Physiological Adaptation

What is the first nursing action that should be taken in caring for a client with symptoms of tuberculosis?

*1. Identify the client's symptoms promptly.* 2. Instruct the client to cover the mouth and nose with tissues when sneezing. 3. Isolate the client in a negative pressure room. 4. Place a surgical mask on the client.

After applying sterile gloves, what process should the nurse use to remove interrupted sutures from a client's surgical wound? Place in the correct order.

1. Moisten dried crust with sterile 0.9% sodium chloride solution 2. Clean suture line with antimicrobial solution 3. Gently grasp the knot with forceps and raise it slightly 4. Place the curved tip of suture scissors directly under the knot 5. Gently cut the suture 6. Pull suture out with forceps 7. Make certain all suture material is removed 8. Put suture on clean gauze 9. Apply sterile wound strips 10. Document date, time, and number of sutures removed

Transphenoidal hypophsectomy

A surgical procedure used to remove a tumor of the pituitary gland through the nose Post op: Sleep with the HOB @35 degrees, notify the HCP if there is an increase in urinary output that indicates diabetes insipidus (adverse rxn), humidified air prevents drying of nasal passages There is no nasal packing - the incision is just above the gum line of the upper teeth + client can eat regular diet

Lyme disease

Bull's-eye rash which starts at the site of a tick bite S/s: fever, headache, muscle aches, joint pain

What lab value alerts the nurse that a client is chronically losing blood?

Elevated reticulocyte count - if a client is chronically losing blood, response is to increase RBC production, so the relic count would increase

A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client?

Firm nodular liver, ascites, increased ALT + AST levels, bleeding from the GI tract With cirrhosis, the liver becomes very large in size and feels very firm and nodular. Ascites occurs due to lowered albumin levels. Increased pressure in the liver causes a backward pressure throughout the GI tract and esophageal varies may form as a result. If varices rupture, there will be GI bleeding + also liver is unable to produce needed clotting factors Ammonia levels rise in clients with cirrhosis b/c liver is unable to convert the ammonia to urea to be excreted by the kidneys

Histoplasmosis

Fungal infection transmitted by eating soil contaminated by bird feces

What are some risk factors for diabetic related renal complications?

Hypertension + hyperglycemia

What is one of the leading causes of end stage renal disease?

Hypertension, renal function is reflected by serum creatinine levels

Following a hemorrhagic stroke, a client had a craniotomy with insertion of a ventriculostomy. Upon arrival in the ICU, the nurse's initial readings indicate an increase in ICP. What is the nurse's priority action?

Hyperventilate client with a bag valve mask! This lowers cerebral CO2 levels, causing vasoconstriction which temporarily decreases blood flow and reduces pressure within the brain.

What clinical manifestations are seen in a right brain stroke?

Impaired judgement + impulsiveness

What clinical manifestations are seen in a left brain stroke?

Impaired language comprehension, impaired speech, and depression

With pernicious anemia, what does the client lack?

Intrinsic factor! Without this, B12 cannot be absorbed and the client will require B12 IM shots throughout their life

What assessment finding in a client 5 hours post cholecystectomy would require the nurse to notify the surgeon?

Jackson Pratt drain that has 90 mL of blood! The drainage should be green (bile)

Which assessments will provide the nurse with the most information regarding a client's neurologic function?

LOC, verbal ability, orientation and ability to move to command

What is given to control BP + decrease seizures in a pregnant woman?

Magnesium sulfate

What are signs of a salicylate overdose?

N/V , dehydration (from N/V), tinnitus, ototoxicity, diaphoresis, hyperventilation + fever

Guillian-Barre Syndrome

Numbness + tingling in the lower extremities that advances upwards, especially after a viral infection Emergency! Must be treated before paralysis of the respirator muscles occurs ∙ Nurse should perform passive ROM as client gets easily fatigued

Toxoplasmosis

Occurs from contact with cat feces S/s: influenza-like, swollen lymph nodes, headache, fever + fatigue, muscle aches and pain

When suctioning a client's endotracheal (ET) tube, the nurse notes that the client's HR has gone from 78 to 44. The nurse stops suctioning the ET tube. What is the nurse's best action?

Oxygenate the client with 100% oxygen The drop in HR indicates acute hypoxia, which can be caused by suctioning

The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority?

Place an eye shield over eye. The eye shield should be protected first to reduce further injury.

A client with a hx of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurses's initial focused assessment of this client?

Please describe your bowel habits and stool Asking the client to describe stool is open ended and will give the nurse more detail

Which ABG results would the nurse expect on a client who has overdosed on aspirin?

Respiratory alkalosis Aspirin stimulates the respiratory center and causes an increase in respiratory rate + depth

A high school nurse is assessing multiple students reporting general flu-like symptoms. Which additional symptoms reported by a student would prompt the nurse to immediately call an ambulance?

Sensitivity to light + Kernig's sign The Kernig's sign is used to assess for meningitis and combined with other stated symptoms is worrisome. Meningitis can be fatal and contagious.

Paroxysmal nocturnal dyspnea

Sudden respiratory distress that occurs when the client is reclining

What does the gallbladder assist in?

The digestion of fat When foods high fat are ingested, bile is released from the gallbladder to assist in digestion - if gallstones are formed, the client may experience epigastric discomfort after a meal high in fat

What are risk factors for developing peripheral neuropathy?

Uncontrolled diabetes, alcohol abuse, Vitamin B deficiency, rheumatoid arthritis + varicella-zoster virus