagnostic value while the client is receiving chemotherapy? bone marrow cells liver tissues heart tissues pancreatic enzymes
Breath sounds Rationale: Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia. Frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it will not help detect pneumonia.
A client diagnosed with leukemia is now experiencing neutropenia. Which assessment is a priority for the nurse? Blood glucose Bowel sounds Heart sounds Breath sounds
replacing fluid and electrolytes Rationale: After establishing a patent airway, fluid resuscitation is critical for the client with a burn injury. The burns will be covered with sterile saline-soaked dressings until the client is stabilized. Positioning to promote normal anatomic alignment is not a priority at this time. There is no reason to suspect that blood flow to the lower extremities is affected, but it might occur if the injury causes circumferential constriction of the legs.
A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority? A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority? replacing fluid and electrolytes covering the wounds with antibacterial dressings supporting the lower extremities in normal anatomic position evaluating the presence and quality of pulses distal to the burn injury
Continue routine monitoring. Rationale: These findings are normal adverse effects to the medication and don't require intervention at this time except for continued routine monitoring. Contacting the health care provider, placing the client on her left side, changing the I.V. flow rate, and giving oxygen are all interventions for abnormal assessment findings.
A client is being treated for premature labor with ritodrine. After receiving this medication for 12 hours, the client's blood pressure is slightly elevated, her chest is clear, and her pulse is 120 bpm. She reports a little nausea, and the fetal heart rate is 145 bpm. Which intervention is correct? Continue routine monitoring. Contact the health care provider immediately. Turn the client on her left side and give oxygen. Increase the flow rate of the I.V. and give oxygen.
"I can resume my normal diet when I feel ok." "I may experience some pain in my right shoulder." "I can take a shower 2 days later." Rationale: Following a laparoscopic cholecystectomy, the client can resume a normal diet as tolerated. The client may experience right shoulder pain from the gas that was used to inflate the abdomen during surgery. The client can take a shower 48 hours after the surgery. The adhesive strips will fall off in about 10 days. The client can resume driving within 3 to 4 days following surgery as long as the client is not taking pain medication. There is no need for the client to maintain bed rest in the days following surgery. Light exercise such as walking can be resumed immediately.
A client who has had a laparoscopic cholecystectomy has adhesive strips over the puncture sites. When preparing the client for discharge, which client statements indicate that the teaching has been successful? Select all that apply. "I can resume my normal diet when I feel ok." "I need to avoid driving for about 4 weeks." "I may experience some pain in my right shoulder." "I should spend 2 to 3 days in bed before resuming activity." "I can take a shower 2 days later."
Monitor the amount of vaginal blood loss Rationale: The nurse should estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (such as hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A vaginal examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute; therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute.
A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client is not in labor. Which nursing intervention should the nurse perform? Allow the client to ambulate with assistance. Perform a vaginal examination to check for cervical dilation. Monitor the amount of vaginal blood loss. Notify the physician for a fetal heart rate of 130 beats/minute.
Assist the client in learning to eat with the left hand. Rationale: It is important to involve the client in care. The client will need to learn to eat with the non-dominant hand. Promoting independence and supporting attainment of this skill will help the client positively meet the goal of rehabilitation. Feeding the client or having the family feed the client does not promote independence. The client is not having difficulty chewing or swallowing, so a thickened liquid diet is not needed.
A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which action is mostimportant for the nurse to take to facilitate rehabilitation with eating? Assist the client in learning to eat with the left hand. Continue feeding the client until the hemiplegia resolves. Request a diet of thickened liquids that can be taken through a straw. Have a family member assist with feeding at mealtimes.
depression Rationale: Depression and anxiety are common mental health problems seen immediately after substance withdrawal. Flashbacks and nightmares are commonly observed in clients with posttraumatic stress disorder. Dissociation occurs when a client undergoes prolonged physical and sexual abuse.
