HESI FINAL TEST

massive ascites

- may cause renal vasoconstriction, triggering the renin-angiotensin system. *This results in sodium and water retention, which increases hydrostatic pressure and the vascular volume and leads to more ascites. -distended abdomen with bulging flanks -orthopnea and dyspnea from increased abdominal distention can interfere with lung expansion. The patient may have difficulty maintaining an erect body posture, and problems with balance may affect walking. Inspect and palpate for the presence of inguinal or umbilical hernias, which are likely to develop because of increased intra-abdominal pressure. Minimal ascites is often more difficult to detect, especially in obese patient. Patient with abdominal ascites in late-stage cirrhosis. When performing an assessment of the abdomen, keep in mind that hepatomegaly (liver enlargement) occurs in many cases of early cirrhosis. Splenomegaly is common in nonalcoholic causes of cirrhosis. As the liver deteriorates, it may become hard and small. Measure the patient's abdominal girth to evaluate the progression of ascites. To measure abdominal girth, the patient lies flat while the nurse or other examiner pulls a tape measure around the largest diameter (usually over the umbilicus) of the abdomen. The girth is measured at the end of exhalation. Mark the abdominal skin and flanks to ensure the same tape measure placement on subsequent readings. Taking daily weights, however, is the most reliable indicator of fluid retention.

Therapeutic Communication: Noncompliance The client is post-menopausal and smokes two packs of cigarettes a day. Her hypertension is uncontrolled even with the prescribed ACE inhibitor. The client took the clinic's online learning course on reducing the risk for heart disease. At the conclusion of the course, the client tells the nurse that she does not need classes because she knows she is going to be healed. Which nursing intervention best promotes effective communication?

-"I believe that God helps those who help themselves." Therapeutic communication should be free of the nurse's personal values. This blocks further communication. -"You will have a heart attack if you don't change your lifestyle." This statement is overly threatening and confrontational, and it does not promote further communication. -"Do you feel that you do not need to be involved in your health care?" Clarification of the client's statement is a useful therapeutic technique that encourages further communication. -"You must accept that you have a responsibility to care for yourself." This statement is confrontational and does not promote further communication.

The ED nurse looks up the prescribed medications and notes that the recommended dosage for losartan is 50 mg PO daily, or 25 mg PO daily in combination with a diuretic. A precaution listed for this medication is increased risk of hypotension and syncope with concurrent use of ACE inhibitors. What action should the nurse implement?

-Acknowledge the losartan medication prescription. Acknowledging prescriptions only verifies the nurse is aware of what has been prescribed. It does not address the issue. A medication that needs to be clarified should not be acknowledged until clarified to prevent the client from receiving an incorrect dose. -Contact the HCP to clarify medication prescriptions. The nurse is responsible for researching potential drug interactions and verifying that the prescribed medication is the appropriate dose and route, prior to administering it to the client. -Administer medications after pharmacy verifies orders. Pharmacy may review the medications and seek clarification; however, it is the nurse's primary responsibility to clarify with the HCP. -Prepare first dose of losartan to be administered. The medication should not be administered until the dosage has been clarified

The healthcare provider (HCP) orders IV nitroglycerin for the client. What changes in the client's cardiac function should the nurse tell the client to expect?

-An increase in the strength of the heart muscle to contract. Increasing the force and velocity of myocardial systolic contraction is not an action of nitroglycerin. -Improved perfusion of oxygenated blood to the heart muscle. Nitrates cause the coronary blood vessels to dilate, allowing improved oxygen delivery to cardiac muscle. In addition, nitrates cause systemic vasodilation, reducing the workload on the heart, which in turn reduces the myocardium's need for oxygen. -Causes the heart muscle to relax between contractions. Nitroglycerin perfuses cardiac muscle, but it does not relax the muscle. -Dissolves the blockage inside the coronary arteries. Nitroglycerin is not a thrombolytic and does not dissolve what is blocking the arteries.

Safe and Effective Care Upon arrival to the ED, the nurse notices that the client is leaning forward in the wheelchair. The client is pale, somnolent, and having difficulty breathing. Q: Which intervention should the nurse initiate first?

-Apply an oxygen mask on the client at 6 liters per minute. The client may need oxygen but getting the client's airway open is priority. -Place the client on a stretcher and open airway. The nurse needs to place the client on a solid, flat surface to align his airway in a neutral position to open his airway for a visual inspection to assess for an airway obstruction. -Check the client's oxygen saturation level. Knowing the client's oxygen saturation will provide the information needed to determine how much supplemental oxygen the client needs, however getting the client's airway open is priority. -Auscultate the client's lung sounds. Lung sounds are important to determine the movement of air, however, getting the client's airway open is a priority.

Which intervention is most important for the nurse to include in the client's plan of care to decrease risk of having a myocardial infarction?

-Arrange a follow-up appointment with a healthcare provider. Follow up will be key upon discharge; however, if risks are not modified, follow up will not help reduce the risk. -Obtain a consult for social worker to provide community resources. Resources are important, but will not directly reduce the risk. -Call the local pharmacy to identify the antihypertensive that the client was prescribed. Knowing what medication the client was taking will not directly decrease his risk. -Identify the client's risk factors for having an acute myocardial infarction. Identifying and informing the client of the risk factors that can be modified is priority. Smoking, drinking, and hypertension are modifiable and/or controllable risk factors. Family history will also increase the client's risks.

In addition to nitroglycerin, the HCP orders morphine sulfate 4mg IV. Which reaction requires immediate intervention by the nurse?

-Blood pressure 100/68 mmHg. The BP is not significantly low. -Onset of sudden drowsiness. Drowsiness is an expected effect of morphine. -Unrelieved pain 15 minutes after injection. While this warrants further assessment, it is not an immediate intervention. -Respiratory rate slowing to 10 breaths/min. Profound respiratory depression is an adverse reaction of opioids such as morphine sulfate. Respiratory rate should remain 12 breaths/min or higher.

The HCP plans to keep the client in the hospital for a few days. The ED nurse is preparing to transfer the client to a medical unit. Which intervention should the nurse implement first?

-Call to provide a report to the receiving nurse. Notifiying the receiving nurse of readiness to transfer will alert all the nurses to obtain any needed equipment prior to the client's arrival on the medical unit. Handoff communication is priority. -Document the transfer in the medical record. Documentation of transfer should be done when client is leaving the ED. -Obtain and apply portable oxygen. Oxygen will be needed for transport but should not be discontinued from the wall oxygen until the client is ready to leave the room. -Administer first dose of prescribed medications. First doses may not all be due or ready for administration. This should not delay transfer to the medical unit.

Psychosocial Integrity/Therapeutic Communication The admitting nurse completes the client's assessment, orients them to the unit, and discusses the plan of care. The nurse also verifies the client's medical and surgical history, updates personal history, and documents a person of contact. It is important for the nurse to develop a therapeutic relationship with the client. When conducting the admission interview, what actions best facilitate the process? (Select all that apply. One, some, or all options may be correct.)

-Clarify information by asking the client more focused questions. Accepting information without questioning and/or clarifying could lead to misunderstanding and lack of pertinent information. Use focused questions when more specific information is needed in an area. -Stand at the foot of the client's bed to conduct the interview. Standing at the foot of the client's bed is an intimidating posture that insinuates the nurse is in a hurry. Sitting in a chair by the bedside will place the nurse at eye level with the client, which helps facilitate conversation and sends the message that the nurse is there to communicate. -Reassure the client that everything will be alright and that he is going to get better. The nurse should not give the client false reassurance. Giving false reassurance could lead to feelings of mistrust and anger. -Let the client do most of the talking and actively listen. The most important element of effective communication is active listening. Watching, observing, and listening to the client's verbal and nonverbal language is very important. -Use open-ended questions that will allow the client to "lead" the conversation. Open-ended questions allow clients to take the conversational lead and introduce pertinent information about a topic. Use focused questions when more specific information is needed in an area.

Nursing Diagnoses and Interventions The nurse assesses the client for changes in vital signs and for dysrhythmias. Other assessment findings related to MI include: Dyspnea Pallor Diaphoresis Weakness Fatigue Nausea Vomiting Fever The client is transferred to the critical care unit for treatment and monitoring. She is still receiving oxygen at 2 L/min and IV nitroglycerin infusion. Her vital signs are stable. Her oxygen saturation is 94%, her breath sounds are clear, and she denies any pain at the present time. The client's nurse develops a plan of care based on the following nursing problems: Pain related to an imbalance between myocardial oxygen supply and demand. Alteration in tissue perfusion (cardiac) related to blood flow interruption. Activity intolerance related to imbalance between oxygen supply and demand. Anxiety related to pain and fear. Which intervention is most important for the nurse to include in the client's plan of care?

-Continuous cardiac monitoring of heart rate and rhythm. The heart rate and rhythm should be continuously monitored. Lethal arrhythmias are the most common immediate complication following an acute myocardial infarction that can be life threatening. -Auscultate lungs for adventitious sounds such as crackles. Auscultating the lungs for crackles or other adventitious sounds can reveal pulmonary edema which is a possible complication following an acute myocardial infarction. Pulmonary edema is often gradual and not immediately life threatening. -Titrate oxygen to keep oxygen saturation greater than 93%. Monitoring and titrating oxygen will help provide the myocardial tissue the oxygen it needs to prevent further injury. A gradual drop in oxygen can be managed and is not immediately life threatening. -Obtain blood to evaluate scheduled serum cardiac markers. Monitoring serum cardiac markers will determine if the mycardial tissue injury is resolving. Knowing the cardiac marker levels will aid in prompt intervention but is a scheduled intervention.

The severity of the client's pleural effusions are confirmed with the enlarged cardiac silhouette on the chest x-ray. The client is having difficulty taking deep breaths and is short of breath when speaking. Which intervention is most important for the nurse to include in the client's plan of care?

-Daily weights. Daily weights will help monitor fluid retention but will not improve the client's symptoms. -Sodium restricted diet. Diet restrictions will decrease complications of further fluid retention due to diet. However, this intervention is not immediately helpful. -Daily fluid restrictions. Fluid restrictions will decrease complications of further fluid retention due to diet. However, this intervention is not immediately helpful. -High Fowler's position. Positioning the client to promote ease of breathing is immediately effective and a priority while treating the underlying cause.

blue nails

-Diffuse blue discoloration that blanches with pressure = Respiratory failureMethemoglobinuriaVenous stasis disease (toenails)

yellow-brown nails

-Diffuse yellow to brown discoloration -Vertical brown banding extending from the proximal nail fold distally (Normal finding in dark-skinned patients. Nevus or melanoma of nail matrix in light-skinned patients) = Jaundice Peripheral lymphedema Bacterial or fungal infections of the nail Psoriasis Diabetes Cardiac failure Staining from tobacco, nail polish, or dyes Long-term tetracycline therapy Normal aging (yellow-gray color)

Later that day, the client reports to the nurse less abdominal pain and nausea, a severe headache, blurry vision, and feels really tired. The nurse assesses the client and notes an irregular heart rate of 56 bpm. Which laboratory tests does the nurse anticipate the HCP will prescribe for the client? (Select all that apply. One, some, or all options may be correct.)

-Digoxin serum level. The client is prescribed digoxin and is congruently taking captopril and diltiazem, which has the potential to increase the levels of the digoxin, leading to toxic levels. Sodium level. Sodium levels are not directly associated with these symptoms. The signs and symptoms that the client is experiencing are related to digoxin and the other medications that increase the potential for digoxin toxicity. -Potassium serum level. Low potassium levels increase the chance of digoxin toxicity. Furosemide may cause hypokalemia, which increases the potential of the occurrence of digoxin toxicity. -Phosphorus serum level. Phosphorus levels are not directly associated with these symptoms. The signs and symptoms that the client is experiencing are related to the prescribed digoxin and other medications that increase the potential for digoxin toxicity. -Calcium serum level. Calcium levels are not directly associated with these symptoms. The signs and symptoms that the client is experiencing are related to the prescribed digoxin and other medications that increase the potential for digoxin toxicity.

Clinical Manifestations The nurse reviews the client's symptoms during the myocardial infarction. Her pain was first noted as a discomfort during the first presentation. She was weak and short of breath. The ECG revealed ST elevation. Later her chest pain increased and the ECG revealed ST elevation in the lower lateral leads which indicated a STEMI. Elevated cardiac specific laboratory findings, ECG findings, and physical assessment confirmed that the client was having an acute myocardial infarction. After 2 doses of sublingual nitroglycerin and 4 mg IV morphine sulfate, the client's pain is 1 out of 10. The nurse is monitoring the client for complications that are common after a myocardial infarction. Which focused assessment finding warrants immediate intervention by the nurse?

