Fundamentals u
The emergency department nurse would administer a prescribed isotonic crystalloid solution to which client? 25 y/o w a closed head injury and signs of increasing ICP 45 y/o w acute gastroenteritis and dehydration 68 y/o w chronic renal failure and hypertensive crisis 60 y/o w seizures and serum sodium of 112
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).
A health care provider prescribes cefuroxime 30 mg/kg/day PO divided in equal doses every 12 hours for a child with a urinary tract infection. The child weighs 32 lb. Based on the cefuroxime label, how many milliliters would the nurse administer per dose? Record your answer using one decimal place. cefuroxime 250 mg/5 mL
4.4 mL
A client postoperative from a transurethral prostatectomy has a triple-lumen Foley catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of 2300 mL at the end of the 8-hour shift. How many milliliters does the nurse document as the total amount of urine output for the shift? Record your answer as a whole number.
900 Total amount of drainage in bag - total amount of irrigating solution infused: 2300 mL - 1400 mL = 900 mL
Immediately after delivery, an 8 lb 9 oz client requires naloxone hydrochloride due to respiratory depression. The health care provider prescribes naloxone 0.01 mg/kg to be given intramuscularly stat. Naloxone 0.04 mg/mL is available. How many milliliters will the nurse administer? Record your answer using two decimal places
0.97 mL
The nurse is to administer an albuterol nebulizer treatment to a client with acute bronchospasm. The prescribed dosage is 5 mg every 4 hours. The available solution is albuterol inhaled, 2.5 mg/3 mL (0.083%). How many mL does the nurse administer with each dose?
6 mL
A nurse is caring for a 3-month-old client with a new tracheostomy. Which findings would indicate a need for suctioning? Select all that apply. audible gurgling HR 105 increased irritability o2 sat 88% RR 30
Artificial airways (eg, tracheostomies, endotracheal tubes) impair the cough mechanism and ciliary function, causing an increase in thick secretions that may occlude the airway. Focused respiratory assessments are critical to determine the need for suctioning and to maintain a patent airway. To decrease the risks associated with the procedure (eg, atelectasis, hypoxemia, trauma, infection), suctioning should be performed only when necessary. Assessment findings that indicate a need for suctioning include: Decreased oxygen saturation (Option 4) Altered mental status (eg, irritability, lethargy) (Option 3) Increased heart rate (normal infant range: 90-160) Increased respiratory rate (normal infant range: 30-60) Increased work of breathing (eg, flared nostrils, use of accessory muscles) Adventitious breath sounds (eg, crackles, wheezes, rhonchi) (Option 1) Pallor, mottled, or cyanotic skin coloring (Options 2 and 5) Respiratory rate of 30/min and heart rate of 105/min are within normal limits for an infant and would not indicate distress or a need for suctioning.
A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. ensuring the client wears an N95 respirator at all times keeping the door of the client's room closed at all times maintaining a log of everyone in and out of the client's room removing both pairs of gloves before removing gown and mask restricting visitors from entering the clients room
Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed (Option 2). Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child) (Option 5). For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms (Option 3). Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial. (Option 1) In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must don appropriate personal protective equipment (PPE). (Option 4) The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last.
The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply. I can mix the med in a bowl of my child's fave cereal I should give another dose if my child vomits after take the med I should measure liquid meds using an oral syringe I will encourage my child to help me as I prep the med I will place my child in time out if the med is refused
For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses (Option 3). Household measuring devices (eg, teaspoon) are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of an unpleasant taste. Preschool children (age 3-6) typically start to take initiative and affirm power over the environment (Erickson's initiative vs. guilt). Encouraging participation (eg, allowing the child to depress the syringe plunger) promotes initiative and cooperation by giving the child a sense of control (Option 4). (Option 1) The child may not finish eating food mixed with medication and would receive only a partial dose. In addition, some medications cannot be given with food. (Option 2) Parents should notify the health care provider if the child vomits after oral medication administration; additional medication may cause an overdose, as some of the medication may have been absorbed. (Option 5) Preschool children respond best to positive reinforcement and rewards (eg, stickers) as incentives for desired behavior. A time-out is more effective in interrupting undesired behavior.
