Med Surg
The nurse reviews the electronic health record and documents care in the nursing progress notes. Orders implemented and provider is contacted as appropriate. The nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestation would the nurse associate with the client's condition?
Ascites, Pruritus, Jaundice, Vomiting, Bruising, Anorexia Ascites is a result of portal hypertension that occurs with liver cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed, and bile enters the bloodstream. Gastrointestinal symptoms such as vomiting are common. Bruising is a sign of poor liver function and is a cirrhosis-related complication. The appetite decreases, not increases, because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver.
The nurse reviews the electronic health record and documents care in the nursing progress notes. Client education provided as appropriate. Which clinical manifestation of acute myelogenous (nonlymphoid) leukemia (AML) would the nurse expect when assessing a child?
Anorexia, Petechiae, Irritability, Fatigue, Listlessness AML can result in anorexia, and vague abdominal discomfort occurs because of areas of intestinal inflammation. Bleeding tendencies (petechiae and bleeding gums) occur because of decreased platelets. Irritability can be attributed to the stress of the pathophysiological changes that occur with the disease. Fatigue in the client with AML is associated with anemia. Listlessness and lethargy result because of decreased erythrocytes (anemia). Pallor rather than redness occurs because of decreased erythrocytes (anemia). Loss of appetite and weight loss, not gain, are common physical findings in the AML client. Neuropathic pain is not a common clinical manifestation of AML.
The nurse reviews the electronic health record system for client information and documents care in the nursing progress notes. Client care implemented per provider orders. When a client develops internal bleeding after abdominal surgery, which clinical manifestation would the nurse expect the client to exhibit?
Pallor, Decreased mean arterial pressure (MAP), Tachycardia Pallor occurs as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. During the initial stages, MAP will decrease 5-10 mm Hg due to the blood pressure dropping. Heart rate accelerates (tachycardia) in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases (the opposite of polyuria) with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. Respirations increase (the opposite of bradypnea) and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension, not hypertension, occurs in response to hemorrhage as the person experiences hypovolemia. With loss of blood the pulse pressure will decrease and skin will become cold, not warm, to the touch and moist due to reduced blood flow.
The nurse reviews the electronic health record for pre-appointment imaging and documents visit-related care in the nursing progress notes. Which finding indicates that a client is at an increased risk for colorectal cancer (CRC)?
Presence of dark, tarry stools Family history of polyposis 20-year history of ulcerative colitis Unintentional 20-pound weight loss Change in bowel pattern for 3 months Dark and tarry stools, a family history of polyposis, a 20-year history of ulcerative colitis, unintentional weight loss of 20 pounds and a change in bowel patterns lasting 3 months are all findings that would warrant further evaluation for CRC. All of these clients are at higher risk for CRC. Dark, tarry stools occur from occult blood loss. A client who reports a longstanding change in bowel pattern should be tested for CRC. Familial polyposis is a precursor to CRC. Ulcerative colitis is an inflammatory bowel disease that increases the client's risk for CRC. Any client who experiences an unexplained and unintentional weight loss should be evaluated for cancer. The use of coffee, caffeine, or alcohol increase an individual's risk for gastritis. Long-term use of NSAIDS such as ibuprofen is a risk factor for both gastritis and peptic ulcer disease. Bacterial infection with H. pylori is also a risk factor for peptic ulcer disease.
The nurse reviews the electronic health record and documents visit-related care in the nursing progress notes. Labs drawn and imaging completed per provider orders. Which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? Select all that apply. One, some, or all responses may be correct.
Crackles, Coughing, Orthopnea, Anxiety, Restlessness, Lethargy In pulmonary edema, fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Sitting upright while leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. The client with pulmonary edema may present as anxious, restless, or with generalized lethargy. Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema the sputum may be frothy and blood tinged. Pulmonary interstitial edema, not dependent edema, occurs.
The nurse reviews the electronic health record and documents care in the nursing progress notes. Labs drawn and imaging obtained per provider orders. The nurse reviews the electronic health record of a client. The nurse suspects hypofunctioning of the adrenal gland based on which finding?
Increased calcium, Decreased cortisol, Weight loss, Decreased sodium, Vitiligo, Hyperpigmentation. Hypofunctioning of the adrenal gland is manifested by increased serum calcium and decreased serum cortisol. Anorexia and weight loss are gastrointestinal symptoms associated with adrenal insufficiency. The client with hypofunctioning adrenal glands will have decreased sodium levels. Skin symptoms associated with adrenal insufficiency include vitiligo or hyperpigmentation. Decreased serum potassium and decreased serum bicarbonate levels are associated with hyperfunctioning of the adrenal gland. Normal to increased serum glucose is associated with hyperfunctioning of the adrenal gland.