-Dysrhythmias. The most common complication after an MI is dysrhythmias. Lethal dysrhythmia often occur within 4 hours from onset of chest pain. Premature ventricular contractions may precede the lethal dysrhythmias ventricular tachycardia and fibrillation. -Bilateral pulmonary crackles. Heart failure is a complication that occurs when the heart's pumping action is reduced and can produces crackles, extra heart sounds (S3 or S4) and jugular vein distention. Heart failure is not immediately life threatening. -Distended jugular vein. Heart failure is a complication that occurs when the heart's pumping action is reduced and can produces crackles, extra heart sounds (S3 or S4) and jugular vein distention. Heart failure is not immediately life threatening. -Pericardial friction rub. Pericarditis is a complication that can occur following an acute myocaridal injury. Signs and symptoms include ECG changes including diffuse ST-segment elevations and an audible pericardial friction rub. Pain is aggrivated with inspiration and is typically described differently than classic chest pain. Pericarditis is not immediately life threatening.

The client is scheduled for percutaneous transluminal coronary angioplasty (PTCA) via femoral insertion. PTCA involves the insertion of a balloon-tipped catheter into the diseased coronary artery. When the balloon is inflated, it compresses the plaque against the vessel wall, resulting in an increase in the inner diameter of the blood vessel so blood can flow more easily. Which nursing intervention should be implemented first when the client returns to her room?

-Encourage intake of oral fluids. For the first 24 hours following the procedure, intake and output should be monitored, but forcing fluids is not indicated. -Immobilize the affected leg. The prevention of catheter dislodgement and of bleeding or oozing at the insertion site is a high priority in the immediate post-procedure period. The site should be immobilized and closely monitored for signs of hematoma formation (bleeding, inflammation, tenderness, or swelling). In addition, distal circulation should be monitored closely by assessment of pedal pulses, color, warmth, and capillary refill. -Obtain apical pulse every 15 minutes. The client should be continuously monitored for the onset of any dysrhythmias, but frequent (every 15 minutes) assessment of the apical pulse is not necessary. -Limit visitors to one per hour. Limiting visitors is not routine or necessary, but it should be implemented if the client's comfort or safety is jeopardized.

Which information in the client's history indicates an increased risk for coronary artery disease (CAD) and requires the nurse to provide disease management education? (Select all that apply. One, some, or all options may be correct.)

-Episodes of hypoglycemia. Hypoglycemia does not increase the risk for CAD. A history of diabetes mellitus is a contributing risk factor. -Family history of hyperlipidemia. Genetic predisposition is a significant factor in the development of CAD. -Consumption of a high-fat diet. Unhealthy habits, such as consuming fatty foods, are contributing risk factors to CAD. -Hypertension controlled with an oral antihypertensive. High blood pressure is a modifiable risk factor. If controlled, then it is not an active risk. -Smoking two packs of cigarettes per day. Smoking is a modifiable risk factor for coronary artery disease.

ECG findings reveal ST segment elevation in leads II and III, and a VF indicating that the client is having an inferior acute myocardial infarction (AMI). Which intervention should the nurse implement first?

-Have the client chew four 81 mg chewable acetylsalicylic acid. The first intervention according to American Heart Association standard is to administer acetylsalicylic acid 160-325 mg PO that acts on the platelets, keeping them from clumping together at the site of the coronary blockage. -Apply oxygen 2 L/nasal cannula. Oxygen is the second intervention according to American Heart Association standard, if the client's oxygen saturation level is less than 94%. Give the client one nitroglycerin tablet to dissolve under her tongue. Nitroglycerin is the third intervention according to American Heart Association standard, and is given to vasodilate the coronary arteries and relieve pain. -Administer morphine sulfate 4 mg IV. Morphine is given if pain is unrelieved by the nitroglycerin, according to American Heart Association standard.

While taking the prescribed antihyperlipidemic, which serum laboratory value requires intervention?

-Heart healthy diet Hearth healthy diet is only one component of the critical healthy lifestyle habits that are needed in conjunction with cholesterol-lowering medication. -Healthy lifestyle habits Lifestyle modifications should be used in conjunction with a cholesterol-lowering medication. Lifestyle modificatios include heart healthy diet, regular exercise, avoiding tobacco products, and maintaining a healthy weight. -Avoid use of tobacco products Avoiding tobacco is only one component of the critical healthy lifestyle habits that are needed in conjunction with cholesterol-lowering medication. -Maintain a healthy weight Maintaining a healthy weight is only one component of the critical healthy lifestyle habits that are needed in conjunction with cholesterol-lowering medication.

white finger nail

-Horizontal white banding or areas of opacity -Generalized pallor of nail beds = Chronic liver or kidney disease (hypoalbuminemia) Shock Anemia Early arteriosclerotic changes (toenails) Myocardial infarction

Acute Myocardial Infarction (AMI) The client's angina remains stable, and she undergoes a hysterectomy for dysmenorrhea related to uterine fibroids. The day after being discharged from the hospital, the client comes to the ED with crushing substernal chest pain radiating down her left arm. She is dyspneic, pale, and diaphoretic. Which nursing intervention should be implemented first?

-IV access and administer morphine sulfate as ordered by the HCP. Acute chest pain related to myocardial infarction, ischemia, or reduced coronary artery blood flow is the most important nursing problem to address for the client with Acute Coronary Syndrome (ACS). Treating pain is critical, as pain activates the sympathetic nervous system and aggravates diaphoresis, weakness, light-headedness, and palpitations which, in turn, increases cardiac workload. -Administer oxygen. Oxygenation to the myocardial tissue is important for pumping activity and tissue damage repair. Rest also helps to improve oxygenation. However, recent guidelines suggest that routine use of supplemental oxygen may not be necessary in clients with uncomplicated ACS without signs of heart failure, hypoxemia, respiratory distress, or for an oxyhemoglobin saturation rate of 94% or greater. -Obtain a 12 lead electrocardiogram (ECG). While this intervention will be useful in establishing the client's baseline rhythm upon arrival in the ED, and will be helpful in locating the area of MI, circulation is the third priority for emergency care. -Assess the client's blood pressure. Obtaining the client's baseline vital signs, including blood pressure, heart rate, and temperature, is important and monitored continuously, but is not the priority.

Psychosocial Integrity/Client-Centered The nurse completes the client's admission interview discovering that the client is homeless and without a job. The client's spouse died after a long battle with cancer leaving the client in financial crisis which lead to being homless. The client has one son who lives out of the country and unaware of the client's current status. Therapeutic communication involves listening and analyzing what the client is conveying. Based on the information provided by the client, which nursing interventions best promote effective communication? (Select all that apply. One, some, or all options may be correct.)

-Inquire about the client's work history including specific job duties. Individuals who had worked in naval and civilian shipyards were exposed to asbestos in the construction of naval ships, which is known to cause mesothelioma. Asbestos was also used in construction material for buildings. Studies have suggested that individuals who worked in the farming industry and were exposed to pesticides are at increased risk of developing cancers, especially prostate cancer. -Ask the client to elaborate on his son's line of work. The client's son's employment and location should not have a direct impact on the client developing cancer and/or blood anomalies. -Assist the client in recalling his diet intake over the last few weeks. Because of his anemia, it is important to ask about protein intake. Iron deficiency anemia is the most common nutritional disorder in the world and adequate protein intake can prevent this condition. -Review with the client any family history of cancer. It is important to ask about family history of cancer because of the risk factor for some cancers. Question the client regarding history of military enlistments. Studies have shown that some individuals who served in Vietnam were exposed to Agent Orange (herbicide). Those individuals are more likely to develop a precursor disease to multiple myelomas.

The nurse completes a problem focused assessment. Which finding warrants immediate intervention by the nurse?

-Irregularly, irregular atrial dysrhythmia. An irregularly, irregular atrial dysrhythmia, known as Atrial Fibrillation is a complication of heart failure. Atrial fibrillation increases as the severity of heart failure increases and promotes thrombus formation within the atria which can break loose and place the client at risk for a life-threatening stroke. -Progressive weight gain. Progressive weight gain is a clinical manifestation of chronic heart failure and is not immediately life-threatening. -Fatigue with usual activities. Fatigue with usual activities is a clinical manifestation of chronic heart failure and is not immediately life-threatening -Dyspnea with mild exertion. Dyspnea with mild exertion is a clinical manifestation of chronic heart failure and is not immediately life-threatening.

Upon reviewing the prescriptions and laboratory results, which intervention(s) should the nurse include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.)

-Keep the client on bedrest until oxygen can be weaned. The client does not need to be placed on bedrest unless there is a suspicion of a more serious problem such as a pulmonary embolism. Mobility as tolerated decreases risk of pulmonary complications. -Ensure NPO instructions are clarified with HCP. The client should be on NPO status for a minimum of 8 hours for the fasting glucose and 12 hours for the lipid profile. -Discuss plan to correct abnormal laboratory values with HCP. The client's abnormal sodium, potassium, and phosphorus need to be addressed. Abnormalities can cause cardiac irritability and lethal arrhythmias. -Increase the frequency of vital signs. The order for vital signs every four hours should be sufficient unless the client's condition decompensates. -Clarify rate of IV fluids while NPO. Increasing the client's IV fluid would exacerbate his congestive heart failure.

Calcium channel blockers enhance the action of digoxin by increasing the serum digoxin levels. Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity?

-Low potassium level. Potassium can increase or decrease the effects of digoxin but is not a sign of toxicity. -Yellow halos around lights. Early signs of toxicity include anorexia, nausea and vomiting, fatigue, headache, depression, and visual changes. -Slow heart rate. Late signs of toxicity include cardiac dysrhythmias such as bradycardia or heart blocks. -Increased liver function test. Digoxin is metabolized by the kidneys and liver. If the client has kidney or liver disease, they have an increase in risk for toxicity. However, this is not a sign of toxicity.

What steps should the nurse take to minimize the development of these adverse effects? (Select all that apply. One, some, or all options may be correct.)

-Monitor serum lidocaine levels. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/mL (6.4 to 21.34 mcmol/L). -Continue the infusion as prescribed. The infusion must be stopped immediately if signs of overdose are present. -Monitor ECG, blood pressure, and respiratory status. Heart rhythm and VS, especially blood pressure and respirations, must be monitored closely. -Monitor the client's anxiety level. Nervousness and excitation are adverse effects of lidocaine and the nurse should monitor the client closely for these developments.

The nurse notes eight high-pitched gurgling sounds occurring at irregular intervals in the right lower abdomen over 15 seconds.

-Move to the right upper quadrant (RUQ) to hear the sounds more distinctly. Client has complained of right upper quadrant pain so moving to that quadrant next is not advised. Continue to auscultate for bowel sounds in the right lower quadrant. The pattern of bowel sounds is typically irregular and the duration of bowel sounds may range from 1 second to several seconds. Expected amount of bowel sounds is between 8-30 over 1 minute. Need to assess if bowel sounds are hypoactive, hyperactive, or normal. Change to the bell of the stethoscope to listen. The diaphragm of the stethoscope should be used to listen to bowel sounds. Listen for 5 minutes before documenting the activity of the bowel sounds. If bowel sounds are not heard, the nurse should listen for 5 minutes to allow sufficient time before documenting the absence of bowel sounds. If bowel sounds are heard, it is not necessary to continue to listen for 5 minutes.

In addition to the ECG, the nurse sent blood to the laboratory to evaluate the client's cardiac isoenzyme. Which serum laboratory values requires intervention by the nurse?

-Myoglobin 60 mcg/L (3.49 nmol/L). Myoglobin (Female) 10 - 65 mcg/L (0.58 - 3.78 nmol/L) (onset: 1-3 hrs, peak: 6-10 hrs, return to normal: 12-24 hrs). -Creatine kinase - MB (CK-MB) 3.0 ng/mL (3.0 mcg/L). Normal CK-MB < 5.0 ng/mL (5.0 ug/L). This is the most sensitive creatine kinase to the cardiac muscle, but is also found in skeletal muscle. -Lactate dehydrogenase (LDH) 200 U/L (3.34 mckat/L). Normal LDH is 140 U/L (0.67 ukat/L) to 280 U/L (4.68 ukat/L). LDH, like creatine phosphokinase (CPK), is an enzyme that is nonspecific to cardiac muscle injury. However, LDH1 is a sensitive cardiac isoenzyme, which is often compared with LDH2 as a ratio during the diagnosis of MI. -Troponin T 0.4 ng/mL (0.4 mcg/L). Troponin T 0 - 0.2 ng/mL (0.2 ug/L) (onset: 2-4 hrs, peak: 10-24 hrs, return to normal: 10-14 days). This indicates acute myocardial injury and requires immediate intervention.