A client's condition is stabilizing after an episode of substance-induced delirium. For which psychosocial health problem should the nurse assess during the initial recovery period. flashbacks depression nightmares dissociation
decrease urine output hearing loss Rationale: Kanamycin is an aminoglycoside antibiotic. Adverse reactions to kanamycin include ototoxicity and nephrotoxicity. Bone damage, dry mouth, and hyperglycemia are not adverse effects of this medication
A nurse is teaching a client about the adverse reactions of kanamycin. What information should the nurse include? Select all that apply. decrease urine output bone damage hearing loss dry mouth increase blood glucose
"I sleep on three pillows each night." Rationale: Orthopnea = LSHF; Swollen feet, ascites, anorexia = RSHF
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? "I sleep on three pillows each night." "My feet are bigger than normal." "My pants don't fit around my waist." "I don't have the same appetite I used to."
IV administration of lactated Ringer's Rationale: The loss of small volumes of blood in children is significant and can lead to hypovolemic shock. In this situation, the blood loss represents approximately 10% of the child's total blood volume. Because the child is exhibiting signs of early hypovolemic shock, the priority action should be the administration of Ringer's lactate for fluid resuscitation. The remaining options may need to be implemented, but the priority is to correct the fluid deficit.
A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take? neurologic assessment with the Glasgow Coma Scale application of telemetry monitoring IV administration of lactated Ringer's insertion of a Foley indwelling catheter
aspirin Rationale: Aspirin administration is associated with the development of Reye syndrome. Acetaminophen, ibuprofen, and guaifenesin have not been associated with the development of Reye syndrome. There has been a decreased incidence of Reye syndrome with the increased use of acetaminophen and ibuprofen for management of fevers in children.
A parent asks the nurse if medications can cause Reye syndrome. The nurse's most appropriate response is that Reye syndrome has been connected to acetaminophen. aspirin. ibuprofen. guaifenesin.
gastric lavage and administration of activated charcoal Rationale: The healthcare provider will probably order gastric lavage or activated charcoal administration. Ipecac syrup is no longer recommended, and an antacid is not an effective treatment for poisoning. Infusing normal saline solution I.V. may be helpful in treating dehydration caused by vomiting, but in itself is not effective in eliminating the poisonous substance.
A parent brings a preschool child to the emergency department after the child ingested an unknown quantity of acetaminophen. Which treatment does the nurse anticipate? administration of a dose of ipecac syrup insertion of a nasogastric tube and administration of an antacid I.V. infusion of normal saline solution gastric lavage and administration of activated charcoal
Notify the HCP Rationale: Bulging fontanels in an infant may indicated increased intracranial pressure, a possible postoperative complication. Calming the infant, teaching the parent, and repositioning the infant will not address the underlying problem of increased intracranial pressure within the skull. Calling the healthcare provider is indicated.
An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which is the nurse's best action? Notify the healthcare provider. Calm the infant. Teach the parent about procedure. Reposition the infant.
Apply direct pressure to the finger with a clean, dry cloth. Rationale: Applying direct pressure to an injury is the initial step in controlling bleeding. Elevation reduces the force of flow, but direct pressure is the first step. The nurse may use pressure point control for severe or arterial bleeding. Pressure points (those areas where large blood vessels can be compressed against bone) include femoral, brachial, facial, carotid, and temporal artery sites. The nurse should avoid applying a tourniquet unless all other measures have failed, because it may further damage the injured extremity.
An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action? Elevate the extremity above the level of the heart. Apply pressure to the radial artery of that extremity to decrease bleeding. Apply direct pressure to the finger with a clean, dry cloth. Apply a tourniquet at the bicept of the affected limb.
"It's a disorder usually carried by females and transmitted to male children." Rationale: The gene for Duchenne's muscular dystrophy is carried by women and transmitted to their male children. It involves an X-linked inheritance pattern. About one-third of new cases involve mutations.