The nurse reviews the electronic health record and previous medical history. Documentation of care recorded in the nursing progress notes. Education provided per provider orders. After initiating antibiotic therapy on a client with syphilis, the nurse suspects a Jarisch-Herxheimer reaction (JHR). Which clinical manifestation supports the nurse's suspicion?
Fever with shaking chills, Generalized aches, Worsening of skin rash. Fever with shaking chills and generalized aches are signs of the Jarisch-Herxheimer reaction (JHR) in a client with syphilis receiving antibiotic therapy. This reaction is caused by the rapid release of products from the disruption of cells of the organism. JHR can also result in a worsening of skin lesions or rashes. Hypotension because of vasodilatation and declining peripheral resistance are late signs of JHR and would not be present at the onset of the reaction. Soreness in the muscle may accompany any injection and is not a sign of JHR. With syphilis treatment, the soreness may be due to the large amount of medicine injected into the muscle. JHR is associated with tachycardia and hyperventilation.
The nurse reviews the electronic health record for pre-appointment labs and imaging, and documents visit-related care in the nursing progress notes. Provides education as appropriate. A 24-hour urine specimen to assess the presence of vanillylmandelic acid (VMA) is ordered to assist in confirmation of the diagnosis of a pheochromocytoma. Which information would the nurse include in the teaching plan regarding this test?
All urine excreted over the 24-hour period must be saved and refrigerated. Avoid chocolate and citrus fruit for 3 days before and during the test. The client should avoid skipping meals while testing. The use of monoamine oxidase (MAO) inhibitors should be reported before testing.
The nurse reviews the electronic health record and documents care in the nursing progress notes. Client education provided as appropriate. A client visited the primary health care provider complaining of inflammatory lesions on the face and is diagnosed with an inflammatory disorder of the sebaceous glands. Which medication would the nurse anticipate being prescribed for this client?
Benzoyl peroxide, Clindamycin, Erythromycin, Dapsone, Retinoid Benzoyl peroxide is a first line treatment for mild acne vulgaris. Clindamycin and erythromycin are topical antibiotics used in the treatment of acne vulgaris, which occurs due to inflammation of the sebaceous glands. To avoid development of bacterial resistance these should be used in combination with benzoyl peroxide. Dapsone, an antibacterial drug, is also a common first line treatment of mild acne vulgaris. Often a retinoid, a prescription anti-acne drug, is used alone as the first line of treatment for mild acne. Bacitracin is an over-the-counter topical antibiotic used in the treatment of dermatological problems; however, it does not treat the most common bacteria found in acne and therefore could worsen the acne. Bacitracin is also petroleum jelly based and could contribute to further clogging of pores. Mupirocin is used in the treatment of superficial Staphylococcus infections such as impetigo. Topical metronidazole is used in the treatment of rosacea and bacterial vaginosis.
The nurse receives report from the emergency department and reviews the electronic health record. Care is implemented per provider orders and documented in the nursing progress notes. A child with iron poisoning resulting from ingestion of several chewable mineral supplement pills containing iron is being assessed. Which symptom would the nurse recognize as indicating that the poisoning has progressed to stage IV?
Jaundice, Hypoglycemia, Confusion, Sluggishness Stage IV iron poisoning occurs between 2 and 5 days after ingestion. It can be characterized by jaundice and hypoglycemia. In this stage the client becomes confused and sluggish and can further progress to coma. Hematochezia, or bloody stools, occurs in stage I, within 6 hours of ingestion. In stage V, seen between 2 and 5 weeks, pyloric stenosis or duodenal obstruction may occur secondary to scarring. Metabolic acidosis is seen in stage 3, between 12 and 24 hours.
The nurse reviews the electronic health record for pre-appointment labs and imaging and documents visit-related care in the nursing progress notes. Provides education as appropriate. After assessing a female client, the nurse suspects that the client has hyperpituitarism. Which questions asked by the nurse are relevant to the diagnosis?
"Is there any change in your vision?" "Do you experience severe headaches?" "Have you noticed any back pain?" "Do you experience joint pain?" "Is there any change in your menstrual cycle?" "Do your shoes feel tight when you put them on?" Hyperpituitarism can manifest with visual disturbances and severe headaches. Back pain and joint pain can result from the increased growth hormone (GH) associated with hyperfunctioning of the pituitary. Due to hypersecretion of prolactin in females, a change in menstrual cycle may also be observed. Because of the increased GH, the client may notice a change in the size of shoes, rings, or hats. Frequent urination is observed in a client with diabetes insipidus. Clients with diabetes mellitus experience intense hunger.
