UWORLD 9

The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement? 1. Avoid suctioning the client 2. Pre-oxygenate the client 3. Raise the head of the bed 4. Reduce the amount of sedation medication

1

What are key points to colostomy and pouch care?

1. Adequate fluids 3000 mL/day 2. Avoid gas producing foods - broccoli, cauliflower, beans. 3. Empty pouch when it becomes 1/3 full to prevent leaks.

The nurse is educating a client in preparation for discharge from the hospital when the client breaks down crying, saying that the health care provider thinks she is crazy because he diagnosed her with a functional disorder. Which statement would be the best reply to this client? 1. "Functional disorder is a general diagnosis for a genuine medical issue that medical science does not yet fully understand." 2. "I am very sorry to hear this, but are you sure that's what he meant?" 3. "The health care provider does not know what he's talking about. I'll give you the information my health care provider used." 4. "Why do you think he said that?"

1

What characteristics are commonly associated with a Hyperosmolar hyperglycemic state?

1. Blood Glucose level >600 2. History of Type II diabetes 3. Neurologic manifestations 4. Older age

An obese client is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? 1. Coffee, tea, flavored club soda 2. Diet soft drinks, tea, water 3. Diet tea, low-fat milk, vegetable juice 4. Sports drinks, unsweetened juice, coffee

1. Coffee, tea, flavored club soda

The nurse prepares to administer IV vancomycin to an 80-year-old client with a methicillin-resistantStaphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply. 1. Blood urea nitrogen is 60 mg/dL (21.4 mmol/L) 2. Creatinine is 2.1 mg/dL (185.6 µmol/L) 3. Glucose is 140 mg/dL (7.7 mmol/L) 4. Hemoglobin is 15 g/dL (150 g/L) 5. Magnesium is 1.5 mEq/L (0.75 mmol/L) 6. White blood cell count is 14,000/mm3 (14.0 × 109/L)

1,2

Which lifestyle and nutritional strategies can help clients reduce and manage the signs and symptoms of gastroesophageal reflux disease? Select all that apply. 1. Avoid caffeine, chocolate, and peppermint 2. Choose foods that are low in fat 3. Eat 3 meals a day with minimal or no snacking 4. Minimize intake of dairy products 5. Sip water with meals

1,2, 5 Lifestyle and dietary measures that prevent GERD or reduce it effects include the following: 1. Weight loss, as excessive belly fat can increase gastric pressure 2. Abdominal breathing exercises to strengthen the LES 3. Small, frequent meals (Option 3) with sips of water or fluids (Option 5) to help facilitate passage of stomach contents into the small intestine 4. Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages (Options 1 and 2) 5. Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus 6. Elevating the head of the bed 7. Refraining from eating at bedtime and/or lying down immediately after eating

A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which interventions can the nurse suggest to help mobilize secretions and improve sleep? Select all that apply. 1. Increase fluids to at least 8 glasses (2-3 L) of water a day 2. Sleep with a cool mist humidifier 3. Take prescribed guaifenesin cough medicine before bedtime 4. Use abdominal breathing and the huff cough technique at bedtime 5. Use pursed-lip breathing during the night

1,2,3,4 Also, Chest physiotherapy (postural drainage, percussion, vibration). Airway clearance handheld devices that use the peak expiratory pressure principle to help loosen secretions.

The nurse caring for a group of clients on the gynecology unit recognizes that which are at increased risk for developing breast cancer? Select all that apply. 1. 24-year-old whose sister had breast cancer at age 38 2. 32-year-old with genetic mutations in the BRCA1 and BRCA2 genes 3. 45-year-old whose menstrual period began at age 17 4. 56-year-old who is postmenopausal and has gained 50 lb (22.6 kg) in the last 5 years 5. 65-year-old who took combined oral contraceptives for 15 years

1,2,4,5

A client diagnosed with cirrhosis is experiencing pruritus. Which actions will the nurse take to promote comfort and minimize pruritus? Select all that apply. 1. Apply cool, wet cloths to skin 2. Encourage hot showers 3. Gently apply calamine lotion 4. Promote the use of cotton gloves 5. Request that the client cut nails short •

1,3,4,5 Also, long sleeve shirts and baking soda baths.

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Select all that apply. 1. Covering client with warm blankets 2. Logrolling the client from side to side frequently 3. Mechanical ventilation 4. Warmed blood administration 5. Warmed IV fluids

1,3,5 Warmed humidified oxygen can also be given.

A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply. 1. Administer an anticholinesterase drug AC 2. Anticipate a need for an anticholinergic drug 3. Develop a bladder training schedule 4. Encourage semi-solid food consumption 5. Teach the necessity for annual flu vaccination

1,4,5 Educational objective: Myasthenia gravis involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations.

What does a neurological assessment include?

