Fundamental Questions Level 3

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? 1 It increases production of short-lived antibodies. 2 It accelerates antigen-antibody union at the hepatic sites. 3 The lymphatic system is stimulated to produce antibodies. 4 The antigen is neutralized by the antibodies that it supplies.

Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function.

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1 Sprinkle the powder from the capsule into a cup of water. 2 Insert a rectal suppository containing 100 mg of phenytoin. 3 Administer 4 mL of phenytoin suspension containing 125 mg/5 mL. 4 Obtain a change in the administration route to allow an intramuscular (IM) injection.

When an oral medication is available in a suspension form, the nurse can use it for clients who cannot swallow capsules. Use the "Desire over Have" formula to solve the problem. Desire 100 mg = x mL Have 125 mg 5 mL 125x = 500 X = 500 ÷ 125 X = 4 mL Because a palatable suspension is available, it is a better alternative than opening the capsule. The route of administration cannot be altered without the health care provider's approval. Intramuscular injections should be avoided because of risks for tissue injury and infection.

When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands that this finding: 1 is a normal occurrence. 2 may indicate atherosclerosis. 3 can be attributed to aortic disease. 4 indicates lymphedema.

When auscultating blood pressures, readings between the arms can vary as much as 10 mm Hg and are often higher in the right arm. Readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta. Lymphedema is swelling in one or more extremities that is the result from impaired flow of the lymphatic system.

A client with hyperthyroidism has been treated with radioactive iodine (131I) to destroy overactive thyroid gland cells. To reduce radiation exposure, the nurse's principles for providing care should be based on: 1 Wearing a lead-shield apron at all times 2 Limiting distance and time spent with the client 3 Wearing a radiation meter to measure exposure 4 Remaining at least 6 feet away from the client at all times

When caring for clients who are radioactive, the three most important concepts for reducing radiation exposure are to limit exposure time, increase distance, and use shielding. In this situation, time and distance provide the best reduction in radiation exposure. Wearing a lead-shield apron will help prevent radiation exposure, but time and distance are the first priorities. A radiation meter measures exposure but does nothing to protect caretakers. Remaining at least 6 feet away from the client at all times is not a practical approach.

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply. Correct1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output Correct4 Administration of antiemetic drugs Correct5 Replacement of fluid and electrolytes

When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1 To avoid strain on the incision 2 To promote drainage of the wound 3 To provide stimulation for the client 4 To reduce edema at the operative site

This position prevents fluid accumulation in the tissue, thereby minimizing edema. This position will neither increase nor decrease strain on the suture line. Drainage from the wound will not be affected by this position. This position will not affect the degree of stimulation.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: 1 Promote equalization of osmotic pressures. 2 Prevent hypoxia associated with diaphoresis. 3 Promote integrity of intracerebral neurons. 4 Reduce brain metabolism and limit hypoxia.

Cooling blankets and antipyretic medications can induce hypothermia thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.

The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that the purpose of the albumin is to: 1 Provide nutrients. 2 Increase protein stores. 3 Elevate the circulating blood volume. 4 Divert blood flow away from the liver temporarily.

Increasing oncotic pressure increases the client's circulating blood volume; salt-poor albumin pulls interstitial fluid into the blood vessels, restoring blood volume and limiting ascites. Nutrients are provided by total parenteral nutrition, not salt-poor albumin. Salt-poor albumin is not given to increase protein stores. Salt-poor albumin has no effect on diverting blood flow away from the liver.

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? 1 Eating beef and veal is prohibited. 2 Consumption of fish with scales is forbidden. 3 Meat and milk at the same meal are forbidden. 4 Consuming alcohol, coffee, and tea are prohibited.

Jewish dietary laws prohibit any combination of milk and meat at the same meal. The Hindu, not Jewish, religion prohibits the ingestion of beef and veal; many Hindus believe that the cow is sacred. Fish that have scales and fins are considered clean, and therefore allowed in the diet. Seventh Day Adventists, Baptists, Mormons, and Muslims prohibit some or all of these beverages.

Negligence

Nursing negligence is described as the *failure to do or not do what a reasonably careful nurse would do under the circumstances. The elements that must be present to determine negligence include whether the nurse fulfilled the legal duties to provide reasonable care and foresee a risk of injury under certain circumstances and whether there was a breach of duty and whether any injury resulted if there was a breach of duty.* The intentional or unintentional nature of a behavior is determined by an understanding of the actions and their consequences.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse identifies an ocular problem common to persons at this client's developmental level, which is: 1 Tropia 2 Myopia 3 Hyperopia 4 Presbyopia

Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. Upon entering the room, what is the most important action the nurse needs to take? 1 Ask the client if he is okay. 2 Call security from the room. 3 Find out if there is anyone else in the room. 4 Ask security to make sure the room is safe.

Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and make sure that any other people in the room are safe.