Reduction of Risk/Physiological Adaptation (Week 3)
1st, 2nd, and 3rd line treatment for cholelithiasis
- 1st line- meds that dissolve gall stones: chenodeoxycholic acid / orsodeoxycholic acid - 2nd line- lithotripsy - 3rd line- cholecystectomy
Priority assessment before administering magnesium sulfate
- Deep tendon reflexes (normal is +2) - if DTR is low, give calcium gluconate instead of magnesium sulfate
Medications for decreasing ICP
- Mannitol - Dexamethasone - 3% NaCl
#1 complication of a liver biopsy and prevention
- bleeding - prevent by instructing client to lay on right side to apply pressure
normal color of peritoneal dialysis fluid
- clear - cloudy fluid indicates infection
signs and symptoms of peritonitis
- discolored drainage - abdominal pain - fever - rigid, board like abdomen
Pain in RUQ
- gallbladder (osmotic pain) - liver (dull pain)
Signs and symptoms of PAD
- intermittent claudication - cold extremities - pale/cyanotic extremities - no hair growth on distal extremities
Decreasing ICP
- keep HOB at 30 degrees - maintain head midline/neutral - minimize suctioning (when suctioning is needed, humidify oxygen and suction for < 10-15 seconds) - avoid coughing/blowing nose - insert indwelling catheter - give stool softeners - avoid fever (fever can increase ICP)
Pain in LUQ
- pancreas - stomach
Assessments when administering mannitol
- urine output - LOC
3 priority assessments for pregnancy-induced hypertension
1. BP 2. Edema 3. Proteinuria
stages of peritoneal dialysis
1. instillation 2. dwelling time
Normal fetal heart rate
120-160 bpm
When should you expect stool output following a bowel resection and colostomy placement
2-4 days
max amount of time to deliver PRBC
4 hours
Treatment for hypoglycemia if alert
4 oz of juice
A client with hypertrophic cardiomyopathy undergoes surgical placement of a dual chamber implantable cardioverter defibrillator (ICD). Prior to discharge, the nurse conducts teaching with the client. What client statement best indicates an understanding of their ICD? 1. "It is important to sit or to lay down if my ICD fires." 2. "I can lift objects as long as they are less than 20 pounds." 3. "I will avoid using the microwave to heat my food." 4. "I should leave the ICD identification card in my safe at home."
ANSWER: 1 - ICD delivers shock - Only lift objects 5 pounds or less - Microwaves are safe - Keep ICD card with you
The nurse is caring for a client with a Blakemore tube inserted for balloon tamponade of bleeding esophageal varices. What item does the nurse determine is most important to have available at the bedside? 1. Scissors 2. Atropine sulfate 3. Defibrillator 4. Arterial blood gas kit
ANSWER: 1 - risk for aspiration
The nurse on a medical-surgical unit is caring for a client who just returned from having an esophagogastroduodenoscopy (EGD) under moderate sedation. What client data is most essential for the nurse to obtain during the client's initial post-procedure assessment? 1. Check gag reflex 2. Monitor gastric pH 3. Auscultate bowel sounds 4. Assess stool characteristics
ANSWER: 1 Checking the gag reflex prevents aspiration
A client with bladder cancer has lost an estimated 500 mL blood in the urine. The client's hemoglobin is 8.0 g/dL, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should: 1. Attach the packed cells to the existing 19G I.V. of normal saline solution using Y tubing 2. Start an additional 22G I.V. site because the packed blood cells must be given in a separate line. 3. Attach the packed blood cells to the existing 18G I.V. of 5% dextrose using Y tubing. 4. Start an additional I.V. access device with a 21G Intracath.
ANSWER: 1 only use normal saline when giving blood products
A female client is diagnosed with cervical cancer and will undergo inpatient temporary internal radiation over the next 3 days. What interventions should the nurse include when planning this client's care? Select all that apply. 1. Assign the client to a private room. 2. Insert an indwelling urinary catheter. 3. Minimize staff contact with the client. 4. Utilize proper shielding equipment. 5. Provide client with a high-fiber diet
ANSWER: 1, 2, 3, 4 - Aim is to keep client in bed to prevent dislodging and minimize radioactive contact with others - Minimizing contact: private room, minimizing staff contact with the client, proper shielding equipment - Keep client in bed: urinary catheter, low fiber to prevent needing bathroom for bowel movement
The nurse is caring for a client receiving external radiation for breast cancer. The nurse is teaching the client about preventing skin complications from the radiation. What instructions are important for the nurse to review with the client? 1. Wear loose-fitting and soft clothing over the treatment area. 2. Use swimming pools to avoid exposure to stagnant water in lakes. 3. Apply skin products immediately after radiation treatments. 4. Wash area with lukewarm water and avoid washing off markings. 5. Apply an occlusive dressing over the treatment site every 3 days.
ANSWER: 1, 4
A client with suspected bacterial meningitis undergoes a lumbar puncture. What post-procedure prescriptions does the nurse anticipate the healthcare provider to prescribe? 1. Administer dexamethasone 4mg intravenously every four hours. 2. Place client in side-lying position for 3 hours after the lumbar puncture 3. Institute droplet precautions after cerebrospinal fluid culture results confirm diagnosis 4. Implement seizure precautions by padding side rails and having suction available 5. Monitor client's body temperature every hour for 4 hours, then once per shift
ANSWER: 1, 4 - dexamethasone treats inflammation - supine position - increased risk for seizures - VS should be monitored more frequently
The nurse is caring for a client using patient-controlled analgesia following an invasive procedure. The nurse enters the client's room and finds the client unresponsive with shallow respirations at a rate of four breaths/minute. What is the priority initial action of the nurse? 1. Apply oxygen using a face mask. 2. Begin bag-valve-mask ventilation. 3. Check respiratory rate for a full minute. 4. Turn the client on their left side.