After observing the presence of rebound tenderness, the nurse notes the onset of involuntary rigidity of the client's abdomen. Which action should the nurse implement?

-Notify the HCP of the findings. Rebound tenderness and involuntary rigidity (guarding) are abnormal findings associated with peritoneal irritation and are signs that should be reported to the HCP immediately for further diagnostic evaluation. Assist the client to a semi-Fowler's position. This action is not useful following the onset of involuntary rigidity (guarding). Administer a pain medication. More assessment is needed prior to the administration of a pain medication, which could mask other symptoms. Place a warm moist pack on the client's abdomen. This action is not useful following the onset of involuntary rigidity (guarding).

The nurse notices that the client's urine is greenish in appearance when a urine sample is collected. Which intervention(s) should the nurse implement? (Select all that apply. One, some, or all options may be correct.)

-Notify the HCP. Some infectious processes such as urinary tract infections (UTIs) caused by pseudomonas can cause the urine to turn green, but this is not indicated at this time. -Recollect the urine sample to be analyzed again. The urine specimen was properly collected; therefore, it is not necessary to collect another sample. -Ask the client to list the food he has eaten in the last 24 hours. Certain foods, such as asparagus and black licorice, as well as medications such as cimetidine and indomethacin can cause urine to appear green. -Record the color and amount of urine in the medical record. The appearance of the urine needs to be documented, along with information the client provides about oral intake from the previous 24 hours. -Prepare to place a urinary catheter. The presence of a urinary catheter is the most important risk factor for bacteriuria. The nurse cannot place a urinary catheter without a prescription from the HCP. A urinary catheter would exacerbate an infection which has not been confirmed at this point.

Several months later, the client visits the clinic for routine lab work. After walking into the clinic on a very hot day, she reports to the nurse that she is experiencing chest pain. After resting for five minutes, the pain is relieved. Following assessment and ECG evaluation, the client is diagnosed with stable angina and receives two prescriptions: Nitroglycerin 0.2 mg/hour transdermal patch. Apply every morning and remove at bedtime daily. Nitroglycerin 0.3 mg SL as needed for chest pain Which intervention is most important for the nurse to include in the client's plan of care for the self-administration of sublingual nitroglycerin?

-Place one tablet at a time under the tongue. Sublingual tablets are placed under the tongue. It is most important to know to take 1 tablet every 5 minutes for 15 minutes, for a total maximum dose of 3 tablets. -Allow tablet to dissolve completely before swallowing. Tablets must completely dissolve to be effective. It is most important to know to take 1 tablet every 5 minutes for 15 minutes, for a total maximum dose of 3 tablets. -Put one tablet every 5 minutes under tongue up to 3 tablets. Nitroglycerin tablets should be placed under the tongue when chest pain occurs. They may be taken one tablet every 5 minutes for 15 minutes, for a total maximum dose of three tablets. If the pain is not relieved after three doses, the client should be instructed to go to the Emergency Department. -Do not drink anything until tablet is completely dissolved. Drinking may cause some of the medication to be swallowed and not absorbed sublingually, slowing the absorption of the nitroglycerin dose. It is most important to know to take 1 tablet every 5 minutes for 15 minutes, for a total maximum dose of three tablets.

A Complication Occurs On the client's second day post-MI, the nurse notes a change in the client's cardiac monitor. The client's rhythm strip changes from normal sinus rhythm to sinus rhythm with short runs of ventricular tachycardia (VT). The nurse assesses the client, whose blood pressure is now 100/54 mmHg. The client is lethargic, but she is able to be aroused. Which intervention should the nurse initiate first?

-Place the crash cart in close proximity to the room. Since the client's condition may be a life-threatening dysrhythmia, this intervention may be required if the client's dysrhythmia does not respond to medication. However, this is not the best initial action. -Administer amiodarone IV. The treatment of choice for frequent premature ventricular contractions (PVCs) and ventricular tachycardia is an immediate IV bolus of amiodarone. -Hang an IV infusion of dopamine. Dopamine is a vasopressor and inotropic agent that is used to treat severe hypotension and shock. This intervention may be required if the client's dysrhythmia is not controlled and cardiogenic shock develops. However, this is not the best initial action. -Charge the defibrillator to 200 joules. Since the client's condition may be a life-threatening dysrhythmia, this intervention may be required if the client's dysrhythmia does not respond to medication. However, this is not the best initial action.

Physiological Integrity The client's chest x-ray reveals consolidation in the lower bases, scattered infiltrates throughout, and an enlarged cardiac silhouette. Based on the diagnostic findings with the physical assessment of dullness with percussion, which assessment finding warrants immediate intervention by the nurse?

-Progressive dry cough. A dry cough is a common symptom for pleural effusions, but is not life threatening. -Decreased breath sounds. The infiltrates are areas of the lungs where there are decreased breath sounds caused by pulmonary edema as a result of heart failure. -Use of accessory muscles. Use of accessory muscles is a sign that the client is failing to compensate and may require life-saving measures. -Dyspnea on exertion. The client can limit activities that cause dyspnea and may need to be placed on bed rest if oxygenation falls below 94% with activity.

The client continues to recover in the intensive care unit. Which interventions should the nurse implement for the client? (Select all that apply. One, some, or all options may be correct.)

-Provide pain medication with onset of pain. Providing optimal pain relief with prescribed analgesics is important because pain can exacerbate tachycardia and increases blood pressure. -Administer anti-anxiety medication as needed. Identify when level of anxiety increases. Anxiety increases the need for oxygen. -Encourage the client to maintain complete bedrest Monitor exercise and provide rest periods to avoid fatigue and to increase activity tolerance without rapidly increasing cardiac workload. Complete bedrest could lead to pulmonary complications. -Assess the client's level of knowledge and ability to learn. Knowledge related to disease process and prognosis is important but should also be realistic. Realistic expectations promotes realistic decision making. -Provide pamphlet listing non-modifiable risk factors. Instruct the patient on cardiac risk factors that are modifiable which include smoking cessation, diet, and exercise. Non-modifiable risk factors are good to know but will not increase patient's control of illness.

Which intervention is most important for the nurse to reinforce when assisting the client in achieving their goal to quit smoking?

-Provide the client with a list of local smoking cessation programs. Prescribed and over-the-counter medications work best when taken in conjunction with a smoking cessation program. -Review a list of over-the-counter smoking cessation aids with the client. Over-the-counter medications work best when taken in conjunction with a smoking cessation program. -Encourge the client to start taking a prescribed nicotinic agonist. Prescribed medications work best when taken in conjunction with a smoking cessation program. -Identify the triggers that cause the client to use nicotine. Even though smokers indicate that they would like to quit, the addictive quality of nicotine makes it very difficult to do so without having support with medication and a program.

As the client is transferred to a stretcher the nurse notices the use of accessory muscles of the chest and neck and an exaggerated effort to breathe. Which intervention should the nurse implement first?

-Raise the head of the stretcher to a semi-Fowler's position. The first intervention is to raise the head of the stretcher to a semi-Fowler's position, allowing for full expansion of the client's lungs and taking pressure off his diaphragm, enhancing the delivery of oxygen to the lungs. -Apply a partial rebreather mask with oxygen at 10 liters per minute. Once positioned so the airway is open and the client is able to breathe easier, oxygen should be applied. -Auscultate the client's lungs bilaterally to assess for diminished breath sounds. Equal breath sounds are important; however, airway patency is a priority. -Monitor the client's oxygen saturation level. Knowing the level of oxygen will help the nurse titrate oxygen once the airway is patent.

The client is transferred from the ED to the medical unit. The ED nurse gives the admitting nurse a hand-off report. Which nursing intervention best promotes effective communication?

-Relay a complete review of the client's past medical history. Handoff communication should be problem focused. A complete history may not be appropriate at handoff. -Report off on all abnormal laboratory and diagnostic procedure results. Handoff of abnormal results can be limited to critical values and results that require nursing intervention. -Use SBAR (Situation-Background-Assessment-Recommendation) when reporting to receiving nurse. SBAR (Situation-Background-Assessment-Recommendation) technique provides a systematic, effective way to report off when a client is moving within units of the hospital. SBAR is a way to communicate the client's condition among members of the healthcare team that is predictable and structured. -Elaborate on the history of smoking and alcohol consumption. Smoking and alcohol consumption can be included in the SBAR if it is immediatly necessary .

The nurse teaches the client about their medications prior to administering them. Which intervention is most important for the nurse to include regarding the amlodipine and diltiazem, which are both calcium-channel blockers?

-Report any episodes of dizziness. Combination calcium-channel blocker therapy is prescribed to better control the client's blood pressure. Since amlodipine and diltiazem are both calcium-channel blockers, it is important for the client to report side effects such as dizziness, which may be a sign of low blood pressure. A very low heart rate may also occur, which will require an adjustment in the client's medications and/or dosages. While in the hospital and on a cardiac monitor, the nurse should monitor for a low, irregular heart rate. -Avoid drinking grapefruit juice. While this may cause an increase in the serum blood levels of calcium channel blockers, a low blood pressure requires immediate intervention. -Tell HCP of daily weight gain. Weighing daily is important to evaluate the amount of fluid retention that may increase as heart failure worsens. The HCP may need to change the medications and/or dosages to better manage these symptoms. Weight gain does not require an immediate intervention. -Keep a blood pressure diary. It will be important for the HCP to evaluate the effectiveness of this combination therapy. However, reporting serious side effects is priority.

When providing education for the prescribed transdermal nitroglycerin, which intervention is most important for the nurse to include?

-Report any redness under the patch site. This is a common side effect that can be managed by rotating patch application sites. -Expect a mild headache after application. This is a common side effect that may be more noticeable when applying a new patch. -Tell the healthcare provider (HCP) of persistant dizziness when standing. Nitroglycerin is a nitrate, causing systemic vasodilation. This often leads to hypotension, which can cause the client to feel dizzy. She should be instructed to change positions slowly and to avoid prolonged standing. If the dizziness is persistant when standing, the client's blood pressure may be too low, requiring the HCP to adust the dosage or change the medication. -Inform HCP of rash around the transdermal patch. This is a common side effect. The HCP should be informed; however, this is not life threatening.

Diagnostic Tests With the client's presenting symptoms, physical examination, electrocardiogram (ECG) findings, and elevated cardiac markers, the healthcare provider (HCP) confirms the diagnosis of myocardial infarction (MI). The client reports an increase in her chest pain as 8 out of 10. The nurse immediately obtains another ECG. Which ECG assessment finding warrants immediate intervention by the nurse?

-ST segment elevation and the development of Q waves. ST segment elevation is indicative of acute myocardial injury leading to infarction and requires immediate intervention (STEMI versus non-STEMI - STEMI causes more deaths). -Tall peaked T waves in all leads. Peaked T waves may indicate an elevated potassium level and should be further evaluated but is not priority over the myocardial injury that is occuring. -Notched P waves in various leads. Notched P waves may be evidence of atrial enlargement and should be further evaluated, but is not priority over the myocardial injury that is occuring. -Prolonged PR interval measuring 0.22 seconds. Prolongation of the PR interval is typical of a first-degree AV block, an electrical conduction disturbance within the heart. While development of a conduction block may occur as a result of myocardial injury, the presence of a prolonged PR interval is not itself indicative of myocardial injury.

Client Teaching: Hyperlipidemia The client's lab results include: Serum cholesterol 280 mg/dL (7.25 mmol/L). Low-density lipoproteins (LDL) 180 mg/dL (4.66. mmol/L). High-density lipoproteins (HDL) 32 mg/dL (0.83 mmol/L). The client asks the nurse if these results are bad. Which nursing intervention best promotes effective communication?

-Serum cholesterol under 300 mg/dL (7.77 mmol/L) is considered a healthy heart level. Serum cholesterol less than 200 mg/dL (5.18 mmol/L) is the desired level. -Serum cholesterol greater than 200 mg/dL (5.18 mmol/L) requires medical intervention. While 200 mg/dL (5.18 mmol/L) or less is considered desirable, medical intervention is not generally initiated for levels under 240 mg/dL (6.22 mmol/L). Clients with cholesterol levels between 200 to 240 mg/dl (5.18 - 6.22 mmol/L) should be advised to begin lifestyle modifications. -LDL less than 200 mg/dL (5.18 mmol/L) is within an acceptable range. This is too high. LDL is the "bad" cholesterol that can accumulate in the arteries, eventually leading to angina, infarction, or CVA. Less than 100 mg/dL (2.59 mmol/L) is considered the optimal level, with readings above 190 (4.92 mmol/L) considered very high. -HDL less than 50 mg/dL (1.29 mmol/L) for women indicates an increased risk. HDL is considered the "good" cholesterol, which reduces the risk of heart disease. Current guidelines state that an HDL of less than 50 mg/dL (1.29 mmol/L) for women is too low to safeguard the arteries.