The nurse reviews the electronic health record for pre-appointment labs and imaging and documents visit-related care in the nursing progress notes. Provides education as appropriate. The nurse provides discharge teaching to a client with acquired immunodeficiency syndrome (AIDS) and a low white blood cell (WBC) count. Which client statement indicates understanding of the content?
"My roommate will take care of our cat's litter box." "I will rinse my toothbrush in bleach once a week." "Each time I get a new drink I will use a different cup." "I will wash my hands thoroughly after shaking hands with anyone." "I will wash my armpits and peri-area twice daily if I can't shower." When the client with AIDS has a low WBC, they should avoid changing the litter box. The client should rinse the toothbrush in bleach weekly and then rinse out the bleach with hot water. The client with a low WBC should not reuse cups and glasses. Hands should be washed with an antimicrobial soap before eating and drinking, after touching a pet, after using the toilet, and after shaking hands with anyone. If a client with AIDS cannot bathe daily with antimicrobial soap, they should ensure they wash their armpits, groin, genitals, and anal area twice daily with antimicrobial soap. Raw fruit and vegetables should be avoided, as should large gatherings of people who might be ill. The client with AIDS should take their temperature daily and also when they don't feel well. The client should avoid working with houseplants or in a garden.
The nurse reviews the electronic health record for pre-appointment labs and documents visit-related care in the nursing progress notes. Provides education and communicates with interdisciplinary team as appropriate. A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) receives pentamidine for a protozoal infection. The nurse will monitor the client for which common side effect?
Hypoglycemia, Decreased blood pressure, Oliguria, Sore throat, Fever Hypoglycemia is a side effect of pentamidine. Decreased blood pressure and dysrhythmias are common side effects of this medication. Other common side effects include decreased urination, sore throat, and fever. Neutropenia, not leukocytosis, is associated with this medication. Electrolyte imbalances associated with pentamidine include hyperkalemia, not hypokalemia, and hypocalcemia, not hypercalcemia.
The nurse reviews the electronic health record system for client information and documents care in the nursing progress notes. Client care implemented per provider orders. A client underwent surgery and developed a wound without tissue loss. While caring for the client, the nurse detects abscess formation. Which assessment made by the nurse supports the observation?
Purulent drainage from the incision site. Localized fluctuance beneath the wound when palpated Purulent drainage from the incision site's portion is detected during checks performed every 24 hours to detect abscess formation until sutures or staples are removed. Localized fluctuance and tenderness beneath a portion of the wound is palpated to detect abscess formation. Wound dehiscence is indicated by the presence of necrosis of skin edges. Swelling of the incision line or erythema of the incision line of more than 1 cm indicates cellulitis. Sanguineous to serosanguineous drainage for the first few days post-surgery is considered normal. Crusting on the incision line is also considered normal. Partial to complete separation of the outer wound layers is indicative of wound dehiscence.
The nurse reviews the electronic health record for pre-appointment labs and documents visit-related care in the nursing progress notes. Provides education as appropriate. Which physiological response would the nurse expect when assessing a client with hyperthyroidism?
Blurred vision, Tremors, Insomnia, Increased appetite, Widened pulse pressure, Diaphoresis Blurred vision may occur as a result of exophthalmos found in hyperthyroidism. Tremors and insomnia are among the neurological symptoms associated with hyperthyroidism. The appetite increases in an attempt to meet the caloric needs of the body. As the systolic pressure increases, it causes a widened pulse pressure (the difference between the systolic and diastolic blood pressures). The client with hyperthyroidism may present with profuse sweating. Tachycardia, not bradycardia, occurs because of the increased metabolic rate. Intolerance to heat, not cold, occurs because of the increased metabolic rate.
The nurse reviews the electronic health record system for client information and documents care in the nursing progress notes. Client care implemented per standing orders. A client is admitted with the diagnosis of acute pancreatitis. Which clinical manifestation would the nurse associate with this diagnosis?
Acute pain, Vomiting, Weight loss, Increased amylase Autodigestion of the pancreas causes severe abdominal pain. Nausea and vomiting are common and associated with weight loss. Obstruction of the pancreatic duct leads to elevated levels of amylase. Obstruction of the common bile duct by inflammation can lead to jaundice, not cyanosis. Lipase levels will be elevated with pancreatitis. Hypotension, not hypertension, is caused by fluid shifting out of the intravascular space. Decreased pancreatic function causes hyperglycemia, not hypoglycemia.