An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse? I understand your desire to leave, but it would be very risky I will ask the palliative care nurse to talk w you to help clarify your goals I will let the HCP know that you want to be d/c and do everything I can to make it happen tell me more about your need to leave the hospital
Knowing that this client has just received bad news with a limited prognosis, the nurse should anticipate that the client's urgent request for discharge may be due to concerns about needing to complete unfinished business while still functioning. Examples of end-of-life "business" include concerns about family, finances, business responsibilities, and dealing with property and possessions. To get more information, the nurse should assess the client's concern and the motivation behind the request by asking an open-ended question, such as "Tell me more about ______." It is important to gain the client's trust, to actively listen, and to avoid immediately jumping to problem-solving during this assessment (Option 4). With the information gained from the assessment, the nurse will be able to problem-solve with the client while intervening and advocating as appropriate. (Option 1) Although leaving may be risky for the client, the nurse's warning is not an appropriate initial action. (Option 2) The nurse is not taking the time to listen but is passing this responsibility to another member of the team. A palliative care nurse referral may be appropriate in this situation, but the nurse needs more information and must take the time to listen to the client now. (Option 3) This option does not acknowledge the HCP's concern about the client still needing to be hospitalized. The nurse must first understand the client's situation and then take this information to the HCP to negotiate for a solution that acknowledges the concerns of both.
The nurse is precepting a new graduate nurse (GN) who is administering a prefilled enoxaparin injection to an obese client. Which action by the GN indicates the need for further education from the nurse preceptor? discourages the client from rubbing the site after the injection ejects the air bubble from the prefilled syringe before admin inserts the needle and injects at a 90 degree angle selects an injection site on the left lateral side of abdomen
Low-molecular-weight heparins (LMWHs) (eg, enoxaparin, dalteparin) are anticoagulants commonly used for prevention and treatment of deep venous thrombosis and pulmonary embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose. During injection, the air bubble follows the medication out of the syringe, ensuring that no medication is left behind. The nurse should not expel the air bubble prior to administration as this could result in an incomplete dose and medication error (Option 2). (Option 1) After subcutaneous anticoagulant injection, the client should not rub the injection site as this increases bruising and the risk for hematoma. (Option 3) A 90-degree angle is appropriate for a subcutaneous injection in an obese client. In general, subcutaneous injections are administered at a 90-degree angle if 2 in (5 cm) of tissue can be grasped or a 45-degree angle if only 1 in (2.5 cm) of tissue can be grasped. (Option 4) Subcutaneous anticoagulants are best absorbed when administered in the lower part of the right or left lateral abdominal wall (ie, "love handles"), at least 2 in (5 cm) away from the umbilicus.
The nurse is teaching a client with insomnia techniques to improve sleep habits. Which statement by the client indicates a need for further teaching? I will avoid caffeine w dinner I will avoid naps later in the day I will keep my bedroom cool I will read in bed if I can't fall asleep
Clients with trouble sleeping should be encouraged to keep good sleep habits, which include the following: Reducing stimuli in the bedroom (eg, reading, television). Reading in bed is not recommended. A client wanting to read before bed should do so in a different setting and then go to bed when ready to sleep. Avoiding naps later in the day. Keeping the bedroom slightly cool, quiet, and dark for comfort. Avoiding caffeine, nicotine, and alcohol (stimulants) within 6 hours of sleep. Avoiding exercise or strenuous activity within 6 hours of going to bed to avoid brain stimulation. Avoiding going to bed hungry. Practicing relaxation techniques if stress is causing insomnia.
Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply. exercise programs good room lighting handrails in stairwell smooth soled shoes staff hourly rounds
Falls are a leading predictor of mortality and morbidity in older adults. General exercise programs, especially those including gait, balance, and strength training, not only reduce the risk of falls but also prevent injuries from falls (Option 1). Vision impairment can contribute to fall risks; most adults need additional light by age 50. The nurse should ensure that clients are wearing needed prescription glasses (Option 2). Handrails, particularly in stairwells, hallways, and bathrooms, have been shown to reduce falls (Option 3). Studies show that staff rounds at regular intervals (hourly or every other hour) decrease falls and call light use. The practice allows staff to intervene early in needs. Typically staff checks on the "Ps": potty, position, pain, and placement/proximity of personal items (eg, bed height, call light, water, tissues, urinal). A common reason clients get out of bed unassisted is to use the bathroom (Option 5). (Option 4) Non-slip rubber-soled shoes are recommended to prevent falls.
A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply. cleanse periurethral area w antiseptics q shift ensure each client has a separate container to empty collection bag keep catheter bag below level of bladder routinely irrigate the catheter w antimicrobial solution use sterile technique when collecting a urine specimine
Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps to prevent infections in clients with urinary catheters include the following: Wash hands thoroughly and regularly Perform routine perineal hygiene with soap and water each shift and after bowel movements Keep drainage system off the floor or contaminated surfaces Keep the catheter bag below the level of the bladder Ensure each client has a separate, clean container to empty collection bag and measure urine Use sterile technique when collecting a urine specimen Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder Avoid prolonged kinking, clamping, or obstruction of the catheter tubing Encourage oral fluid intake in clients who are awake and if not contraindicated Secure the catheter in accordance with hospital policy (tape or Velcro device) Inspect the catheter and tubing for integrity, secure connections, and possible kinks (Option 1) Perineal hygiene is performed using soap and water only every shift and as needed. Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the development of drug-resistant bacteria. (Option 4) Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention.
A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention? UAP has attached a bed alarm to the client's gown/bed UAP has been making hourly rounds on the client UAP has lowered the bed and raised all 4 side rails UAP has placed fall risk ID band on client's wrist
Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate. (Option 1) Placing a bed alarm would be an appropriate intervention for this client. (Option 2) Making rounds at least hourly is appropriate for this client. The nurse should assess if more frequent rounds are warranted. (Option 4) Placing a fall risk ID band will help communicate to other members of the interdisciplinary team that the client is at risk for falls.
The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the total output in milliliters for the 8-hour shift. Record your answer as a whole number. Intake and output record Emesis 120 mL Wet diaper 1 50 g Wet diaper 2 52 g Wet diaper 3 46 g *Weight of a dry diaper = 30 g
To measure the urinary output of an infant in diapers, subtract the weight of the diaper when dry from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid. Adequate urinary output for an infant is 2 mL/kg/hr. Calculation: Urine output in diapers: Diaper 1: 50 − 30 = 20 g Diaper 2: 52 − 30 = 22 g Diaper 3: 46 − 30 = 16 g Total mg of urine: 58 g = 58 mL Total output: (Emesis) + (Urine) = 120 mL + 58 mL = 178 mL
A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate? please try not to worry you have an excellent surgeon tell me about how you feel about your surgery why are you considering refusing the surgery you have the right to make your decisions and can refuse the surgery
"Tell me about how you feel about your surgery," is the most appropriate statement to encourage the client to express the source of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support. (Option 1) This statement is nontherapeutic as giving false reassurance minimizes the client's concerns and diminishes trust between the nurse and client. (Option 3) This statement is nontherapeutic and intimidating. Asking "why" and "how" is an ineffective method of gathering information. (Option 4) A client may share a decision with the nurse in an effort to discuss feelings. This statement is nontherapeutic because giving approval of the client's decision does not encourage the client to express concerns about the surgery.