After discussing these test results with the healthcare provider (HCP) and the nurse, the client expresses interest in learning how to lower her cholesterol and lose weight. The HCP prescribes the antihyperlipidemic agent lovastatin 20 mg PO daily. Which intervention is most important for the nurse to include in the client's plan of care related to the use of an antihyperlipidemic?

-TSH 3.9 mclU/mL (3.9 mIU/L). This is a normal TSH level. Antihyperlipidemics do not affect thyroid function. -ALT 60 U/L (1.0 mckat/L). Normal ALT is 4 - 36 U/L (0.07 - 0.60 mckat/L). Antihyperlipidemics can cause increased liver enzymes and should be monitored periodically during treatment. -Amylase 44 U/L (0.73 mckat/L). This is a normal amylase level. Antihyperlipidemics do not affect pancreatic function. -Potassium 4.8 mEq/L (4.8 mmol/L). This is a normal potassium level. Electrolytes and potassium are not affected by antihyperlipidemic therapy.

During client education, the client reports to the nurse that even though breathing is easier, they do not like the dizzy feeling they experience when changing positions or when getting out of bed. Which nursing intervention best promotes effective communication?

-Tell the client to get into position quickly to minimize the dizziness. Rising quickly may cause syncope. -Explain to the client that the symptoms should start to decrease as the body gets used to the medications. This is not a symptom that gets better. It is a side effect of the medication. The orthostatic hypotension remains a risk for the client and he should be instructed to slowly change positions. -Have the client hold the medications and ask his HCP to decrease the dose of the medications to lessen the effect. This is a common side effect of the medications due to the mechanism of the medications. Medication should not be held unless instructed to do so by the HCP first. Decreasing the medications can cause the client's blood pressure to increase. -Instruct the client to change positions and stand slowly. This is a common side effect of the medications. The client needs to be aware of the orthostatic hypotension and be aware to slowly change his position and to rise slowly to a sitting and/or standing position.

The HCP prescribes a stress echocardiogram. When preparing the client for the test, which instruction is most important for the nurse to provide?

-Tell the client to have nothing by mouth four hours before the test. Food and drink within hours of test may cause nausea and discomfort, but will not affect the outcome of the test. -Instruct the client not to smoke on the day of the test. The client smokes and should be specifically instructed not to smoke prior to test. Nicotine can interfere with the heart rate. -Wear loose-fitting clothes and good walking shoes. Wearing loose-fitting clothes and good walking shoes may be more comfortable for completing the test but should not affect the outcome of the test. -Avoid drinking caffeine-containing beverages prior to the test. Caffeine may affect the heart rate, but not as pronounced as nicotine. Caffeine should be reported prior to the test but should not affect the outcome.

The nurse verified the prescriptions and the dose to be given to the client. When preparing to administer the furosemide, which assessment finding(s) warrant intervention by the nurse? (Select all that apply. One, some, or all options may be correct.)

-Tenderness at the IV insertion site. The intravenous site should be assessed a minimum of every two hours and whenever getting ready to initiate an IV medication. Tenderness may be a sign of infection or infiltration and requires further assessment. Blood pressure 160/90 mmHg. The baseline blood pressure and pulse before administering the diuretic bolus and during the administration should be assessed. A diuretic may lower blood pressure which would be desirable in this scenario. Occasional premature ventricular complexes. Occasional premature ventricular complexes (PVCs) are a sign of cardic muscle irritability. The client has a low potassium and sodium level. Administering a diuretic will increase the urine output and may lower the value of the electrolyes more. PVCs should be reported and electrolytes assessed before administering a diuretic. -The client's bladder. Assessment of the bladder is not necessary unless the client is experiencing urinary retention, which may require a urinary catheterization prior to the administration of the furosemide 40 mg IV. -The client's potassium level for any preexisting hypokalemia. Monitor electrolytes, particularly potassium, before and during therapy.

Discharge Preparation The nurse determines that these individuals are beginning nursing students who are learning to interview clients and the nurse asks the group to leave the client's room. The nurse reviews the importance of promoting client rights and ways to achieve this. Upon learning the students' goals, the client welcomes the opportunity to visit with the nursing students. She talks with them at length about her impending discharge, the concerns she has, and her plans to engage in a healthier lifestyle. The nurse completes the client's discharge teaching and schedules the client to begin therapy at the cardiac rehabilitation unit the following week.

-The client chooses walking as her initial form of exercise. Walking is the best initial activity/exercise for the post-MI client. The client should be instructed to establish a gradually progressive walking schedule and to assess pulse and tolerance when increasing activity. Activities such as heavy lifting that cause straining should be avoided for several weeks. -The client recognizes the need to avoid all aspirin products. This is not an expected outcome, unless the client is taking a prescribed anticoagulant, such as warfarin. Daily low-dose aspirin is frequently prescribed to reduce the risk for thrombosis. -The client talks with her husband about avoiding sexual intercourse for the next six months. This is not an expected outcome. Sexual activity can be resumed once the client's tolerance to activity has been assessed. Generally, once the client can tolerate walking approximately one block or climbing two flights of stairs, intercourse can be resumed. The nurse should instruct the client regarding measures such as positioning, and waiting at least half an hour after eating to avoid undue strain, and using prophylactic nitroglycerin prior to intercourse. The client states that she feels confident about driving herself home from the hospital. This is not a desired outcome. Clients discharged post-MI can be weak and can become fatigued easily. Activities that could cause straining or excessive stress should be avoided. The client chooses a diet low in saturated fat and cholesterol. A diet low in saturated fat and cholesterol will reduce the risk for the client developing another MI.

Ethical-Legal Considerations: Client Rights While the nurse is assessing the client, a group of people dressed in street clothes and lab coats enters the client's room. They are carrying clipboards and pens, and they begin to ask the client questions related to her hospitalization. The client seems unsure how to respond. The nurse should immediately intervene to prevent violation of which client right?

-The right to be free from assault and battery. This client right is not being violated in this situation. -The right to sufficient information to make an informed decision about treatment. This client right is not being violated in this situation. -The right to have information about the qualifications of caregivers. The individuals in the group should wear name tags that clearly identify their roles, they should introduce themselves, and they should explain to the client why they would like to ask her some questions. Clients have the right to privacy during examination and treatment, as well as the right to refuse observation by those not directly involved in their care -The right to healthcare without discrimination. This client right is not being violated in this situation.

Red nails

-Thin, dark red vertical lines 1-3 mm long (splinter hemorrhages) -Red discoloration of the lunula -Dark red nail beds = Bacterial endocarditis Trichinosis Trauma to the nail bed Normal findings in some patients Cardiac insufficiency Polycythemia vera

Management Issues: Priorities The next day, the client is transferred to the Progressive Cardiac Unit. During report, the nurse is assigned four clients. Which client should the nurse assess first?

-This client, post-PTCA, whose pulse distal to the insertion site is +3, with capillary refill of 2 seconds. This client's condition is stable, and her circulation is strong, so assessment of this client is not the highest priority. -A client with unstable angina who is complaining of chest discomfort and who has been given one nitroglycerin tablet sublingually (SL). This is the least stable of the four clients. The nurse needs to assess for the effectiveness of the nitroglycerin and for other symptoms that may indicate the onset of an MI. -A client 5 days post-MI who is complaining that he is constipated and demands that his healthcare provider (HCP) be called. Although it is important to ensure that clients avoid straining post-MI, another client requires more immediate assessment. -A client recently started on propranolol and aspirin for coronary artery disease. This client's condition is stable. Propranolol is a beta-blocker frequently used to reduce myocardial oxygen demand, and aspirin is used to reduce the risk of thrombus formation. This client's response to the medications should be monitored, but this is not the nurse's most immediate priority.

Safe and Effective Care Policies and procedures are in place to assess, predict, and prevent falls from occuring. Healthcare facilities have fall risk assessments that are completed upon admission and regularly throughout the admission. A fall risk score is determined using a fall risk scale which provides vital information to the staff while caring for their clients. Due to the client's report of orthostatic hypotension, the HCP writes a prescription to place the client on fall precautions for the duration of their stay to include the following: A brightly colored wrist band signifying fall precautions. A sign placed outside the client's room so that staff members are aware. Instructions given to the client not get out of the bed without calling for assistance. The nurse assesses the client's fall risk factors and determines they score a moderate fall risk. What change(s) in the client's care should the nurse tell him to expect? (Select all that apply. One, some, or all options may be correct.)

-Two side rails up while in bed. For a low to high fall risk only two side rails should be up as a reminder to call for assistance unless the client is in the intensive care unit. -Four side rails up at all times. Only two side rails should be up. Clients can get wedged between rails while trying to get out of bed if they do not call for help. -Soft wrist restraints tied loosely. Restraints are not indicated unless the client is at risk of harming self or others. Not to be used as a reminder to call for help. -A UAP will assist with trips to the bathroom. Supervision and assistance to the bathroom is required while on moderate fall risk precautions. -Non-skid footwear to be worn while out of bed. Use of properly fitting nonskid footwear decreases the risk of falling when the client is walking, especially when unsteady.

The client is settled in and the nurse is planning the client's care. Based on the prescriptions provided, which actions should the nurse delegate to the unlicensed assistive personnel (UAP)?

-Weigh the client on the medical unit's scale. This is within the scope of responsibility for the UAP. -Place the cardiac monitor on the client. This is within the scope of responsibility for the UAP. -Put a fluid restriction sign at the head of bed. This is within the scope of responsibility for the UAP. -Set up the oxygen delivery system at 10 liters/minute. This is not within the scope of responsibility for the UAP. -Adjust oxygen rate if oxygen saturations decrease while ambulating. This is not within the scope of responsibility for the UAP.

Discharge planning is started with the admission process. With the information that the nurse has gathered, which intervention is most important for the nurse to include in the client's discharge plan?

-identify available community resources. Once the client is discharged, community resources can address his healthcare, financial, and transportation needs. The resources will be key in the client's overall well-being. -Ensure the client that they will have a room at the homeless shelter. Discharging the client to the street is not an option; however, community resouces may be able to identify adequate housing. -Teach the client about foods high in protein. It is important for the client to increase foods that will improve the dietary anemia. However, without resources to purchase food, other choices are more important to address first. -Schedule follow-up appointments. The client will need to follow-up with a HCP after discharge. However, without resources he will not have transportation.

Pharmacological and Parenteral Therapies. After completing the pain assessment, the nurse prepares to administer a prescribed opioid analgesic: Morphine Sulfate 6 mg by intravenous push every 6 hours. Morphine is available in 10 mg/1 mL vials. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the tenth.)

0.6 (6/10)

priority nursing diagnoses for patients with chronic obstructive pulmonary disease (COPD):

1. Impaired Gas Exchange related to alveolar-capillary membrane changes, reduced airway size, ventilatory muscle fatigue, and excessive mucus production 2. Ineffective Breathing Pattern related to airway obstruction, diaphragm flattening, fatigue, and decreased energy 3. Ineffective Airway Clearance related to excessive secretions, fatigue, decreased energy, and ineffective cough 4. Imbalanced Nutrition: Less Than Body Requirements related to dyspnea, excessive secretions, anorexia, and fatigue 5. Anxiety related to dyspnea, a change in health status, and situational crisis 6. Activity Intolerance related to fatigue, dyspnea, and an imbalance between oxygen supply and demand • Fatigue related to a change in metabolic energy or hypoxemia • Deficient Knowledge (disease process, prescribed treatments, activity limitations) related to unfamiliarity with information resources • Sexual Dysfunction related to extreme fatigue • Impaired Spontaneous Ventilation related to ventilatory muscle fatigue • Sleep Deprivation related to dyspnea or an unfamiliar environment (hospitalization) • Disturbed Thought Processes related to hypoxemia or sleep deprivation • Ineffective Coping related to high degree of threat, inadequate level of perception of control, changes in lifestyle, situational crisis, or knowledge deficit expected... - Maintenance of SpO2 of at least 88% -Absence of cyanosis -Maintenance of cognitive orientation Monitor results of pulmonary function tests, particularly vital capacity, maximal inspiratory force, forced expiratory volume in 1 second (FEV1), and FEV1/FVC, as appropriate. • Assist patient to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed. • Encourage patient to take several deep breaths. • Encourage patient to take a deep breath, hold it for 2 seconds, and cough two or three times in succession. • Instruct the patient to inhale deeply several times, to exhale slowly, and to cough at the end of exhalation. • Instruct patient to follow coughing with several maximal inhalation breaths.

To ensure the most accurate assessment of the abdomen, what actions should the nurse take? (Place in order from first action through last action.)