The nurse reviews the electronic health record for pre-appointment labs and imaging and documents visit-related care in the nursing progress notes. When assessing a client with varicose veins, which clinical manifestation would the nurse expect to find?
Presence of ankle edema, Increased leg fatigue, Report of leg fullness and pruritis. Presence of ankle edema, increased leg fatigue, and a report of leg fullness and pruritus are signs of varicose veins, due to poor venous return and increased venous pressure. Diminished peripheral pulses occur with decreased arterial blood flow. Intermittent claudication (as evidenced by leg pain with activity that resolves with rest) occurs with decreased arterial, not venous, perfusion. Additional signs of peripheral artery disease (PAD) include hair loss on lower calf, ankle, and foot areas along with thickened toenails. The nurse would expect to see brown pigmentation or skin staining, not pallor, associated with extravasated red blood cells in lower extremities.
The nurse obtains report and reviews the electronic health record. Documentation related to care provided is recorded in nursing progress notes. Orders noted in EHR implemented appropriately. Which clinical manifestations does the nurse expect the client to report when admitted for surgical resection of a rectosigmoid colon cancer?
Feeling tired, Rectal bleeding, Change in shape of stools, Feeling of abdominal bloating, Straining to pass stools Anemia may manifest as fatigue, feeling tired, and/or generalized weakness. Anemia is common with rectosigmoid colon cancer from the loss of blood rectally. Passage of red blood (hematochezia) is one of the cardinal signs of rectosigmoid colon cancer; ulceration of the tumor and straining to pass stool precipitate this clinical finding. A cancerous mass can grow into the lumen of the sigmoid colon, altering the shape of stool; stools may be ribbonlike or pencil thin. Tumors in the rectosigmoid colon cause partial and eventually complete obstruction of the intestinal lumen. Because there is less fluid in the stool of the descending and sigmoid colon, a formed mass develops; thus, the client commonly has gas pains (causing a feeling of abdominal bloating), cramping, and incomplete evacuation, causing the client to strain to pass stools. An inability to digest fat is not specific to rectosigmoid colon cancer; therefore, stools will not float and will contain bile, which causes stool to be brown in color, not clay-colored.
The nurse reviews the electronic health record and documents care in the nursing progress notes. Client education provided as appropriate. When reviewing the results of a toddler's complete blood count, the nurse notes decreased hemoglobin and hematocrit levels. Which additional laboratory findings would the nurse expect in iron-deficiency anemia?
Microcytic red blood cells, Slightly reduced reticulocyte count, Decreased serum ferritin. In iron-deficiency anemia the red blood cells are microcytic with a decreased mean corpuscular volume. The reticulocyte count is within the expected range or slightly reduced. Serum ferritin values are less than 10 ng/mL with this type of anemia, normal values are 10-300 ng/mL. The red blood cells are hypochromic, not hyperchromic. The total iron-binding capacity is increased in children with iron-deficiency anemia as the body attempts to absorb more iron. An increased ESR indicates an inflammatory process. The ESR is not related to iron-deficiency anemia.
The nurse reviews the electronic health record and documents care in the nursing progress notes. Client education provided as appropriate. Which assessment would the nurse include when taking the health history of a toddler with an exacerbation of eczema?
Wearing polyester clothes, Exposure to new foods, Increased emotional stress, Smoking in the home, Use of fragrant detergents. Eczema is a common manifestation of allergies in the young child and is often related to foods and clothing. Fabrics such as polyester or wool are common triggers for eczema. Exposure to new foods is a common trigger for eczema. Although it is not known why, increased emotional stress can trigger an eczema exacerbation. Cigarette smoke can serve as a trigger for eczema outbreaks. Perfumes, dyes, and detergents are common triggers for eczema. Appetite does not play a role in the occurrence of eczema. Eczema is an allergic manifestation; it is not contagious and therefore cannot be transmitted by being around a viral infection, someone else with eczema, or through travel.
The nurse reviews the electronic health record and previous medical history. Documentation of care recorded in the nursing progress notes. Education provided per provider orders. Which factor would the nurse identify as increasing the risk of human immunodeficiency virus (HIV) transmission?
