Hurst 8

The nurse manager of a long-term care facility notes an increase in pressure ulcers over the last six months. What new protocol developed by the nurse manager is most likely to decrease the occurrence of decubiti? 1. Bedfast clients must be repositioned every two hours. 2. All clients should have egg crate mattress on the bed. 3. Clients bathed in bed need lotion applied to all joints. 4. Provide back massage daily to all clients on bed rest.

1. CORRECT: Repositioning clients every two hours prevents excessive, prolonged pressure on skin and bony prominences. Such an action also provides an opportunity for visible inspection of the client by staff. This repositioning applies not only to bedfast clients, but also to those who sit in a chair for prolonged periods of time. 2. INCORRECT: An egg crate, foam mattress topper can be useful, both on a bed or a chair seat, to decrease shearing forces and cushion skin. But padding a surface does not guarantee the client will not develop a pressure sore. 3. INCORRECT: Applying lotion to body will help lubricate dry skin. However, massaging the skin directly over joints is not advised, since that skin is generally thinner and more fragile. Additionally, this action alone would not ensure a reduction in the occurrence of pressure ulcers. 4. INCORRECT: A daily back massage does stimulate circulation and allow for inspection of the spine, particularly for clients on bed rest. But this action alone would not decrease the occurrence of decubiti.

What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? 1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform 5. Pyrexia 6. Purulent drainage

1., 2., 3., & 4. Correct: These are signs of cannula displacement. Observe for signs of cannula displacement into the tissues which will be swelling, bleeding, lack of a normal arterial waveform, fluid leakage, blanching, and pain or discomfort. 5. Incorrect. This is a sign of infection rather than cannula displacement. Signs of infection include pain, redness, purulent drainage, and fever. 6. Incorrect. This is a sign of infection rather than cannula displacement.Signs of infection include pain, redness, purulent drainage, and fever.

What should the nurse monitor when caring for a client post fasciotomy of the arm? 1. Bleeding 2. Capillary refill 3. Color 4. Distal pulses 5. Infection 6. Sensation

1., 2., 3., 4., & 6. Correct: Fasciotomy is a surgical procedure that cuts away the fascia to relieve tension or pressure. So after the procedure, the nurse wants to make certain that pressure has been relieved and circulation distally is good. The nurse will thus need to monitor skin color, capillary refill, distal pulses, and sensation. Since this is a surgical procedure, bleeding will also need to be monitored. 5. Incorrect: Infection can be a complication, however, it will not be an immediate concern.

Which signs and symptoms does the nurse expect to see in a client admitted to the medical unit with Parkinson's disease? 1. Blank affect. 2. Decreased ability to swing arms. 3. Waddling gait. 4. Walking on toes. 5. Pill-rolling tremor. 6. Stiff muscles.

1., 2., 5., & 6. Correct: Classic characteristics of Parkinson's disease include a blank facial expression, forward tilt in the posture, slow/slurred speech, tremor, and a short shuffling gait. These symptoms also are manifested by a decreased ability to swing the arms and stiff muscles. 3. Incorrect: This is a sign of Duchenne Muscular Dystrophy. The client with Parkinson's disease has a shuffling gait. 4. Incorrect: This is a sign of Duchenne Muscular Dystrophy. The client with Parkinson's disease has a shuffling gait.

What signs/symptoms would the nurse expect to find in a client diagnosed with pernicious anemia? 1. Pain 2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion

2., 3., 4., & 5. Pernicious anemia symptoms could include a smooth tongue that is red in color rather than a healthy pink. And neurological problems such as a burning feeling in the feet, slow reflexes, and disorientation. Light headedness, dyspnea on exertion, fatigue, and breathlessness are anemia symptoms that clients often report. 1. Incorrect. Pain is a symptom seen in sickle cell anemia.

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? 1. Have client ambulate back to bed. 2. Initiate 100% oxygen per nonrebreather mask. 3. Obtain client's blood pressure. 4. Prepare for cardioversion. 5. Auscultate lung sounds. 6. Administer nitroglycerin 1 tab SL.