1. Inspection. 2. Auscultation. 3. Percussion. 4. Palpation. The correct order of the assessment is inspection, auscultation, percussion, and palpation. Percussion and palpation of the abdomen may stimulate peristalsis, so inspection and then auscultation should be completed first to ensure an accurate assessment of peristalsis.

Medication: Captopril 25 mg PO twice daily Losartan 25 mg PO daily Diltiazem 30 mg PO three times daily Digoxin loading dose: 500 mcg PO then 500 mcg PO 6 hours later Digoxin maintenance dose: 125 mcg PO daily Furosemide 40 mg IV to be administered over 15 mins; repeat in one (1) hour Furosemide maintenance dose: 80 mg PO every morning The nurse administered the first doses of digoxin and furosemide at 0800. What is the earliest time the second dose of digoxin can be given?

1400 as instructed. Pay attention to order details. First and second dose of digoxin prescription is the loading dose. The second dose should be administered 6 hours after the first dose at 1400.

The primary healthcare provider (HCP) prescribes a continuous IV infusion of amiodarone 1 mg/min for the client. The available drug is amiodarone 900 mg in 500 mL of D5W. The nurse should set the IV pump at how many mL/hr? (Enter numerical value only. If rounding is necessary, round to the whole number.)

33

Cirrhosis

A chronic, degenerative disease of the liver that interferes with normal liver function. Assess for: • Fatigue • Significant change in weight • GI symptoms, such as anorexia and vomiting • Abdominal pain and liver tenderness (both of which may be ignored by the patient) The first sign may present before the onset of symptoms when routine laboratory tests, presurgical evaluations, or life and health insurance assessments show abnormalities. These tests could indicate abnormal liver function or thrombocytopenia, requiring a more thorough diagnostic workup. The development of late signs of advanced cirrhosis (also called "end-stage liver failure") usually cause the patient to seek medical treatment. GI bleeding, jaundice, ascites, and spontaneous bruising indicate poor liver function and complications of cirrhosis. Thoroughly assess the patient with liver dysfunction or failure because it affects every body system. The clinical picture and course vary from patient to patient depending on the severity of the disease. Assess for: • Obvious yellowing of the skin (jaundice) and sclerae (icterus) • Dry skin • Rashes • Purpuric lesions, such as petechiae (round, pinpoint, red-purple lesions) or ecchymoses (large purple, blue, or yellow bruises) • Warm and bright red palms of the hands (palmar erythema) • Vascular lesions with a red center and radiating branches, known as "spider angiomas" (telangiectases, spider nevi, or vascular spiders), on the nose, cheeks, upper thorax, and shoulders • Ascites (abdominal fluid) • Peripheral dependent edema of the extremities and sacrum • Vitamin deficiency (especially fat-soluble vitamins A, D, E, and K) -Observe vomitus and stool for blood. This may be indicated by frank blood in the excrement or by a positive fecal occult blood test (FOBT) (Hema-Check, Hematest). -Gastritis, stomach ulceration, or oozing esophageal varices may be responsible for the blood in the stool. -Note the presence of fetor hepaticus, which is the distinctive breath odor of chronic liver disease and hepatic encephalopathy and is characterized by a fruity or musty odor. -Amenorrhea (no menstrual period) may occur in women, and men may exhibit testicular atrophy, gynecomastia (enlarged breasts), and impotence as a result of inactive hormones. -Patients with problems of the hematologic system caused by hepatic failure may have bruising and petechiae (small, purplish hemorrhagic spots on the skin). -Continually assess the patient's neurologic function. Subtle changes in mental status and personality often progress to coma—a late complication of encephalopathy. -Monitor for asterixis—a coarse tremor characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers (hand-flapping).

pulmonary disease (COPD)

A group of lung diseases that block airflow and make it difficult to breath -Ask about risk factors such as age, gender, occupational history, and ethnic-cultural background when taking a history from a patient -more often in older men. some types of emphysema occur in families, especially those with alpha1-antitrypsin (AAT) deficiency. Obtain a thorough smoking history, because tobacco use is a major risk factor. Ask about the length of time the patient has smoked and the number of packs smoked daily. Use these data to determine the pack-year smoking history. If the patient smokes, use this opportunity as a teachable moment to discuss smoking cessation strategies (see Chart 32-3). Ask the patient to describe his or her breathing problems. Assess whether the patient has any difficulty breathing while talking. Can he or she speak in complete sentences, or is it necessary to take a breath between every one or two words? Ask about the presence, duration, or worsening of wheezing, coughing, and shortness of breath. Determine what activities trigger these problems. Assess the patient's cough pattern. If the cough is productive, ask whether sputum is clear or colored and how much is produced each day. Ask the patient to recall the time of day when the sputum production is greatest. Smokers often have a productive cough when they get up in the morning; nonsmokers generally do not. Ask whether sputum production has increased or changed during the past year. Check the relationship between activity tolerance and dyspnea by asking the patient to compare his or her activity level and shortness of breath now with those of a month ago and a year ago. Likewise, ask about any difficulty with eating and sleeping. Many patients sleep in a semi-sitting position because breathlessness is worse when lying down (orthopnea). Ask about usual daily activities and any difficulty with sleeping, bathing, dressing, or sexual activity. Document this initial assessment to serve as a starting point for determining the intervention plan and its effectiveness. Weigh the patient, and compare this weight with previous weights. Unplanned weight loss occurs with an increase in COPD severity. COPD increases metabolic needs as a result of the increased work of breathing. Dyspnea and mucus production often result in poor food intake and inadequate nutrition. Ask the patient to recall a typical day's meals and fluid intake. When heart failure is present with COPD, general edema with weight gain may occur. -General appearance can provide clues about the patient's respiratory status and energy level. Observe his or her weight in proportion to height, posture, mobility, muscle mass, and overall hygiene. The patient with increasingly severe COPD is thin, with loss of muscle mass in the extremities, although the neck muscles may be enlarged. He or she tends to be slow moving and slightly stooped. Usually the person sits with a forward-bending posture, sometimes with the arms held forward (Fig. 32-8). When dyspnea becomes severe, activity intolerance may be so great that bathing and general grooming are neglected. -Respiratory changes occur as a result of obstruction, changes in chest size, and fatigue. Inspect the chest to assess the breathing rate and pattern. The patient with respiratory muscle fatigue breathes with rapid,

oxygen therapy

Administration of oxygen and monitoring of its effectiveness. • Clear oral, nasal, and tracheal secretions, as appropriate. • Restrict smoking. • Maintain airway patency. • Set up oxygen equipment and administer through a heated, humidified system. • Monitor the oxygen liter flow. • Monitor position of oxygen delivery device. • Periodically check oxygen delivery device to ensure that the prescribed concentration is being delivered. • Monitor the effectiveness of oxygen therapy (e.g., pulse oximetry, ABGs), as appropriate. • Assure replacement of oxygen mask/cannula whenever the device is removed. • Monitor patient's ability to tolerate removal of oxygen while eating. • Observe for signs of oxygen-induced hypoventilation. • Monitor for signs of oxygen toxicity and absorption atelectasis. • Monitor oxygen equipment to ensure that it is not interfering with the patient's attempts to breathe. • Monitor patient's anxiety related to need for oxygen therapy. • Monitor for skin breakdown from friction of oxygen device. • Provide for oxygen when patient is transported. • Instruct patient and family about use of oxygen at home. • Arrange for use of oxygen devices that facilitate mobility and teach patient accordingly. Is prescribed for relief of hypoxemia (decreased blood oxygen levels) and hypoxia (decreased tissue oxygenation). The need for oxygen therapy and its effectiveness can be determined by arterial blood gas values and oxygen saturation by pulse oxymetry. The patient with COPD may need an oxygen flow of 2 to 4 L/min via nasal cannula or up to 40% via Venturi mask. The patient who is hypoxemic and also has chronic hypercarbia requires lower levels of oxygen delivery, usually 1 to 2 L/min via nasal cannula. A low arterial oxygen level is this patient's primary drive for breathing. Do not increase the oxygen flow rate in patients with hypercarbia because this may lower their respiratory rate or even make them stop breathing spontaneously. Ensure that there are no open flames or other combustion hazards in rooms in which oxygen is in use. More information on oxygen therapy is found in Chapter 30. Drug therapy for COPD involves the same inhaled and systemic drugs as for asthma. These drugs include beta-adrenergic agents, cholinergic antagonists, methylxanthines, corticosteroids, and NSAIDS (see Chart 32-5). The focus is on long-term control therapy with longer duration drugs, such as arformoterol (Brovana) and tiotropium (Spiriva). The patient with COPD is more likely to be taking systemic agents (in addition to inhaled drugs) than is the patient with asthma. An additional drug class for COPD is the mucolytics, which thin secretions, making them easier to expectorate. Mucolytic agents are prescribed for the patient with thick, tenacious (sticky) mucous secretions. Nebulizer treatments with normal saline or with a mucolytic agent such as acetylcysteine

based on the client's assessment, what condition would the nurse suspect?

Appendicitis Pain is usually in the right lower quadrant when experiencing an appendicitis. Patient also had a appedectomy in the past. Liver failure Assessment did not demonstrate fluid in abdomen, jaundice, or other signs of liver failure. Cholecystitis Characterized by right upper quadrant pain, nausea, and vomiting after eating. Ureteral colic Characterized by flank pain that wraps around to the groin. Nausea and vomiting may be present.

The client vomits 200 milliliters of yellow-green liquid. The client continues to feel nauseated. The nurse administers a PRN dose of a prescribed antiemetic. Shortly after the nurse administers the antiemetic, the client states she feels better. The nurse offers to provide oral care with a mint-flavored foam swab and cool water Which assessment takes priority while the nurse provides oral care?

Assess for presence of dentures. This information may be important, but another assessment takes priority at this time. Observe the condition of the mucus membranes. Because the client has a recent history of nausea, vomiting, and weight loss, the RN should assess the client for signs of fluid volume deficit, including observing the mucus membranes for excessive dryness. Evaluate the color of the gums Considering the client's recent history of nausea and vomiting, another assessment takes priority at this time. Check for the presence of cavities. Considering the client's recent history of nausea and vomiting, another assessment takes priority at this time.

The nurse questions the client if there are any foods she cannot eat. The client reports that she doesn't tolerate spicy foods. What questions should the nurse ask next? (Select all that apply.)

Can you identify which spicy foods cause a problem? This information will be helpful in planning interventions for meal preparation. How often do you eat spicy foods? Other information is more useful in assessing the client's inability to tolerate spicy foods. What happens when you eat spicy foods? The client's response is the most useful regarding the nature of her inability to eat spicy foods and any underlying problems. Does anyone in your family have problems with spicy food? This information is not helpful in assessing the client's inability to eat spicy foods. Why do you think spicy foods are a problem? This question not help determine food intolerances.

The nurse completes an admission assessment. The client tells the nurse that she feels like she needs to vomit. The nurse helps the client to sit up at the side of the bed and provides her with an emesis basin. The client vomits into the emesis basin and then remains sitting on the side of the bed, stating that she may need to throw up again. Which assessment should the nurse complete first?

Check the pulse. Another assessment should be completed before assessing the client's pulse rate, which might be elevated secondary to vomiting. Listen to bowel sounds. Another assessment should be completed before assessing for bowel sounds. Observe the color of the emesis (vomiting). Since the client is vomiting, the nurse should first observe the color and appearance of the emesis for any obvious bleeding or other indications of risk to the client's homeostasis. Obtain a STAT blood pressure. The nurse will need to obtain a blood pressure, but that is not a priority at this time, as it might be elevated secondary to the vomiting.

The nurse is documenting the client's vomitus. Which documentation should be included in the client's medical record? (Select all that apply.)