The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply. area around insertion site feels cool to the touch client reports mild arm discomfort since the infusion started edema is observed on the dependent side of the involved arm intraop peripheral iv catheter is placed in left a//c region serous fluid leaks from the site despite secure connections
Peripheral IV (PIV) catheter sites should be changed usually no more frequently than every 72-96 hours unless signs of complications develop. Signs of phlebitis include erythema, edema, warmth, pain, and palpable venous cord. Manifestations of infiltration include edema and coolness to the touch around the insertion site (Option 1). The nurse should also monitor for edema related to infiltration under the involved limb. Infiltrated fluid may leak into loose skin, causing edema in dependent areas without obvious signs of infiltration at the PIV site, particularly in the elderly (Option 3). If a PIV site is leaking fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter; all of these issues require a site change (Option 5). (Option 2) Potassium is a known irritant to veins. Discomfort is not a sign of infiltration, although the site should be regularly monitored for complications. (Option 4) Locations where flexion occurs (eg, antecubital region) are generally avoided; however, these sites may be required for certain medications or situations. Unless a problem develops, PIV sites are not changed based solely on location.
The nurse is caring for a client on droplet precautions who has a prescription for a CT scan. When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room. Which instruction should the nurse give the transporter?
Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet precautions should wear a mask at all times when outside the hospital room. (Option 2) Gloves are not required as part of droplet precautions. Standard precautions should guide the use of gloves in clients on droplet precautions. (Option 3) The transporter does not need to wear a mask outside of the client's room as long as the client keeps a mask on to prevent transmission of infection. (Option 4) An isolation gown is not required for droplet precautions.
incentive spirometry steps
Incentive spirometry (IS) is a respiratory therapy that may be prescribed to postoperative clients to prevent atelectasis associated with incisional pain, especially upper abdominal incisions that are close to the diaphragm. The nurse instructing a client with an open cholecystectomy on IS should teach the following steps: Assume a sitting or high-Fowler position to maximize lung expansion and apply gentle pressure to the abdomen using a pillow (ie, splinting) to reduce incisional stress and discomfort (Option 5) Seal the lips tightly around the mouthpiece following a normal exhalation (Option 1) Inhale deeply and slowly through the mouth until the ball or piston is elevated to the predetermined level of tidal volume (Option 3) Hold the breath for at least 2-3 seconds to promote opening and expansion of alveoli (Option 2) Remove the mouthpiece and exhale slowly using pursed lips, coughing up any loosened secretions, and repeat until prescribed repetitions are achieved hourly while awake (Option 4)
The nurse is assisting a client who has a bedside needle liver biopsy scheduled. Which are the essential actions? Select all that apply. assess for rising pulse and RR after check PT/INR and PTT values before ensure clients blood is type/crossed have the client void to ensure empty bladder position the client flat or on left side after
The client's coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding risk should be assessed and corrected prior to the biopsy (Option 2). Blood should be typed and crossmatched in case hemorrhage occurs (Option 3).After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring later (Option 1). (Option 4) The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety. (Option 5) The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.
The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate? the client has acute urinary retention the client is confused and incontinent the client is elderly and at risk for falls the client is receiving IV diuretics
Catheter-associated urinary tract infections are prevalent in hospital settings. Only indwelling urinary catheters should be used when appropriate. Appropriate uses include the following: Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients Perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery During prolonged immobilization when bedrest is essential To improve end-of-life comfort To facilitate healing of an open perineal or sacral wound in incontinent clients Inappropriate uses include the following: Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently (Options 2, 3, and 4) For obtaining a urine culture when the client can follow instructions and void voluntarily Postoperatively for prolonged periods when other appropriate indications are not present
The nurse plans to administer 9:00 AM medications via the nasogastric (NG) route to a client with an NG tube. The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route? Select all that apply. enteric coated ibuprofen 200 mg tab extra strength acetaminophen 500 mg tab metoprolo extended releaase 50 mg tab sulfamethoxazole double strength 800 mg tab tamsulosin 0.4 mg slow release capsule
Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect the stomach from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes. Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time frame. Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood levels due to more rapid drug absorption. Therefore, the nurse should first contact the PHCP for clarification. (Options 2 and 4) Double- and extra-strength drugs such as sulfamethoxazole and acetaminophen may be crushed and administered separately through an NG tube as long as they are not enteric-coated. The nurse should flush the tube with water before and after each drug administration.