1. Glasgow Coma Scale (GCS)—best eye, verbal, and motor responses. Best verbal response assesses orientation to person, place, and time (time is the most sensitive). 2. Pupils—equal, round, response to light, and accommodate (PERRLA) 3. Motor—strength and movement in all four extremities 4. Vital signs—especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood pressure readings). The nurse is assessing for signs of increased intracranial pressure (ICP).

What is part of the procedure for safe blood administration?

1. Obtain a unit of blood from the blood bank and verify the blood product with type and crossmatch results and at least 2 client identifiers with another nurse at the client's bedside. The blood is obtained and infused one unit at a time (Option 2). 2. Assess the client, obtain vital signs for baseline, and teach signs of a transfusion reaction and how to call for help. 3. Use a Y tubing, prime with NS, and then clamp the NS side (Option 6). 4. Spike the blood product, leaving the blood side of the Y tube open while keeping the saline side clamped for infusion. The saline is only used to prime the tubing and flush after the infusion. It does not infuse simultaneously. 5. Set the infusion pump to deliver blood over 2-4 hours as prescribed (Option 5). Rapid infusion of the blood puts the client at greater risk for transfusion reaction and fluid volume overload. 6. Remain with the client for at least the 1st 15 minutes and watch for signs of blood transfusion reaction, including fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. Stop the transfusion immediately if a reaction occurs. The first 15 minutes of infusion should be slow to watch for these reactions. 7. Take another set of vital signs 15 minutes after infusion starts and continue in accordance with facility policy. Always take a final set of vital signs after the infusion is complete. 8. On completion of the blood transfusion, open the saline side clamp of the Y tubing to flush all blood in the tubing through with NS. 9. Return the blood bag with the attached set-up to the laboratory after completion or dispose of in accordance with hospital policy. Use new IV Y tubing set-up for the second unit of blood.

A child with autism spectrum disorder is being admitted to an acute care unit. Which is the most importantnursing action? 1. Placing the child in a private room away from the nurses' station 2. Placing the child in a private room near the playroom 3. Placing the child in a semi-private room near the nurses' station 4. Placing the child in a semi-private room with another child with autism spectrum disorder

1. Placing the child in a private room away from the nurses' station Autistic children are very sensitive to noise - alarms, monitors, etc..

The nurse sticks himself with a needle from an HIV infected client. What is the protocol of action the nurse should take?

1. Remove gloves 2. wash area with soap and water 3. Notify the nurse supervisor 4. Go to the employee health clinic 5. Baseline blood draw 6. Take post-exposure prophylaxis

If a transfusion reaction (eg, chills, fever, low back pain, flushing, itching) occurs, what are the steps that should be taken?

1. Stop transfusion immediately and disconnect tubing at the catheter hub 2. Maintain IV access with normal saline, using new tubing 3. Monitor vital signs 4. Notify health care provider (HCP) and blood bank 5. Recheck tags, numbers, and client's blood type 6. Treat client's symptoms according to HCP's prescription 7. Return bag of blood and tubing set to the blood bank so additional testing can be done 8. Collect blood and urine specimens to evaluate for hemolysis 9. Complete necessary facility paperwork to document the reaction

What are common Asthma triggers?

1. Viral upper respiratory infections URI 2. Tobacco smoke 3. Beta Blockers 4. Aspirin 5. NSAID's 6. Mold's, pollen, dust mites, cockroaches, animal dander

How long should a patient wait for returning to vigorous activity post-tonsillectomy?

2 weeks. Bleeding can occur at up to 14 days.

A nurse is preparing to perform postmortem care on a client who recently died from metastatic cancer. No family members were present at the time of death. What interventions can be delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Notifying the family of the client's death 2. Placing dentures in the client's mouth 3. Positioning a pillow beneath the client's head 4. Transporting the client to the morgue 5. Washing the client's body

2,3,4,5

A client is admitted with palpitations. The electrocardiogram (ECG) shows supraventricular tachycardia (SVT) with a rate of 220/min. The nurse has received an order to administer adenosine 6 mg intravenously (IV). Which action should the nurse take? 1. Adenosine is contraindicated for SVT. Verify the order with the health care provider. 2. Administer medication rapidly over 1-3 seconds followed by a saline flush 3. Administer medication only through a central venous access 4. Mix medication in 50 mL normal saline and administer over 10 minutes

2. Administer medication rapidly over 1-3 seconds followed by a saline flush Adenosine has a half life of less then 5 seconds, so it needs to be administered rapidly as a 6mg bolus over 1-3 seconds followed by a 20 mL saline flush. The injection should be as close to the heart as possible (antecubital area).

Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence? 1. Coaching related to Kegel exercises 2. Importance of voiding every 2 hours 3. Minimizing caffeine and alcohol 4. Use of incontinence pads and pessary

2. Importance of voiding every 2 hours All of the answers are valid methods for managing stress incontinence, but 2 is the priority.