The mother of a child with newly diagnosed Duchenne's muscular dystrophy asks how her child developed the disease. The nurse gives a response incorporating which statement about its transmission? "It's an autosomal recessive genetic disorder." "It's a genetic disorder carried by males and transmitted to male children." "It's a disorder primarily transmitted by males in the family." "It's a disorder usually carried by females and transmitted to male children."
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Rationale: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3-occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.
The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis? pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L
Ensure airway patency and optimal oxygen levels and protect from injury. Rationale: Because there is rapid progression of the subdural hematoma, with changes in consciousness, the priority is to maintain airway patency. Relaxation of the tongue and jaw may result in airway obstruction, and because the client is experiencing changes in consciousness, protection from injury is very important. When the cause and damage of subdural hematoma has been corrected, blood pressure hopefully will be corrected. Nutrition, hydration, elimination, and skin integrity are secondary in importance.
The nurse is caring for a client with a subdural hematoma. Which is the priorityoutcome? Restore blood pressure to the normal range. Ensure airway patency and optimal oxygen levels and protect from injury. Ensure adequate nutrition, hydration, and elimination. Provide psychological support and maintain skin integrity and effective thermoregulation.
Maintaining adequate hydration Rationale: Maintaining fluid intake is essential in a client with DI. The client is at risk for developing hypovolemic shock because of increased urine output. Weight should be measured daily to monitor fluid balance. Urine specific gravity should be monitored for low osmolality, generally <1.005, due to the body's inability to concentrate urine.
The nurse is caring for a client with diabetes insipidus (DI). What is the nurse's priority intervention? Watching for signs and symptoms of septic shock Maintaining adequate hydration Checking weight every three days Monitoring urine for specific gravity >1.030
metabolic acidosis Rationale: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? metabolic acidosis respiratory acidosis metabolic alkalosis respiratory alkalosis
ortolani's sign Rationale: Assessment in a child with a congenital hip dislocation typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.
The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which findings should the nurse anticipate? symmetrical thigh and gluteal folds ortolani's sign increased hip abduction femoral lengthening
ECG Electrodes Rationale: The nurse should first apply the ECG electrodes to the client's chest. If the client is found to be in ventricular fibrillation, the immediate priority is to defibrillate the client. Pulse oximetry is not an immediate priority. The client's oxygenation is evaluated in a code situation using arterial blood gas analysis. The client's blood pressure is evaluated after the ECG rhythm has been established. A portable Doppler ultrasound unit may be needed to check for the presence of a pulse or to check the blood pressure in a code situation.
The rapid response team arrives in the room of a client who has had a cardiac arrest. The nurse should first apply which piece of monitoring equipment? electrocardiogram (ECG) electrodes pulse oximeter blood pressure cuff Doppler pulse detection unit
Carefully test the temperature of bath water. Avoid hot water bottles and heating pads. Inspect the skin daily for injury or pressure points. Wear warm clothing when outside in cold temperatures. Rationale: A client with impaired peripheral sensation does not feel pain as readily as someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully. The client should be advised to avoid using hot water bottles or heating pads and to protect against cold temperatures. Because the client cannot rely on minor pain as an indicator of damaged skin or sore spots, the client should carefully inspect the skin daily to visualize any injuries that he cannot feel. The client should not be instructed to avoid kitchen activities out of fear of injury; independence and self-care are also important. However, the client should meet with an occupational therapist to learn about assistive devices and techniques that can reduce injuries, such as burns and cuts that are common in kitchen activities.
Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. Carefully test the temperature of bath water. Avoid kitchen activities because of the risk of injury. Avoid hot water bottles and heating pads. Inspect the skin daily for injury or pressure points. Wear warm clothing when outside in cold temperatures.
signs of increased ICP Rationale: Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessing for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who is ill from nearly any cause. This doesn't pose a great danger to life.
Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis? onset and character of fever degree and extent of nuchal rigidity signs of increased intracranial pressure (ICP) occurrence of urinary and fecal incontinence