A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action? check the urethral catheter and drainage tubing irrigate the catheter w 30 mL sterile NS notify the HCP remove and reinsert the next larger size catheter
Obstruction (eg, clots, sediment), kinking/compression of catheter tubing, bladder spasms, and improper catheter size can cause leakage of urine from the insertion site of an indwelling urinary catheter. The nurse's first action should be to assess for a mechanical obstruction by inspecting the catheter tubing (Option 1). These interventions may alleviate obstruction: Remove kinking or compression of the catheter or tubing. Attempt to dislodge a visible obstruction by milking the tubing. This involves squeezing and releasing the full length of the tubing, starting from a point close to the client and ending at the drainage bag. If these interventions fail, the nurse should then notify the health care provider (HCP) (Option 3). (Option 2) Irrigation is usually avoided as pus or sediment can be washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to urine flow. If there is a discrepancy in expected urine output compared with fluid intake, a blockage is suspected and a bladder scan is then performed to confirm the presence of urine in the bladder. (Option 4) The client has the recommended size of catheter and balloon for an adult male. The HCP may prescribe removal and reinsertion of a different-size catheter if other measures fail to relieve obstruction.
The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this client? Laboratory results White blood cells 1,100/mm3 (1.1 x 109/L) Absolute neutrophil count 400/mm3 (0.4 x 109/L) Hemoglobin 8.2 g/dL (82 g/L) Platelets 78,000/mm3 (78 x 109/L)
The client's laboratory results show severe neutropenia, with a reduced white blood cell count (normal 4,000-11,000/mm3 [4.0-11.0×109/L]) and reduced absolute neutrophil count (normal 2200-7700/mm3 [2.2-7.7 ×109/L]). Protection against infection is the most important goal for this client. The following neutropenic precautions are indicated: A private room Strict handwashing Avoiding exposure to people who are sick Avoiding all fresh fruits, vegetables, and flowers Ensuring that all equipment used with the client has been disinfected (Option 1) The client's laboratory results show moderate anemia. Blood transfusion and/or erythropoietin injections are important but not a priority. Infections in immunocompromised clients are life threatening. (Option 2) The client's platelet count of 78,000/mm3 (78 ×109/L) is decreased but not dangerously low; therefore, it is not the highest priority intervention. Avoiding intramuscular injections and minimizing venipunctures is most important when the platelet count is below 50,000/mm3 (50 ×109/L), as these can cause prolonged bleeding. (Option 3) This client would need SCDs for prevention of deep vein thrombosis to the legs as anticoagulants may not be used due to the risk of bleeding from low borderline platelet count. However, this is not a priority over infection prevention.
A client receives intermittent bolus enteral feedings through a nasogastric tube. Which are appropriate nursing actions prior to starting the feeding? Select all that apply. discard aspirated residual volume in a biohazard container flush the tube before/after feeding place the client in semi fowlers start the feeding after obtaining a residual vol <100 mL start the feeding when residual vol has pH of 6
The head of the bed should be elevated to a minimum of 30 degrees (semi-Fowler position) during enteral feedings and for 30-60 minutes afterward, thereby decreasing aspiration risk. Many institutions have policies that require the nurse to hold the feeding if the client must be supine (eg, diagnostic tests). Gastric residual volumes are checked every 4 hours with continuous feeding or before each intermittent feeding and medication administration. Continuing feedings despite a large volume residual increases the client's risk for emesis and aspiration. Recent evidence suggests that holding the feeding for a residual volume >100 mL is not necessary, and some institutional policies allow a residual volume of up to >500 mL as long as the client is asymptomatic. Flush the tube before and after bolus feedings to keep the tube patent and avoid contamination of the stagnant feeding solution. Sterile fluid is used to help prevent infection in vulnerable clients. (Option 1) Aspirated residual volume should be returned to the stomach. If acidic gastric juices are repeatedly discarded (2,500 mL secreted daily), there is risk for metabolic alkalosis and hypokalemia. (Option 5) Gastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. In addition, any newly inserted nasogastric tube requires x-ray confirmation of tube location.