Childbirth, Breast-feeding, Anal sex, Needle sharing, Oral sexual contact. HIV can be spread through childbirth and breast-feeding. Anal sex increases transmission because of exposure to mucous membranes to infected semen. Sharing needles can be a parenteral route for HIV transmission. Oral sexual contact with infected semen or vaginal secretions increases the risk of transmission. Having multiple sexual partners, not monogamy, increases the risk of HIV transmission. HIV cannot be transmitted through sharing plates and cups. Sharing toilet facilities does not transmit HIV.
The nurse obtains report and reviews the electronic health record. Documentation related to care provided is recorded in nursing progress notes. Diagnostics completed as ordered. A client is scheduled for a barium swallow. How would the nurse prepare the client for the test?
Clarify procedural questions before the consent is signed. Ensure that a laxative is prescribed after the test. Instruct to withold prescribed opioids for 1 day before the test. Assess the client's ability to swallow. Before the procedure the nurse should ensure the consent is signed and clarify any remaining concerns or questions. Barium will harden and may lead to constipation and a possible impaction; a laxative and increased fluids promote elimination of barium. Opioids are withheld for 24 hours before the test to prevent intestinal immobility. The radiologist should be notified prior to the test if the client has a tendency to aspirate. Iodine is not used with a barium swallow test. Administering cleansing enemas before the test is not part of the preparation; feces in the lower gastrointestinal (GI) tract will not interfere with visualization of the upper GI tract. The client is kept to nothing by mouth 8 to 12 hours before the test to ensure that the upper GI tract is free of food. In addition, a low-residue diet may be prescribed several days before the test. The barium enema, not barium swallow, visualizes the lower GI tract which requires stool to be clear and the nurse would ensure the bowel is adequately cleansed prior to testing.
The nurse reviews the electronic health record system for patient information and documents care in the nursing progress notes. Patient care implemented per standing orders. A client is taught how to recognize signs of a hypoglycemic reaction. Which symptom identified by the client indicates to the nurse that the teaching was effective?
Fatigue, Weakness, Nervousness, Heart pounding, Increased perspiration, Hunger, Confusion. Fatigue is related to hypoglycemia. Weakness is related to a decrease in glucose within the central nervous system. Nervousness and heart pounding are caused by increased adrenergic activity and increased secretion of catecholamines. Some cholinergic symptoms associated with hypoglycemia include increased perspiration and hunger. Confusion is a neuroglycopenic symptom of hypoglycemia. Nausea is related to hyperglycemia, not hypoglycemia. Increased thirst with an excessive oral fluid intake (polydipsia) is associated with hyperglycemia and is one of the cardinal manifestations of diabetes mellitus.
The nurse reviews the electronic health record and documents care in the nursing progress notes. Client education provided as appropriate. An ambulatory client with relapsing-remitting multiple sclerosis (RRMS) is to receive every-other-day injections of interferon beta-1a. Which adverse effect would the nurse explain may occur when taking this medication?
Depression, Flu-like symptoms, Increased risk for infection Central nervous system effects include depression that may lead to suicide attempts. Interferon immune modifier medications also cause flu-like symptoms, such as fever, muscle aches, and lethargy. Myelosuppression can cause leukopenia, thus increasing the risk for infection. It also increases the risk for anemia because of decreased production of red blood cells (RBCs); this is the opposite of polycythemia (too many RBCs). Muscle spasms are a side effect of the medication, and spastic, not flaccid muscles are associated with MS. Hypertonia, not hypotonia, is a side effect of this medication. An integumentary response to this medication is sweating, not lack of perspiration (anhidrosis). The MS client taking interferon may experience fatigue as a side effect, but not hyperactivity.
The nurse receives report, reviews the electronic health record, and documents care in the nursing progress notes. Labs drawn and diagnostics completed per provider orders. Education provided as appropriate. An older adult in the hospital has an order for strict bed rest. The client has an increased risk for which complication?
Friction injury, Atelectasis, Pressure injury, Urinary tract infection, Contractures, Muscle loss, Shearing damage A friction injury to the skin is caused when surfaces rub the skin, such as when a patient is moved across bed linens. Clients on bed rest are at risk for complications secondary to immobility, such as atelectasis, pressure injuries, urinary tract infections, contractures, muscle loss, and shearing damage. Damage from shearing is caused when the skin is stationary, but the tissues below the skin move causing reduced blood supply to the area. Immobility also increases the risk of constipation, not diarrhea.