ANSWER: 2
At 1200, the nurse assesses a client who experienced a myocardial infarction three days ago and notes the client is unusually fatigued and dyspneic. In caring for this client, what is the nurse's priority initial action? 1. Administer 0.4mg nitroglycerin sublingually. 2. Compare client's prior weight with current weight. 3. Continue to monitor client's vital signs every 4 hours. 4. Instruct client to take more frequent rest periods.
ANSWER: 2 - Common complication of an MI is heart failure. Check for fluid retention and changes in BNP.
A client with a pituitary tumor is scheduled to undergo surgery by a transsphenoidal approach for tumor removal. The nurse reviews postoperative instructions with the client. What postoperative instruction is most essential for the nurse emphasize? 1. "You must stay in bed and lie flat for 24 hours after your surgery." 2. "You must avoid coughing, sneezing, and blowing your nose." 3. "You must restrict your fluid intake following this surgery." 4. "You must report any ringing in your ears immediately."
ANSWER: 2 - can cause bleeding, increased ICP, CSF leak
A client receiving chemotherapy for metastatic colon cancer is admitted to the oncology unit due to several days of vomiting. Assessment findings include: irregular pulse of 120 per minute blood pressure 88/48 mmHg, respiratory rate of 14, serum potassium of 2.9 mEq/L, and arterial blood gas—pH 7.46, PCO2 45, PO2 95, bicarbonate level 29 mEq/L. Which of the following interventions is appropriate for the nurse to administer to the client? 1. Oxygen at 4L per nasal cannula. 2. Potassium 40 mEq PO now 3. 5% Dextrose in 0.45% Normal Saline with KCl 40 mEq/L at 125 mL/hour. 4. NaHCO3 75 mEq IV. Alkaline
ANSWER: 3 - Need to replace potassium - 02 is WDL - Nothing PO b/c pt is vomiting - Nothing alkaline b/c pt is in metabolic acidosis
A client is receiving an intravenous (IV) infusion of doxorubicin through a peripheral line at the outpatient center. The client reports pain at the peripheral IV site. What action is most important for the nurse to do first? 1. Apply a cold compress to the IV site. 2. Elevate the affected arm on a pillow. 3. Stop the doxorubicin infusion. 4. Flush the IV with normal saline.
ANSWER: 3 - never flush the line if pt is complaining of pain during chemo
The medical-surgical nurse is caring for a client who performs their own peritoneal dialysis. What assessment is most important for the nurse to make while the dialysis solution is dwelling in the client's abdomen? 1. Monitor client's electrolyte levels. 2. Assess for presence of urticaria. 3. Monitor for drainage at catheter site. 4. Observe client's respiratory status.
ANSWER: 4 - PD can cause compression of diaphragm and can lead to difficulty breathing
The nurse is caring for a client with a chest drainage system. The nurse notes that the chest tube has fallen out of the client's chest wall. What is the nurse's priority of care? 1. Notify the provider immediately. 2. Assess lung sounds and oxygenation. 3. Ask the client how the tube fell out. 4. Apply a dressing to the chest wall site.
ANSWER: 4 open hole will cause air to go into chest wall and lung will collapse
Priority action with evisceration
Apply gauze moistened with saline to the site
Treatment for hypoglycemia with decreased LOC
IV dextrose
Treatment for DKA
IV insulin and fluids
Grey colostomy stoma indicates:
Infection
Drug of choice for pregnancy-induced hypertension
Magnesium sulfate
diet with pancreatitis
NPO or low fat
Blue colostomy stoma indicates:
Poor perfusion
Colostomy diet
Resume regular diet gradually
Would a colostomy be more watery on the left or right abdomen
Right. Right sided colostomies are in the ascending colon whereas left sided colostomies are in the descending colostomy which has had more water removed.
positioning for pancreatitis
Semi Fowler to reduce risk of bleeding and promote lung expansion
Positioning with prolapsed umbilical cord
Trendelenburg (relieves pressure)
aplastic anemia
all blood cells are low
Pain in RLQ
appendix
Pain in LLQ
colon
Warning sign of seizures in eclampsia
epigastric pain
S/S of a perforated bowel after EGD
epigastric pain and dark, tarry stools
Positioning patients with PAD
extremities should be in dependent position to promote distal blood flow
Priority action with a boggy uterus
fundal massage
electrolyte imbalance in pancreatitis
hypocalcemia
vital signs in hypovolemic shock
hypotension, tachycardia
signs and symptoms of biliary obstruction
jaundice, pale/fatty stool, dark urine
Positioning for pregnancy-induced hypertension
left lateral position to promote uteroplacental circulation
diet with cholecystitis/cholelithiasis
low fat
Why is hydration important post lumbar puncture
must replace the fluid that was lost
early sign of hypocalcemia
numbness and tingling around the lips and fingers
Nursing priority in cholecystitis/cholelithiasis
pain
intermittent claudication
pain in the leg muscles that occurs during exercise and is relieved by rest
Biggest complication of peritoneal dialysis
peritonitis
Why is supine position indicated post-lumbar puncture
prevents CSF leak which causes spinal headache
If a chest tube is disconnect, what should the nurse do with the tube?
put the tip of the tube in water
teletherapy
radiation therapy administered at a distance from the body
Biggest risk factor for PAD
smoking
brachytherapy
the use of radioactive materials in contact with or implanted into the tissues to be treated
Blakemore tube
tube used in the management of upper gastrointestinal hemorrhage due to bleeding from esophageal varices
primary assessment before giving potassium
urine output
Causes of postpartum hemorrhage
uterine atony, lacerations, retained placental fragments,