The nurse auscultates rhonchi in a client with a tracheostomy tube and performs endotracheal suctioning to clear the secretions. Which nursing interventions are most appropriate to limit the risks associated with suctioning? Select all that apply. apply suction only while withdrawing catheter instill sterile NS to loosen secretions limit aspiration time to 10 sec w each suction pass maintain sterile technique throughout suctioning procedure pre-oxygenate w/ 100% o2
Endotracheal suctioning is performed to maintain a patent airway if a client cannot mobilize secretions independently. Inserting a catheter into the airway compromises the sterility of the lower airway and increases the risk for infection. Suctioning removes oxygen in addition to secretions, placing the client at risk for hypoxemia. High suction levels or the contact of the catheter with the trachea can cause trauma, such as barotrauma, damage to tracheal mucosa, and microatelectasis. In order to decrease the occurrence of these complications: Use strict sterile technique throughout suctioning process. Pre-oxygenate with 100% oxygen (hyperoxygenation) for 3-4 breaths. Aspirate during withdrawal of catheter only, limiting each suction pass to 10 seconds. Allow client 4-5 recovery breaths between suction passes to replenish oxygen. (Option 2) Instilling 5-10 mL of sterile normal saline solution (NSS) is thought to help loosen thick secretions and stimulate cough. Although saline lavage is a common practice in some facilities, the installation of NSS into the airway prior to suctioning is not recommended. It can dislodge bacteria, causing increased bacterial colonization, and can stimulate excessive coughing.
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? complete abstinence from ETOH proper use of meds including lactulose the importance of calling the HCP immediately if bleeding occurs the purpose and use o DNR bracelet
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.
An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with the unlicensed assistive personnel (UAP), who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the registered nurse. Which statement would be the most appropriate response? I'll talk w the client to see why the client is angry it sounds like you shouldn't work w the client so I will reassign you let's go together to talk about the client's concerns why don't you go talk with the client about why the client is angry
Anger is often a sign of psychological distress stemming from anxiety, fear, or loss of control. This elderly veteran has likely had life-long control. Now, with worsening health issues and an acute illness, the client has lost control, causing anger. The feelings are probably accentuated by hospitalization and by staff such as the UAP trying to do things for the client that the client could do alone. A client who is angry should be given the opportunity to express concerns openly. It is important to approach the conversation with an open, accepting, nonjudgmental attitude. The nurse can show the UAP how to deal with these issues. The UAP plays an important role in developing an interdisciplinary plan of care for hygiene and activities of daily living (ADLs) that the client will accept. Therefore, the nurse and the UAP should go together to learn about the client's concerns. They can then work with the client to create a plan for hygiene and ADLs that will allow the client more control while ensuring safety and quality care (Option 3). (Option 1) This is a team problem, so the nurse should seek a solution that includes the UAP, who can contribute to the solution and will learn from the process. (Option 2) Reassigning the UAP will not address the client's concern, and the client may get angry with other staff. (Option 4) This situation will require skilled communication and an empathetic approach, which the UAP is probably not ready to handle alone.