Which finding would the nurse expect when assessing a client with peripheral arterial disease (PAD)? Select all that apply. One, some, or all responses may be correct. Pallor of feet Warm extremities Ulcers on the toes Delayed capillary refill Thick, hardened skin Hair loss to lower extremities Muscle atrophy Intermittent claudication
Pallor of feet, Ulcers on the toes, Delayed capillary refill, Hair loss to lower extremities, Muscle atrophy, Intermittent claudication. PAD affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit pallor, ulcers on the feet and toes, cool skin, and capillary refill longer than 3 seconds. Hair loss to the lower calf, ankle and foot are noted with PAD. Chronic PAD can result in muscle atrophy. Intermittent claudication is the most common presenting symptom of this disease. Warm extremities occur with venous disease. Venous disease leads to thick, hardened skin on the legs.
The nurse receives report from the emergency department and reviews the electronic health record. Care is documented in the nursing progress notes. Diagnostics completed per provider orders. A 3-year-old child with sickle cell disease (SCD) is admitted with a vasoocclusive crisis (VOC or a pain episode). Which intervention is the priority nursing concern?
Hydration, Pain management, Oxygen supplementation The triad of treatment for a client experiencing a sickle cell crisis is: hydration, pain management, and oxygenation. Hydration will provide more circulating volume for the sickle cells. Pain management is typically the primary reason this client presents for treatment; the pain becomes unbearable. Supplemental oxygen will provide more oxygen molecules to attach to the red cells, providing more oxygen to the tissue and joints. Because this is a crisis, priority nursing concerns will not include education on topics such as nutrition. The diet of a client with SCD should include foods that are high in folic acid and those that are high in calcium, such as green-leafy vegetables. The client and family may benefit from community support groups and genetic counseling, but that is not a priority during a crisis. The client with SCD is at increased risk of infection due to decreased immunity, therefore the family should be taught how to recognize and report signs of infection early, as well as how to prevent infections. Parental education, such as already listed, along with home care instructions, should be provided prior to discharge.
The nurse reviews previous medical history and establishes an electronic health record. Documentation of care recorded in the nursing progress notes. Education provided per provider orders. A client who has recently moved to the country attends the prenatal clinic at 30 weeks gestation for the first time. Although she states that she has had immunizations, she does not know which ones. Which immunization would the nurse recommend?
Influenza Tetanus, Diphtheria, Pertussis (TDAP) Hepatitis B The influenza, TDAP, and Hepatitis B vaccines contain dead viruses and can be administered safely during pregnancy. The mumps, measles, and rubella (MMR), shingles, and varicella vaccines are all contraindicated because they contain live viruses, which are teratogenic.
The nurse reviews the electronic health record and documents visit-related care in the nursing progress notes. Labs drawn and imaging completed per provider orders. When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factor that may have contributed to the ankle swelling?
Intake of salty foods, Increased fluid consumption, Medication compliance, Recent travel, Alcohol intake Fluid retention in heart failure may be caused by increased salt intake, with associated water retention. This may also be caused by increased dietary fluids. Poor adherence to medication used to treat heart failure, such as angiotensin-converting-enzyme inhibitors and diuretics, may also cause fluid retention. Recent travel may cause fluid retention because of changes in environmental temperature, effects of airplane travel on fluid retention, or changes in dietary sodium intake. Increased alcohol intake can worsen the effects of heart failure, including edema. Increased or decreased dietary fat intake will not cause fluid retention. Stress is not a contributor to fluid retention. The client with heart failure is encouraged to stay as active as possible, without overdoing it. A sedentary, not active, lifestyle would contribute to fluid accumulation.
The nurse reviews the electronic health record and documents care in the nursing progress notes. Client education provided as appropriate. The nurse is providing instructions about foot care for a client with diabetes mellitus. Which teaching point would the nurse include in the instructions?
Wear shoes when out of bed, Dry between the toes after bathing, Do not smoke or use nicotine products Wearing shoes at all times when out of bed protects the feet from trauma; they should fit well and should be worn over clean socks. Drying between the toes after bathing prevents maceration and skin breakdown, thus maintaining skin integrity. Vascular complications are associated with tobacco use and should be avoided in the diabetic client. Soaking the feet is contraindicated because it can cause macerations and skin breakdown, which allow a portal of entry for pathogenic organisms. Clients should not self-treat corns, calluses, warts, or ingrown toenails because of the potential for trauma and skin breakdown; these conditions should be treated by a podiatrist. Toenails should be cut straight across, not rounded. Use of a heating pad, hot water bottle, or hot water is contraindicated because of the potential for burns; diabetic neuropathy, if present, does not allow the client to accurately evaluate the extremes of temperature. The client should be taught to inspect feet daily, not weekly, including between the toes.
