LAUNDRY LIST: PREPU: Capstone
2-year-old is brought into the ED by parents for cough, high fever, and rash. Per the parent report, they noticed a rash on child's head and neck early yesterday morning and by later this evening it had traveled downward toward the child's trunk. Parents state they do not believe in vaccinations and none of their children have been vaccinated.
1.Isolation Precaution 2. Oxygen saturation 3.Temapature The client is exhibiting the prime characteristics of measles (rubeola): a high fever, a confluent maculopapular rash (Koplik spots), and blue-white spots in the buccal mucosa. While the client has not received a final diagnosis, measles should be suspected, and the client should immediately be placed on airborne precautions and necessary personal protective equipment (PPE) should be worn. Measles is highly contagious; therefore, this action should be the priority intervention to prevent the spread of the disease. Parental support for the client is important, especially for the developmental level of a 2-year-old child, but is not a priority during this immediate time. Measles is highly contagious and the client's siblings should be cautious and self-isolate, but this is not a priority during this immediate time. The client is exhibiting signs of shortness of breath, low oxygenation levels, bilateral crackles, and increased respiratory rate. Pneumonia is a common complication of measles; oxygen support may be needed. The airway is always a priority. The client's respiratory rate is tachypneic and their heart rate is slightly elevated; however, addressing the client's oxygenation saturation should also allow for ease of breathing and a decrease in respiratory and heart rates. The client's blood pressure is within normal limits for their age. A rash is commonly seen with measles and while it may be irritating, it is a not a priority to treat at this time. Sustained high temperature can cause neurologic and organ damage. In a toddler, a fever can cause febrile seizures and make it harder for their body to fight off the infection. Once the client is placed on proper isolation precautions and their oxygenation saturation is addressed, the next priority should be
The nurse is making client rounds following the shift report. Which client should the nurse assess first?
75-year-old client with metastatic prostate cancer with a pathologic fracture of the femur who is in pain Explanation: The nurse should first assess the 75-year-old client with prostate cancer because of the client's age, need for pain management, extended bed rest, and potential for preexisting nutritional deficits. The nurse should plan to spend a focused but short time with the client receiving internal radiation. The client who will receive chemotherapy will require more observation after receiving the medication. The nurse can assess the client who will have a central venous catheter after assuring the older client is comfortable.
A client who had a gastrectomy has been in the post anesthesia recovery room for 30 minutes when the vital signs suddenly change. The nurse checks the recovery room record (see chart). In addition to notifying the health care provider, what other action should the nurse take immediately?
Administer dantrolene. The client is demonstrating signs of malignant hyperthermia. Unless the body is cooled and the influx of calcium into the muscle cells is reversed, lethal cardiac arrhythmia and hypermetabolism occur. The client's body temperature can rise as high as 109°F (42.8° C) as body muscles contract. Dantrolene, an IV skeletal muscle relaxant, is used to reverse muscle rigidity. Elevating the head of the bed will not reverse the hyperthermia. Adding fluids and inserting an indwelling urinary catheter are not immediately beneficial steps in reversing the progression of malignant hyperthermia.
A client is receiving fluid replacement with lactated Ringer's solution after 40% of the body was burned 10 hours ago. The assessment reveals a temperature of 97.1°F (36.2°C), heart rate of 122 bpm, blood pressure of 84/42 mm Hg, central venous pressure (CVP) of 2 mm Hg, and urine output of 25 mL for the last 2 hours. The intravenous (IV) rate is currently at 375 mL per hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse should request which prescription from the health care provider?
IV rate increase Explanation: The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.
A nurse is completing an admission fall assessment with an adult client. What are important nursing considerations to determine a high risk for falls? Select all that apply.
advanced age urinary urgency benzodiazepine medication Fall risk factors include advanced age due to changes in balance, urinary elimination symptoms such as urgency and the need to get to the bathroom more frequently. The use of benzodiazepines can cause the client to feel dizzy and lose balance. The use of anticoagulants is a consideration after a fall. Clients with low blood pressure are considered at risk for falls related to potential dizziness.
What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home?
checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment Explanation: Safety and access in the client's home are important to assess before discharge to ensure that the client can manage at home
A client was brought to the hospital in an agitated state and admitted to a psychiatric unit for observation and treatment. On admission, the client was found to be talking rapidly and folding and unfolding garments several times while putting personal belongings away. The client is unable to settle down. Which assessment of the client would have highest priority at this time?
feelings of anxiety Explanation: Anxiety is the top priority at this time. The client is exhibiting behavior that is indicative of anxiety, including restlessness, irritability, rapid speech, and inability to complete tasks. The other aspects of the nursing assessment are significant but are not the top priority.
A registered nurse (RN) and licensed practical/vocational nurse (LPN/VN) are working together in the emergency department to care for a client who is hemorrhaging. Which actions could be delegated to the LPN/VN? Select all that apply.
monitoring of vital signs dressing wound documentation of vital signs during infusion of blood products repositioning of client to take pressure off the wound site The RN has the primary responsibility for the client, but the RN may delegate tasks within the scope of practice of the LPN/VN. Assessment of the client falls to the RN. In this situation, that includes assessment of the wound, as well as initiation of blood products and assessment for a transfusion reaction. Once the client is stable, the nurse may choose to delegate ongoing reassessment (not initial assessment) of vital signs and documentation of vital signs during blood transfusion. Once the RN has assessed the wound, the dressing procedure can be delegated, and the client may be repositioned.
A nurse is considering employment at a hospital where nurses belong to a collective bargaining unit. How will the potential employee benefit from the collective bargaining unit? Select all that apply.
negotiation for wages negotiation for improved work environment organization of social activities Explanation: Nurses who belong to a collective bargaining unit will have negotiation for wages and improved work environments. Collective bargaining units may sponsor social activities for members. The collective bargaining unit does not help with preferred work hours or childcare. The membership for a collective bargaining unit is not free; dues for membership are required.
Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer?
nurse with 3 years' experience working in oncology Brachytherapy is internal radiation and nurses must use the principles of time, distance, and shielding. Radiation has cumulative effects and the nurse already working with a client receiving radiation should not be exposed to additional radiation. Working with clients who are receiving internal radiation takes a certain skill set, and the nurse who has floated from the operating room is not the best person to work with this client. Radiation is harmful to the fetus, and the nurse who suspects they are pregnant should not be exposed to radiation.
A client is transferred from the postanesthesia recovery unit to a medical-surgical unit. Which action(s) can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply.
obtaining the client's admission vital signs making sure the client's call light is within reach recording the client's urinary output giving the client a cup of ice Tasks within the UAP's scope of practice include obtaining vital signs and recording the urinary output, as well as placing the call light within reach and giving the client a cup of ice. Assessing the client on admission and assessing the client's level of pain are nursing interventions that are in the registered nurse's scope of practice.