The nurse is forming a plan of care for an 82-year-old client with a history of anxiety, hypertension, urinary incontinence, and arthritic back pain. Which nursing diagnosis should be addressed first? furosemide metoprolol xl oxybutynin xl kcl hydrocodone/acetaminophen prn lorazepam prn anxiety chronic pain r/f acute confusion risk for falls
When determining which nursing diagnosis to address first, the nurse should consider factors that affect client safety. Risk for falls is an immediate safety concern (Option 4). Nursing diagnoses that relate to chronic conditions (eg, anxiety, chronic pain) are addressed after risk for falls. The nurse should immediately implement fall risk precautions by placing the bed in the lowest position, ensuring that the call light is within reach, and turning on the bed alarm. Interventions for addressing other client needs may be carried out after measures to ensure client safety. Advanced age is associated with decreased visual acuity, muscle mass, strength, and reaction time. Medications that cause dizziness or drowsiness increase the risk for falls. Diuretics (eg, furosemide) increase urinary frequency and may cause hypotension. Antihypertensive medications (eg, lisinopril, metoprolol) may cause bradycardia and dizziness. (Option 1) Safety needs are addressed before love and belonging needs (eg, anxiety). Anxiety interventions (eg, therapeutic touch, medication) may be implemented after safety interventions. (Option 2) Safety is the immediate concern for a client with a high fall risk. Arthritic joint changes are a source of chronic pain. Pain interventions (eg, medication, repositioning) may be implemented after safety interventions. (Option 3) A client with advanced age in an unfamiliar environment may develop acute confusion during the hospital course, but a high fall risk is a more immediate concern on admission.
A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? 51 y/o who received a perm pacemaker 48 hrs ago 60 y/o who had an MI 24 hrs ago 74 y/o w stroke and indwelling catheter for 3 days 75 y/o w dementia and dehydration on IVF
A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. (Option 1) This client does have a surgical incision, which poses a risk for infection. However, this client is younger and does not have any underlying chronic condition to compromise the immune system. (Option 2) This client does not fall in the category of elderly and has no surgical incision or indwelling catheters other than a possible IV site. (Option 4) This client is at risk due to age and presence of an IV catheter. However, the risk is not as high as the client with the urinary catheter.
The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all that apply. gloves when contact w body fluids is anticipated gloves when starting an iv gown, gloves, face shield, goggles for every client encounter hand hygiene before/after providing client care n95 respiratory mask/face shield
Hand hygiene is performed before and after providing client care. HIV is a blood-borne virus, and standard precautions are sufficient protection against viral transmission. The nurse wears gloves when anticipating exposure to blood or body fluids. Isolation gowns are applied if the nurse anticipates splashing of body fluids on clothing. A face shield and goggles are applied if splashing in the eyes is a possibility. The nurse should always don gloves when starting an intravenous line. (Option 3) This would be an acceptable level of protective equipment if the client undergoes a non-sterile procedure with significant splash risk, such as vaginal delivery. (Option 5) Face shields are used when splashing on the face or in the eyes is anticipated. A N95 respirator mask is used when caring for a client with airborne isolation precautions.
The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply. ensuring bed alarms remain activated initiating an hourly rounding schedule inserting an indwelling urinary catheter moving the client to a room close to nurse station raising all side rails of clients bed
Falls can occur with any client; however, advanced age, incontinence, confusion, and presence of lines, tubes, and drains increase the risk for falls and injury. Interventions to reduce falls in high-risk clients include: Hourly rounding (eg, assessing pain, offering toileting and nutrition) (Option 2) Moving the client to a room close to the nurses' station (Option 4) Activating bed alarms to alert staff if the client gets out of bed unassisted (Option 1) Asking family members or visitors to stay at the bedside with the client (Option 3) Lines, tubes, and drains (eg, indwelling urinary catheter, IV tubing) tether (ie, tie) the client to the bed or equipment and limit mobility, increasing fall risk. In addition, indwelling urinary catheters increase risk for infection and should be used only when clinically indicated (eg, strict hourly output, critical illness), not for the nurse's convenience (eg, clients requiring frequent toileting or incontinence care). The nurse can reduce urinary urgency and incontinence episodes by offering clients toileting with hourly rounding. (Option 5) Raising all side rails is considered a physical restraint and is associated with more severe fall injuries from clients attempting to climb over the side rails.