3. & 5. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds. 1. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall. 2. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100%. Start with the least amount of oxygen that could relieve symptoms. 4. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs. 6. Incorrect: Nitroglycerin would be given if the client is experiencing chest pain or is suspected of having an MI. Get the client back in bed and provide the client with oxygen at 2 L/NC first.

What should the nurse teach a client about testicular self examination? 1. This exam should be performed bi-annually. 2. The exam should be performed during a cold shower. 3. Gently roll each testicle with slight pressure between the fingers. 4. The epididymis should feel like a hard, knotty rope

3. Correct: Examine one testicle at a time. Use both hands to gently roll each testicle, with slight pressure, between the fingers to feel for lumps, swelling, soreness or a harder consistency. 1. Incorrect: All men 15 years and older need to perform this examination monthly. 2. Incorrect: The exam should be performed during or right after a warm shower or bath when the the scrotum is less thick. 4. Incorrect: The epididymis should feel soft, rope like, and slightly tender to pressure. It is located at the top of the back part of each testicle. It is not a lump.

The nurse just received an arterial blood gas (ABG) report that shows a borderline high PCO2 on a client who had chest surgery. What should be the priority nursing intervention? 1. Tell the client to breathe faster. 2. Medicate for pain and ambulate. 3. Have client use the incentive spirometer. 4. Prepare to administer bicarbonate to buffer.

3. Correct: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2 the client needs to turn, cough, and deep breath. Incentive spirometry can be provided to assist the client with this effort. 1. Incorrect: Breathing faster will only work for a few minutes. The problem is the client needs to breathe deeper to get more oxygen to the tissue and more CO2 out of the lungs. Hyperventilating will lead to respiratory alkalosis. 2. Incorrect: No more sedation! The client is not breathing enough. Walking would be okay. This client needs to take deep breaths. 4. Incorrect: No, we want the client to blow off the CO2. Bircarb will make the pH happy for a short period of time but will not correct the problem. The problem is shallow respirations, so fix the problem.

A client has received 850 mL of an isotonic solution intravenously in less than 60 minutes. Which central venous pressure (CVP) reading noted by the nurse indicates a problem related to the amount of intravenous fluids infused? 1. 1 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

4. Correct: Normal CVP is 2-6 mmHg. This client has received an isotonic solution amount of time. Remember that isotonic fluids stay "where I put them". The vascular space will increase in volume. More volume, more pressure! 1. Incorrect: This CVP reading indicates fluid volume deficit. There is no indication in the stem that the client is losing fluid. 2. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 3. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg.

A client with a history of syncope and transient arrhythmias has been ordered a Holter monitor for 48 hours. The nurse knows that teaching has been effective when the client makes what statement? 1. No follow up care will be needed after the monitor is removed. 2. It is okay to shower or bath while wearing this equipment. 3. I have to take it easy and not exercise for the next two days. 4. It's important to write down all my activities during this time.

4. Correct:The purpose of the Holter monitor is to detect cardiac irregularities over an extended period of time, in this case 48 hours. Although the monitor will record heart rate and rhythm for two days, it is vital for the client to keep a log or diary during that time, indicating the precise time and type of every activity. Additionally, this log needs to indicate any chest pain or palpitations the client experiences during that time, to assist the primary healthcare provider in diagnosing cardiac dysfunctions. 1. Incorrect: A Holter monitor is a mobile diagnostic test utilized by the cardiologist to help determine a cause for this client's syncopal episodes or arrhythmias. Once the client has the monitor and electrodes removed, the primary healthcare provider will analyze the data before meeting with the client to discuss the findings. Regardless of any suggested treatment options, the cardiologist needs a follow up visit with the client. 2. Incorrect: Showering or tub bathing is not permitted while wearing the Holter monitor as this may interfere with the functioning of the equipment. Only a careful sponge bath is permitted. Clients are also instructed to avoid heavy machinery, electric razors, microwave ovens and even hair dryers since can also affect accuracy and performance of the monitor. 3. Incorrect: The purpose of wearing Holter monitor for 24-48 hours is to diagnose cardiac arrhythmias during ADL's or exercise. The client cannot remove the monitor at any time during that period since that would cause inaccurate readings, or even the loss of valuable data. The client is instructed to complete all routine daily activities during that time, including work or exercise, to help identify actions that contribute to the symptoms or cardiac irregularities.