Client vomited green with undigested food particles. It is important for the nurse to describe the appearance of the emesis, which includes the color. Vomit without odor. It is important for the nurse to describe any odor of the emesis, which could indicate the presence of blood, undigested foods, or fecal contaminant. Vomit is soft in consistency. This is not characteristics of emesis. Approximately 250ml of vomit was noted. It is important for the nurse to describe the volume or amount of emesis. Client vomited x 1 lasting approximately 2 minutes. The duration will describe if the episodes of vomiting were short, sporadic, ongoing, or intermittent.

lymph system

Conditions Lymphadenopathy (adenopathy)—enlarged lymph node(s) Lymphadenitis—inflamed and enlarged lymph node(s) Lymphangitis—inflammation of the lymphatics that drain an area of infection; tender erythematous streaks extend proximally from the infected area; regional nodes may also be tender Lymphedema—edematous swelling due to excess accumulation of lymph fluid in tissues caused by inadequate lymph drainage Lymphangioma—congenital malformation of dilated lymphatics Nodes Shotty—small non-tender nodes that feel like BBs or buckshot under the skin Fluctuant—wavelike motion that is felt when the node is palpated Matted—group of nodes that feel connected and seem to move as a unit Reminders about Nodes • A hard, fixed, painless node suggests a malignant process. • The more tender a node, the more likely it is an inflammatory process. • Nodes do not pulsate; arteries do. • A palpable supraclavicular node on the left (Virchow node) is a significant clue to thoracic or abdominal malignancy. • Slow nodal enlargement over weeks and months suggests a benign process; rapid enlargement without signs of inflammation suggests malignancy. -With bacterial infection, nodes may become warm or tender to the touch, matted, and much less discrete, particularly if the infection persists. It is possible to infer the site of an infection from the pattern of lymph node enlargement. For example, infections of the ear usually drain to the preauricular, retropharyngeal, and deep cervical nodes Fluctuant nodes—nodes that feel like they contain fluid—suggest suppuration from infection. Fixation of the nodes to underlying tissue is most common in metastatic cancer but can also occur with chronic inflammation DIFFERENTIAL DIAGNOSIS Conditions Simulating Lymph Node Enlargement • Lymphangioma (transilluminates; hemangiomas do not) • Cystic hygroma (thin-walled, contains clear lymph fluid) • Hemangioma (tends to feel spongy; appears reddish blue, with color depending on size and extent of blood vessel involvement; Valsalva maneuver may enlarge the mass) • Branchial cleft cyst (sometimes accompanied by a tiny orifice in the neck along the lower third of the anteromedial border of the sternocleidomastoid muscle between the muscle and the overlying skin; may fluctuate in size when inflamed) • Thyroglossal duct cyst (midline in the neck; may retract when tongue is protruded) • Granular cell tumor • Laryngocele • Esophageal diverticulum • Thyroid goiter • Graves disease • Hashimoto thyroiditis • Parotid swelling (e.g., from parotitis or tumor) • Femoral hernia (below inguinal ligament; protrudes with cough; reducible)

Breathing Exercises

DIAPHRAGMATIC OR ABDOMINAL BREATHING • Lie on your back with your knees bent. • Place your hands or a book on your abdomen to create resistance. • Begin breathing from your abdomen while keeping your chest still. You can tell if you are breathing correctly if your hands or the book rises and falls accordingly. PURSED-LIP BREATHING • Close your mouth, and breathe in through your nose. • Purse your lips as you would to whistle. Breathe out slowly through your mouth, without puffing your cheeks. Spend at least twice the amount of time it took you to breathe in. • Use your abdominal muscles to squeeze out every bit of air you can. • Remember to use pursed-lip breathing during any physical activity. Always inhale before beginning the activity and exhale while performing the activity. Never hold your breath.

While inspecting the client's abdomen, the nurse notes the following: Abdomen is rounded and symmetrical. No bulges or masses seen. Umbilicus is inverted and midline. No rashes noted. Silvery white striae noted on the lower abdomen. A four centimeter scar is noted on the right lower quadrant of the abdomen. No visible pulsations or perstalsis noted. No hair noted What statements from the client's focused interview correlate to the abnormal inspection findings? (Select all that apply.).

Daily bowel movements This information is not related to the development of striae or external scarring. Past surgical history of an appendectomy. Appendectomy scars will usually be present in the right lower quadrant. Nausea and vomiting. Nausea and vomiting does not cause striae or external scarring. Food intolerance to spicy foods. Striae are not related to food intolerance. . Change in body mass index (BMI). Striae are the result of a change in skin pigmentation that occurs following significant stretching of the elastic fibers of the skin on the abdomen. Causes can include obesity or pregnancy.

The nurse's goal in palpating the client's abdomen is to screen for any masses or tenderness. To achieve this goal, what action should the nurse take first?

Deeply palpate each abdominal organ. Deep palpation of the organs is not the first step when palpating the abdomen. Carefully palpate areas of tenderness. Palpation of any areas of tenderness should be saved for last to prevent resulting discomfort or muscle rigidity. Lightly palpate the abdominal surface. Light palpation allows the nurse to screen the abdomen for any obvious masses or tenderness before applying deeper palpation that may cause pain or rigidity. Gently palpate the edges of the liver. Deep palpation used to palpate the liver is not the first step when screening the abdomen.

DlCO (difusion capacity of carbon monoxide) reflects the surface area of the alveolocapillary membrane. The patient inhales a small amount of CO, holds for 10 sec, and then exhales. The amount inhaled is compared with the amount exhaled.

DlCO is reduced whenever the alveolocapillary membrane is diminished, such as occurs in emphysema, pulmonary hypertension, and pulmonary fibrosis. It is increased with exercise and in conditions such as polycythemia and congestive heart disease.

What additional focused interview questions will be important for the nurse to ask the client?

Do you have a history of any abdominal conditions or surgeries? Important to establish baseline of what has occurred in the client's past. Have you experienced any weight gain or weight loss? Weight gain or loss can be indicative of more complex GI problems or a side effect of certain medications. Are you have any difficulty with urination? This is an important question but not indicated given the client's symptoms. Are you experiencing any shortness of breath? This is an important question but not indicated given the client's symptoms. Do you have any difficulty swallowing your food? This is an important question but not indicated given the client's symptoms.

Health Promotion and Maintenance

Encourage all people to use masks and adequate ventilation when exposed to inhalation irritants. Psychosocial Integrity • Explain all diagnostic procedures, restrictions, and follow-up care to the patient scheduled for tests. Physiological Integrity • Assess the degree to which breathing problems interfere with the patient's ability to perform ADLs. • Document any known specific allergies that have respiratory manifestations. • Ask the patient about recent travel. • Assess the airway and breathing effectiveness for any patient who has shortness of breath or any change in mental status. • Assess the patient's respiratory status every 15 minutes for at least the first 2 hours after undergoing an endoscopic test for respiratory disorders.

The nurse prepares the client for the physical assessment of the abdomen. What actions should the nurse take prior to initiating the assessment? (Select all that apply.)

Encourage the client to empty her bladder. Emptying the bladder will help promote relaxation of the abdominal wall. Place a pillow under the client's knees. Placing a pillow under the client's knees promotes relaxation of the abdominal muscles. Inquire where the client is experiencing pain. This guides the nurse with the examination during percussion and palpation. Quadrants with pain are examined last due to muscle guarding. Instruct the client to place her hands over her head. Placing the hands over the head can cause the abdominal muscles to tense. Discuss the sequence of steps performed during the abdominal assessment. Telling the client what to expect during a procedure helps promote relaxation.

In response to the client's statement that she is in a lot of pain, what action should the nurse take first?

Explain to the client that post-operative pain is normal. This is a non-therapeutic response to the client's current situation. Ask the client to describe her pain location and intensity. The nurse should begin by gathering further data about the pain, including location, intensity, and quality. Ask the client if she has passed gas since surgery. This question may be relevant, but other actions have priority. Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. St. Louis, MO: Elsevier. p. 167. Assess the client's heart rate and blood pressure. This action may be warranted, but it is not the first action the nurse should implement when the client reports pain.

To learn about the intensity of the client's pain, what pain scale is most appropriate to use to assess the client's pain?

FLACC behavioral pain scale This is most appropriate for infants and toddlers. Numeric pain scale A numeric pain scale is an effective tool for measuring pain intensity. A numeric pain scale is an effective tool for measuring pain intensity. Faces Pain scale Usually indicated for children but can be used for adults that are non-verbal. Patient is able to verbalize pain. Non-verbal cues While this assessment is important, it does not provide information about the intensity of the client's pain

The nurse assesses the patient's vomitus. Which finding would the nurse be the most concerned about?

Green vomit with particles of food. Not the most concerning. Green may indicate the presence of bile. This is typically found in the small intestine but can be found in vomit if the patient has eaten recently. Can also indicate presence of medical problem so should be followed up on. Particles of food is a normal finding if the patient just ate. Thick dark brown vomit Thick dark brown vomit may indicate the presents of stool or blood. This is an abnormal finding that would need to be investigated and communicated. White foamy vomit White foamy vomit indicates the presence of stomach acid. Yellow clear vomit Not the most concerning finding. Yellow may indicate the presence of bile. This is typically found in the small intestine but can be found in vomit if the patient has eaten recently. Can also indicate presence of medical problem so should be followed up on.

Management of Care Fifteen minutes after receiving the antiemetic, the client stops vomiting, appears relaxed, and denies further nausea. She states that she is comfortable enough for the nurse to begin the admission assessment. The nurse questions the client about what brought her to the hospital. The client states she had right upper quadrant abdominal pain, nausea and vomiting right after she ate lunch. Pain remains at 5/10. The client states her last bowel movement was yesterday. For the nurse to learn about the client's bowel patterns, which questions are most important to ask the client? (Select all that apply.)

Have you had any recent onset of heartburn? While the onset of heartburn may be important, this is not specific to bowel patterns. Do you take any prescription or over-the-counter medications? Medications can cause adverse GI effects. Assess for presence of laxatives, stool softeners, or antidiarrheal medications. Have you had any changes in your bowel movements? Changes in bowel habits can be due to various etiologies, such as diet, stress, activity, and medications. What is the color and consistency of your bowel movements? Black or red stools can indicate the presence of bleeding in the GI system. Establishing a baseline of what a normal for the client is important for further assessment. How often do you have a bowel movement? This information is an important part of the client's history. It establishes a baseline for assessment purposes.

FRC (functional residual capacity) is the amount of air remaining in the lungs after normal expiration. FRC test requires use of the helium dilution, nitrogen washout, or body plethysmography technique.

Increased FRC indicates hyperinflation or air trapping, which may result from obstructive pulmonary disease. FRC is normal or decreased in restrictive pulmonary diseases.

TLC (total lung capacity) is the amount of air in the lungs at the end of maximum inhalation.

Increased TLC indicates air trapping associated with obstructive pulmonary disease. Decreased TLC indicates restrictive disease.

inspection of abdomen

Inspect the skin, and note any of these findings: • Overall asymmetry of the abdomen • Presence of discolorations or scarring • Abdominal distention • Bulging flanks • Taut, glistening skin The contour of the abdomen can be rounded, flat, concave, or distended. It is best determined when standing at the side of the bed or treatment table and looking down on the abdomen. View the abdomen at eye level from the side. Note whether the contour is symmetric or asymmetric. Asymmetry of the abdomen can indicate problems affecting the underlying body structures. Note the shape and position of the umbilicus for any deviations. - observe the patient's abdominal movements, including the normal rising and falling with inspiration and expiration, and note any distress during movement. Occasionally, pulsations may be visible, particularly in the area of the abdominal aorta. -If a bulging, pulsating mass is present during the assessment of the abdomen, do not touch the area because the patient may have an abdominal aortic aneurysm, a life-threatening problem. Notify the health care provider of this finding immediately! Peristaltic movements are rarely seen unless the patient is thin and has increased peristalsis. If these movements are observed, note the quadrant of origin and the direction of peristaltic flow. Report this finding to the health care provider because it may indicate an intestinal obstruction.

Classification of COPD Severity

Mild Moderate Severe Very severe

What further assessment technique would the nurse consider to confirm a problem with the gallbladder?

Murphy's sign Pain is elicited when gallbladder inflammation is present. Illiopsoas test Indicated with a suspected appendicitis. Obturator test An inflamed appedix elicits a painful response with this test. The Alvarado score This test is used to assess right lower quadrant pain.

Common Inflammatory Skin Conditions

Nonspecific Eczematous Dermatitis Evolution of lesions from vesicles to weeping papules and plaques. Lichenification occurs in chronic disease. Oozing, crusting, fissuring, excoriation, or scaling may be present. Itching is common. Anywhere on the body; localized eczema commonly involves the hands or feet. Contact Dermatitis Localized eczematous eruption with well-defined, geometric margins that are consistent with contact by an irritant or allergen. Usually seen in the acute form, but may become chronic if exposure is repeated. Allergy to plants (e.g., poison ivy or oak) classically occurs as linear streaks of vesicles or papules. Cosmetic/perfume allergy: head and neck. Hair product allergy: scalp. Shoe/rubber allergy: dorsum of feet. Nickel allergy: earlobes. Mouthwash/toothpaste allergy: perioral region. Airborne contact allergy (e.g., paint, ragweed): generalized. Atopic Dermatitis Hallmark in adults is lichenification with scaling and excoriation. Extremely itchy. Face involvement is seen as dry skin with mild to moderate erythema, perioral pallor, and skinfolds beneath the eyes (Dennie-Morgan lines). Associated with linear markings on the palms. Face, neck, upper chest, and antecubital and popliteal fossae. Drug Eruption Bright red erythematous macules and papules are found. Skin blisters in extreme cases. Lesions tend to be confluent in large areas. Moderately itchy. Fever is rare. Dehydration and hypothermia can occur with extensive involvement. Condition clears only after offending drug has been discontinued. Generalized. Involvement begins on trunk, proceeds distally (legs are the last to be involved).