The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? Select all that apply. I can apply vaseline to my nose when my nostrils feel dry from the o2 I can cook on my own gas stove as long as I have a fire extinguisher in the kitchen I can increase the liter flow from 2->6 whenever I feel SOB I should not polish my nails when using my o2 I should not use a wool blanket on my bed
Oxygen is a colorless, odorless gas that supports combustion and makes up about 21% of the atmosphere. Oxygen is not combustible itself, but it can feed a fire if one occurs. When using home oxygen, safety precautions are imperative. Vaseline is an oil-based, flammable product and should be avoided. A water-soluble lubricant may be used instead. Oxygen canisters should be kept at least 5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, or other sources of open flames. Clients should use precautions as cooking oils and grease are highly flammable. The prescribed concentration of oxygen, usually 24%-28% for clients with COPD, should be maintained. Oxygen is prescribed to raise the PaO2 to 60-70 mm Hg and the saturations from 90%-93%. A flow rate of 2 L/min provides approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher rates usually do not help and can even be dangerous in clients with COPD as they can decrease the drive to breathe. The client should notify the care provider about excessive shortness of breath as additional treatment may be indicated. (Option 4) The client understands that nail polish remover and nail polish contain acetone, which is highly combustible. (Option 5) Clients should avoid synthetic and wool fabrics because they can cause static electricity, which may ignite a fire in the presence of oxygen. Clients should use cotton blankets and wear cotton fabrics.
A client with left lobar pneumonia is transferred to the intensive care unit due to increasing respiratory distress. While providing care for the client, the nurse notes a significant drop in saturation when the client is placed in which position? high fowlers left side right side semi fowlers
Pneumonia decreases gas exchange in the affected areas of the lung. This client is experiencing ventilation to perfusion (V/Q) mismatch, because the affected area is receiving adequate perfusion from the pulmonary artery, but lung infiltrates are obstructing effective gas exchange. Arterioles in the affected area compensate by vasoconstricting, which re-directs blood flow away from the hypoxic alveoli and toward better-ventilated areas of the lung. This is known as hypoxic pulmonary vasoconstriction. This client with left lobar pneumonia should be positioned with the good lung down. If the client is positioned on the left side, because of gravity, blood flow will be directed to the area of pulmonary vasoconstriction, V/Q mismatch will increase, and saturation can drop significantly. Positioning the good lung down also promotes re-expansion (of atelectasis) and drainage of the bad lung. (Options 1 and 4) Positioning in high Fowler's or semi-Fowler's position will not cause a significant drop in saturation. (Option 3) Positioning with the right or good lung down will help improve V/Q matching and gas exchange because gravity causes more blood to go through the well-ventilated lung.
The nurse is caring for a hospitalized client with an acute exacerbation of heart failure. The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily. The client's child reports that the client has trouble swallowing the large KCl pill. The client's potassium level is 3.7 mEq/L (3.7 mmol/L). What action should the nurse take first? consult the pharmacist to see if other oral forms of KCL are available crush the pill and mix it w applesauce or pudding hold the KCL until the HCP makes rounds instruct the client to tuck the chin to the chest when swallowing the pill
Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. Oral KCl is available in extended-release tablets, capsules, dissolvable packets, and effervescent tablets, and as an oral liquid. If a client has difficulty swallowing large pills, the nurse should consult the pharmacist to see if other forms of KCl are currently available and to determine if the medication is safe to crush. If a more appropriate form (eg, liquid) is available, the nurse would then discuss that change in route with the health care provider and obtain an updated prescription. (Option 2) Some pills or capsules are sustained-release formulations, and crushing may alter the release of the drug and cause an overdose of the medication. The nurse should consult the pharmacist before altering the form of the drug. (Option 3) The use of a loop diuretic, such as furosemide, is a common cause of potassium depletion. Holding the KCl dose may cause the client's potassium level to fall below normal (<3.5 mEq/L [3.5 mmol/L]), which can potentiate digoxin toxicity (eg, cardiac dysrhythmias, gastrointestinal upset). (Option 4) Tucking the chin to the chest during swallowing is a technique used to prevent aspiration. This most likely will not help the client swallow the large pill.