Thoracentesis

Position for thoracentesis. Before the procedure, ask the patient about any allergy to local anesthetic agents. Verify that the patient has signed an informed consent. The entire chest or back is exposed, and the aspiration site is shaved if necessary. The actual site depends on the volume and location of the effusion (determined by x-rays, sonography, and percussion). Procedure. Thoracentesis is often performed at the bedside by a nurse practitioner or a physician, although computed tomography or ultrasound may be used to guide it. The person performing the procedure and any assistants wear goggles and masks to prevent accidental eye or oral splash exposure to the pleural fluid. After draping the patient and cleaning the skin with an antiseptic agent, a local anesthetic is injected into the selected site. Keep the patient informed of the procedure while observing for shock, pain, nausea, pallor, diaphoresis, cyanosis, tachypnea, and dyspnea. The short 18- to 25-gauge thoracentesis needle (with an attached syringe) is advanced into the pleural space. Gentle suction is applied as the fluid in the pleural space is slowly aspirated. A vacuum collection bottle is sometimes needed to remove larger volumes of fluid. To prevent re-expansion pulmonary edema, usually no more than 1000 mL of fluid is removed at one time. If a pleural biopsy is to be performed, a second, larger needle with a cutting edge and collection chamber is used. After the needle is withdrawn, pressure is applied to the puncture site and a small sterile dressing is applied. Follow-up Care. After thoracentesis, a chest x-ray is performed to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures toward one side). Monitor vital signs, and auscultate breath sounds for absent or reduced sounds on the affected side. Check the puncture site and dressing for leakage or bleeding. Also assess for complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, infection, and tension pneumothorax. Urge the patient to breathe deeply to promote expansion of the lung. Document the procedure, including the patient's response; the volume and character of the fluid removed; any specimens sent to the laboratory; the location of the puncture site; and respiratory assessment findings before, during, and after the procedure (Rushing, 2006). Teach the patient about the manifestations of a pneumothorax (partial or complete collapse of the lung), which can occur within the first 24 hours after a thoracentesis. Manifestations include: • Pain on the affected side that is worse at the end of inhalation and the end of exhalation • Rapid heart rate • Rapid, shallow respirations • A feeling of air hunger • Prominence of the affected side that does not move in and out with respiratory effort • Trachea slanted more to the unaffected side instead of being in the center of the neck Instruct the patient to come to the emergency department immediately if these manifestations occur. Lung Biopsy A lung biopsy is performed to obtain tissue for histologic analysis, culture, or cytologic examination. The tissue samples are used to make a definite diagnosis about the type of cancer, infection, inflammation, or lung disease. There are several types of lung biopsies. The site and extent of the lesion determine which one is used. Transbronchial biopsy (TBB) and transbronchial needle aspiration (TBNA) are performed during bronchoscopy. Transthoracic needle aspiration is an approach through the skin (percutaneous) for areas that cannot be reached by bronchoscopy. An open lung biopsy is performed in the operating room. Patient Preparation. The patient may worry about the outcome of the biopsy and may associate the term biopsy with cancer. Explain what to expect before and after the procedure, and explore the patient's feelings and fears. To reduce discomfort and anxiety, an analgesic or sedative may be prescribed before the procedure. Inform the patient undergoing percutaneous biopsy that discomfort is reduced with a local anesthetic agent but that pressure may be felt during needle insertion and tissue aspiration. Open lung biopsy is performed in the operating room with the patient under general anesthesia, and the usual preparations before surgery apply (see Chapter 16). Procedure. Percutaneous lung biopsy may be performed in the patient's room or in the radiology department after an informed consent has been obtained. Fluoroscopy or CT is often used to visualize more clearly the area undergoing biopsy and to guide the procedure. Positioning of the patient is similar to that for thoracentesis. The skin is cleansed with an antiseptic agent, and a local anesthetic is given. Under sterile conditions, a spinal-type 18- to 22-gauge needle is inserted through the skin into the desired area (e.g., tissue, nodule, lymph node) and tissue needed for microscopic examination is obtained. Apply a dressing after the procedure. An open lung biopsy is performed in the operating room. The patient undergoes a thoracotomy in which lung tissue is exposed. At least two tissue specimens are taken (usually from an upper lobe and a lower lobe site). A chest tube is placed to remove air and fluid so the lung can re-inflate, and then the chest is closed. Follow-up Care. Monitor the patient's vital signs and breath sounds at least every 4 hours for 24 hours, and assess for signs of respiratory distress (e.g., dyspnea, pallor, diaphoresis, tachypnea). Pneumothorax is a serious complication of needle biopsy and open lung biopsy. Report reduced or absent breath sounds immediately. Monitor for hemoptysis (which may be scant and transient) or, in rare cases, for frank bleeding from vascular or lung trauma.

When completing the pain assessment, how should the nurse assess for rebound tenderness?

Position the client on her right side. It is not necessary to position the client on her side. Lightly palpate over the painful area. When assessing for rebound tenderness, palpation should not be performed over the painful area. Ask the client to describe the pain. A description of the client's pain is not part of the assessment for rebound tenderness. Push down on the left side of the abdomen. After applying pressure at a site away from the area of pain, the nurse quickly lifts and removes the hand from the client's abdomen. Pain upon release of the pressure is referred to as rebound tenderness.

RV (residual volume) is the amount of air remaining in the lungs at the end of a full, forced exhalation.

RV is increased in obstructive pulmonary disease such as emphysema.

laboratory tests (Chart 29-3) are useful in assessing respiratory problem

Red blood cells Females: 4.2-5.4 million/mm3 Males: 4.7-6.1 million/mm3 Elevated levels (polycythemia) may be due to the excessive production of erythropoietin, which occurs in response to a hypoxic stimulus, as in COPD, and from living at a high altitude. Decreased levels indicate possible anemia, hemorrhage, or hemolysis. Hemoglobin, total Females: 12-16 g/dL, or 7.4-9.9 mmol/L Males: 14-18 g/dL, or 8.7-11.2 mmol/L Same as for red blood cells. Hematocrit Females: 37%-47%, or 0.37-0.47 SI units Males: 42%-52%, or 0.42-0.52 SI units Same as for red blood cells. White blood cell count (leukocyte count, WBC count) Total: 5,000-10,000/mm3 Elevations indicate possible acute infections or inflammations, pneumonia, meningitis, tonsillitis, or emphysema. Decreased levels may indicate an overwhelming infection, an autoimmune disorder, or immunosuppressant therapy. DIFFERENTIAL WHITE BLOOD CELL (LEUKOCYTE) COUNT Neutrophils 2500-8000/mm3 or 55%-70% of total Elevations indicate possible acute bacterial infection (pneumonia), COPD, or inflammatory conditions (smoking). Decreased levels indicate possible viral disease (influenza). Eosinophils 50-500/mm3 or 1%-4% of total Elevations indicate possible COPD, asthma, or allergies. Decreased levels indicate pyogenic infections. Basophils 25-100/mm3 or 0.5%-1% of total Elevations indicate possible inflammation; seen in chronic sinusitis, hypersensitivity reactions. Decreased levels may be seen in an acute infection. Lymphocytes 1000-4000/mm3 or 20%-40% of total Elevations indicate possible viral infection, pertussis, and infectious mononucleosis. Decreased levels may be seen during corticosteroid therapy. Monocytes 100-700/mm3 or 2%-8% of total Elevations: see Lymphocytes; also may indicate active tuberculosis. Decreased levels: see Lymphocytes. ARTERIAL BLOOD GASES Pao2 80-100 mm Hg Older adults: values may be lower Elevations indicate possible excessive oxygen administration. Decreased levels indicate possible COPD, asthma, chronic bronchitis, cancer of the bronchi and lungs, cystic fibrosis, respiratory distress syndrome, anemias, atelectasis, or any other cause of hypoxia. Paco2 35-45 mm Hg Elevations indicate possible COPD, asthma, pneumonia, anesthesia effects, or use of opioids (respiratory acidosis). Decreased levels indicate hyperventilation/respiratory alkalosis. pH Up to 60 yr: 7.35-7.45 60-90 yr: 7.31-7.42 >90 yr: 7.26-7.43 Elevations indicate metabolic or respiratory alkalosis. Decreased levels indicate metabolic or respiratory acidosis. HCO3 21-28 mEq/L Elevations indicate possible respiratory acidosis as compensation for a primary metabolic alkalosis. Decreased levels indicate possible respiratory alkalosis as compensation for a primary metabolic acidosis. Spo2 95%-100% Older adults: values may be slightly lower Decreased levels indicate possible impaired ability of hemoglobin to release oxygen to tissues.

A dull sound is heard when the nurse percusses over the suprapubic area. What action should the nurse take in response to this finding?

Reposition the client to her right side. Repositioning the client will not change the sound heard upon percussion of the lower abdomen. Observe the area for bladder distention. A dull sound upon percussion may be heard over a distended bladder. Determine if the client feels bloated or gaseous. Gaseous distention may cause a hyperresonant sound. Assist the client to a sitting position immediately. This action is not warranted in response to this finding.

Where should the nurse begin abdominal auscultation?

Right lower quadrant (RLQ) Place the stethoscope lightly on the abdominal wall, beginning in the RLQ in the area of the ileocecal valve, where bowel sounds are normally present. Proceed with listening to other quadrants in a systemic manner.

The client is having periods of confusion and appears weak and fatigued. The client tells the nurse they feel like their heart is fluttering at times. Which laboratory value(s) could be related to the client's symptoms? (Select all that apply. One, some, or all options may be correct.)

Sodium. Common symptoms of low sodium (hyponatremia) include confusion, lethargy, headache, and dizziness. Potassium Common symptoms of low potassium (hypokalemia) include weakness, fatigue, and palpitations. Chloride. The chloride level is within normal limits. Blood urea nitrogen. Common symptoms of high blood urea nitrogen (BUN) levels include fatigue, edema, shortness of breath, confusion, and dehydration. Phosphorus. Common symptoms of high phosphorus (hyperphosphatemia) include fatigue, shortness of breath, anorexia, nausea, vomiting, and sleep disturbances.

The nurse listens in all areas and hears gurgling sounds at each location between 8 to 20 sounds per minute. After auscultating the client's bowel sounds, the nurse also listens for abdominal vascular sounds, which are soft, low-pitched, and continuous. The nurse does not hear any venous sounds.

Stop the assessment and notify the healthcare provider (HCP) immediately of the assessment finding. This finding does not require notification of the HCP. Take the client's blood pressure and heart rate after the assessment. This finding does not require immediate assessment of the vital signs. Call another nurse to verify the finding. Abdominal vascular sounds are not normally heard, so getting another nurse to verify the finding is not necessary. Document this normal finding on the client's assessment record. Abdominal vascular sounds are not normally heard, so the only action necessary is to record this normal finding on the assessment record.

Regional Distribution of Skin Lesions

Sun-Exposed Areas • Sunburn • Lupus erythematosus • Viral exanthem • Porphyria Cloth-Covered Areas • Contact dermatitis • Miliaria Flexural Aspects of Extremities • Atopic dermatitis • Intertrigo • Candidiasis • Tinea cruris Extensor Aspects of Extremities • Psoriasis Stocking and Glove (Acrodermatitis) • Viral exanthem/atopic dermatitis • Tinea pedis with "id" reaction* • Poststreptococcal infection Truncal • Pityriasis rosea (Christmas tree pattern) • Atopic dermatitis • Drug reaction Face, Shoulder, Back • Acne vulgaris • Drug-induced acne • Cushing syndrome

Thirty minutes later, the nurse returns to assess the client's response to the medication. Which findings provide the best data about the effectiveness of the medication? (Select all that apply.)

The client's vital signs are within normal limits. The client's vital signs (within normal limits) provide useful data about the client's response to pain. The client is holding a pillow over her abdomen. The client's actions may provide useful data about her response to pain, but they are not the most useful source of information about the effectiveness of an analgesic. The client's facial expression is calm and relaxed. The client's nonverbal behavior can provide valuable data about her response to pain, and it is a useful source of information about the effectiveness of an analgesic. The client states a lessening of her pain. The client's subjective report regarding her pain is important information for the nurse to assess when evaluating the effectiveness of analgesic administration. The spouse reports that the client looks like her pain has improved. This input is not the most useful data for the nurse as it is not the patient's own description of the effectiveness of the medication.

The nurse is completing an inspection of the abdomen. Which findings would cue the nurse of the need for action?

The presence of striae on the right and left lower quadrants. Do not require further work up. Striae occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching as in pregnancy or excessive weight gain. A protruberant shaped abdomen. A protruberant shaped abdomen indicates abdominal distention. A midline, inverted umbilicus. A midline, inverted umbilicus is an expected finding. A large amount of pigmented nevi scattered accross the abdomen. Pigmented nevi or moles are a common finding on the abdomen. Marked visible peristalsis. Visible peristalsis may be seen in very thin people. Especially in the presence of a protruberant abdomen may indicate a bowl obstruction and would require the nurse to follow up.

FEF25%-75% records the forced expiratory flow over the 25%-75% volume (middle half) of the FVC.

This measure provides a more sensitive index of obstruction in the smaller airways.

FEV1/FVC is the ratio of expiratory volume in 1 sec to FVC.

This ratio provides a much more sensitive indication of obstruction to airflow. This ratio is the hallmark of obstructive pulmonary disease. It is normal or increased in restrictive disease.

What action should the nurse take?

Use the client's own hand to assist with palpation. The nurse will place their hand over the client's hand and fingers. People are not ticklish to themselves. Switch to using the heel of the hand to palpate. The heel of the hand should not be used. Obtain an order for a muscle relaxant. The nurse is using the correct amount of pressure and does not need to decrease the amount of pressure applied. Stop any further palpation immediately. Discontinuing further palpation is not warranted.

HUMAN NEEDS ASSESSMENT REVIEW

What should you expect to NOTICE in a patient with adequate oxygenation and tissue perfusion related to respiratory function? Vital Signs • Respiratory rate and heart rate within normal range • Oxygen saturation of 95% or higher Physical Assessment • Able to speak a sentence of 12 words without stopping for breath • Able to walk and talk without stopping for breath • Skin color normal (no cyanosis, pallor, or jaundice) • Oral mucous membrane and nail beds pink with rapid capillary refill • Fingertips and nails normal-shaped, no clubbing • Anterior to posterior diameter of chest about two-thirds smaller than lateral diameter • Space between each rib no larger than the breadth of the patient's finger • Usually breathes in through the nose and out through the mouth or nose • Breathing quiet • Air movement heard (with a stethoscope) in all lobes of both lungs • Sputum production minimal, clear or white • Muscle development even with no muscle loss on arms and legs • Weight proportionate to height; does not appear underweight Psychological Assessment • Oriented and not confused • Energy level good, can engage in desired work, recreational, and personal activities Laboratory Assessment • Red blood cell, hemoglobin, hematocrit, and white blood cell levels within normal limits for age and gender

amenorrhea

absence of menstruation; termed secondary amenorrhea when menstruation has begun and then ceases; most common cause is pregnancy (1) the absence of both menarche and secondary sexual characteristics by age 13 years; (2) the absence of menses by age 16.5 years, regardless of normal growth and development (primary amenorrhea); (3) a 6-month or more cessation of menses after a period of menstruation (secondary amenorrhea) -It may occur from any defect or interruption in the hypothalamic-pituitary-ovarian-uterine axis. It may also result from anatomic abnormalities, other endocrine disorders such as hypothyroidism or hyperthyroidism, chronic diseases such as type 1 diabetes, medications such as phenytoin (Dilantin), illicit drug abuse (opiates, marijuana, cocaine), eating disorders, strenuous exercise, emotional stress, and oral contraceptive use. Hypogonadotropic Amenorrhea Hypogonadotropic amenorrhea reflects a problem in the central hypothalamic-pituitary axis. In rare instances a pituitary lesion or genetic inability to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH) is at fault. Hypogonadotropic amenorrhea often results from hypothalamic suppression as a result of stress (in the home, school, or workplace) or a sudden and severe weight loss, eating disorders, strenuous exercise, or mental illness

digital clubbing

ardiac changes occur as a result of the anatomic changes associated with COPD. Assess the patient's heart rate and rhythm. Check for swelling of the feet and ankles (dependent edema) or other manifestations of right-sided heart failure. Examine nail beds and oral mucous membranes. The patient with later-stage emphysema may have pallor or frank cyanosis. Psychosocial Assessment COPD affects all aspects of a person's life. Socialization may be reduced when friends and family avoid the patient with COPD because of annoying coughs, excessive sputum, or dyspnea. The patient may choose to be isolated because dyspnea causes fatigue or because of embarrassment from coughing and excessive sputum production. In addition, because of the association with cigarette smoking and disease development, the patient may feel a social stigma. Ask the patient about interests and hobbies to assess whether socialization has decreased or whether hobbies cause exposure to inhalation irritants. Ask about home conditions for exposure to smoke or crowded living conditions that promote transmission of respiratory infections. Economic status may be affected by the disease through changes in income and health insurance coverage. If the patient is the head of the household, severe COPD may require role changes that have a negative impact on self-image. Drugs, especially the metered dose inhalers (MDIs) and dry powder inhalers (DPI), are expensive, and many patients with limited incomes may use them only during exacerbations and not as prescribed on a scheduled basis.

hirsutism

excessive hair growth over the body -Growth of terminal hair in women in the male distribution pattern on the face, body, and pubic areas • Caused by high androgen levels (from ovaries or adrenal glands) or by hair follicles that are more sensitive to normal androgen levels; free testosterone is the androgen that causes hair growth. • Many causes, including genetic, physiologic, endocrine, drug-related, and systemic disorders Excessive hair growth on the face or body • Onset, severity, and rate depend on underlying cause • Presence of thick, dark terminal hairs in androgen-sensitive sites: face, chest, areola, external genitalia, upper and lower back, buttocks, inner thigh, and linea alba (Fig. 8-64) • Hirsutism may or may not be accompanied by other signs of virilization.

When continuing to assess the abdominal area, the nurse hears a swishing sound. In what area would this sound be heard?

femoral artery. This area would produce a swishing sound that occurs during systole (vascular sounds). Epigastric area. The midline areas would not produce this sound. Umbilical area. The umbilical area would not produce this sound. Right quadrants. The right quadrants would not produce this sound.

FVC (forced vital capacity) records the maximum amount of air that can be exhaled as quickly as possible after maximum inspiration.

gives an indication of respiratory muscle strength and ventilatory reserve. FVC is often reduced in obstructive disease (because of air trapping) and in restrictive disease.

FEV1 (forced expiratory volume in 1 sec) records the maximum amount of air that can be exhaled in the first second of expiration.

is effort dependent and declines normally with age. It is reduced in certain obstructive and restrictive disorders.

The nurse is assessing for costo-vertebral angle (CVA) tenderness. Which statements best describe this percussion assessment? (Select all that apply.)

it is normal for a client to feel pain with this percussion assessment. Incorrect, pain is only present if kidney inflammation is present. This is an abnormal finding. Percussion is completed over the 12th rib in the back bilaterally. Correct, Percussion is completed over the 12th rib at the CVA angle in the back bilaterally. Place one hand over the flank area and hit the hand with the ulnar side of the fist. Correct, Place one hand palm side down and strike the hand with the ulnar side of your fist gently. Client will need to take a deep breath prior to completion of the percussion technique. Incorrect, The client does not have to hold their breath during this assessment technique. . Technique is used to assess for inflamation of the kidney. Correct, pain illicited during this technique may indicate inflamation of the kidney.

Menorrhagia (hypermenorrhea)

profuse or prolonged bleeding during regular menstruation e excessive bleeding associated with menorrhagia can be characterized as an increased duration (more than 7 days), increased amount (more than 80 mL), or both. Anovulatory uterine bleeding is the most common cause of menorrhagia. An unopposed estrogen state continues to build up the endometrium until it becomes unstable, resulting in menorrhagia. For young women with excessive bleeding, clotting disorders must be considered. Uterine fibroids (also called leiomyomas) and endometrial polyps are common causes of menorrhagia for women in their childbearing years.[6] Metrorrhagia. Metrorrhagia, also referred to as spotting or breakthrough bleeding, is bleeding between menstrual periods. For all reproductive-age women, pregnancy complications such as spontaneous abortion or ectopic pregnancy must be considered as a possible cause. Other causes include cervical or endometrial polyps, infection, and cancer. Spotting is common during the first three cycles of oral contraceptives. If spotting continues beyond that, a different pill formulation can be prescribed once other causes of metrorrhagia have been ruled out. Spotting with long-acting progestin therapy (e.g., Mirena intrauterine device [IUD]) or progestin-only pills (medroxyprogesterone [Depo-Provera, Provera]) is also common. For postmenopausal women, endometrial cancer must be considered whenever spotting is experienced. In postmenopausal women, exogenous estrogen administration during hormone therapy is a common cause of metrorrhagia. Diagnostic Studies and Collaborative Care Because abnormal vaginal bleeding has multiple causes, the diagnostic and collaborative care varies. A health history and physical examination directed at the most likely causes of vaginal bleeding for the woman's age-group is the first step. These findings provide the basis for selecting laboratory tests and diagnostic procedures. Treatment depends on the etiology of the problem (e.g., menorrhagia, amenorrhea), degree of threat to the patient's health, and whether children are desired in the future. Combined oral contraceptives may be prescribed for a woman with amenorrhea to ensure regular shedding of the endometrium if she also wants contraception. Tranexamic acid (Lysteda) may be used to treat heavy menstrual bleeding. This drug stabilizes a protein that helps blood to clot. Side effects may include headache, back pain, abdominal pain, muscle and joint pain, anemia, and fatigue. Women using hormonal contraception should take tranexamic acid only if they have a strong medical need, since there is an increased risk of blood clots and stroke. Estradiol valerate/dienogest (Natazia) may be given to women with heavy menstrual bleeding who desire an oral contraceptive to prevent pregnancy. The treatment goal for women with menorrhagia is to minimize further blood loss. If menorrhagia is the result of anovulatory cycles, the endometrium must be stabilized by a combination of oral estrogen and progesterone.

Evaluate the care of the patient with COPD on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes are that the patient should:

• Attain and maintain gas exchange at a level within his or her chronic baseline values • Achieve an effective breathing pattern that decreases the work of breathing • Maintain a patent airway • Achieve and maintain a body weight within 10% of his or her ideal weight • Have decreased anxiety • Increase activity to a level acceptable to him or her • Avoid serious respiratory infections

COPD is expected to increase activity to a level acceptable to him or her. Indicators include:

• Maintenance of baseline SaO2 with activity • Performance of ADLs with no or minimal assistance • Performance of selected activities with minimal dyspnea or tachycardia • Participation in family, work, or social activities as desired

ASSESS RESPIRATORY STATUS AND ADEQUACY OF VENTILATION

• Measure rate, depth, and rhythm of respirations. • Examine mucous membranes and nail beds for evidence of hypoxia. • Determine use of accessory muscles. • Examine chest and abdomen for paradoxical breathing. • Count number of words patient can speak between breaths. • Determine need and use of supplemental oxygen. (How many liters per minute is the patient using?) • Determine level of consciousness and presence/absence of confusion. • Auscultate lungs for abnormal breath sounds. • Measure oxygen saturation by pulse oximetry. • Determine sputum production, color, and amount. • Ask about activity level. • Observe general hygiene. • Measure body temperature.

ASSESS CARDIAC STATUS

• Measure rate, quality, and rhythm of pulse. • Check dependent areas for edema. • Check neck veins for distention with the patient in a sitting position. • Measure capillary refill.

The patient with COPD is expected to achieve an effective breathing pattern that decreases the work of breathing. Indicators include:

• Respiratory rhythm within normal limits for the patient's age • Presence of synchronous thoracoabdominal movement • Use of accessory muscles appropriate to the patient's activity level • Increased activity tolerance

he patient with COPD is expected to remain free from serious respiratory infection. Indicators include that the patient consistently demonstrates these behaviors:

• Verbalizes clinical manifestations of respiratory infection • Describes respiratory infection-monitoring procedures • Uses prevention activities such as pneumonia and influenza vaccination and crowd avoidance • Seeks medical assistance when manifestations of respiratory infection first appear

ASSESS NUTRITIONAL STATUS

• Weight maintenance, loss, or gain • Food and fluid intake • Use of nutritional supplements • General condition of the skin • Assess patient's and caregiver's adherence and understanding of illness and treatment, including: • Correct use of supplemental oxygen • Correct use of inhalers • Drug schedule and side effects • Manifestations to report to the health care provider indicating the need for acute care • Increasing severity of resting dyspnea • Increasing severity of usual symptoms • Development of new symptoms associated with poor oxygenation • Respiratory infection • Failure to obtain the usual degree of relief with prescribed therapies • Unusual change in condition • Use of pursed-lip and diaphragmatic breathing techniques • Scheduling of rest periods and priority activities • Participation in rehabilitation activities