A client had a percutaneous nephrolithotripsy to remove left kidney stones 3 hours ago. Since then, the indwelling urethral catheter has drained 125 mL of urine, and the nephrostomy tube has drained 0 mL. The client now reports left flank pain radiating to the left groin and severe nausea. What is the appropriate nursing intervention? 1. Assess the urethral catheter for kinks and obstruction 2. Irrigate the nephrostomy tube with 5 mL of sterile normal saline as prescribed 3. Irrigate the urethral catheter with 50 mL of sterile normal saline as prescribed 4. Place the client in the prone position to facilitate urine drainage

2. Irrigate the nephrostomy tube with 5 mL of sterile normal saline as prescribed

The registered nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction? 1. "I will make sure there is a firm mattress in the crib." 2. "I will put my baby to bed with a pacifier." 3. "I will tie bumper pads to the sides of the crib to protect my baby's head." 4. "I will use a sleeping sack or a thin tucked blanket to cover my baby."

3

A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action? 1. Ask the UAP to take the postoperative client's vital signs and report back immediately 2. Direct the UAP to ask the client to rate the pain on a scale of 0-10 and report back immediately 3. Direct the UAP to tell the client that you will be there shortly, and complete the sterile dressing change 4. Interrupt the dressing change to medicate the postoperative client

3 Rationale: The nurse can prioritize care according to the degree of urgency, the extent of threat to the client's survival, and the potential for complications. At this time, the other client's pain issue is of medium urgency and does not pose an immediate threat to survival. The most appropriate nursing action is to inform the postoperative client that you will be there shortly, and complete changing the sterile dressing

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? 1. ECG 2. IV morphine 2 mg 3. Normal saline bolus 4. Urine sample

3. Normal saline bolus The myoglobin needs to be flushed from the client or kidney damage can occur.

The public health nurse provides care for a client on a directly observed therapy (DOT) program to treat tuberculosis (TB). Which option best describes the care the nurse provides on this program? 1. Follows the client until 3 sputum cultures are normal 2. Gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits 3. Provides and watches the client swallow every prescribed medication 4. Screens all of the client's close contacts

3. Provides and watches the client swallow every prescribed medication Noncompliance with the treatment plan is a major problem for treatment of TB due to the length of time (6 months) and the unpleasant side effects.

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical laceration 2. Inversion of the uterus 3. Uterine atony 4. Vaginal hematoma

4

A client has a deep vein thrombosis and is receiving a heparin drip. The client's activated partial thromboplastin time (aPTT) has been in the therapeutic range for the past 24 hours. The most recent laboratory value shows that the current aPTT equals the control value. What explanation should the nurse consider? 1. The client became tolerant to heparin 2. The client consumed spinach 3. The client developed thrombocytopenia 4. The client's intravenous (IV) line is infiltrated

4 With a heparin drip infusion, the goal is to reach the therapeutic range of the drug's effect and not the "normal" or "control value." Once the therapeutic effect range has been reached (usually 1.5-2.0 times the control value), it usually remains within this range without titrating the heparin infusion rate. Heparin has a short duration (approximately 2-6 hours IV). Therefore, if it is not being infused, the aPTT level will go back to the control value (aPTT level without administration of anticoagulants). In addition, the volume of heparin being infused is small (because the standard concentration is 100 units/mL) so it is possible to miss an infiltration.

In the intensive care unit, a client is on mechanical ventilation (MV) after having undergone a fresh tracheostomy with retention sutures placed yesterday. The nurse hears the MV alarm sound and enters the room. The client is coughing, respirations are 40/min, heart rate is 132/min, and the pulse oximeter reading is 80%. The nurse also sees the tracheostomy tube lying on the client's chest. What is the nurse's immediate action? 1. Apply a rebreathing mask with high concentration oxygen at 12 L/min 2. Attempt to reinsert the tube with the obturator in place 3. Insert a sterile catheter into the stoma and suction the airway 4. Pull the retention sutures apart to lift the trachea and hold the stoma open

4 Rationale: Accidental dislodgement of the tube after a fresh (immature, <1 week) tracheostomy is a medical emergency as the tract is not yet healed (matured). Significant tracheal inflammation, edema, bleeding, and closure of the tract (resulting in airway loss) can occur. The goal is to keep the stoma open to maintain the airway and oxygenate the client. If accidental dislodgement occurs, immediate nursing actions should include pulling the retention sutures apart (if present) to lift the trachea and hold the stoma open or inserting a curved hemostatto hold the stoma open if sutures are not present. If desaturation progresses while awaiting the arrival of the emergency team, the nurse can apply a sterile occlusive dressing over the stoma and ventilate the client with a bag-valve mask over the nose and mouth (using gentle pressure).

What is an important fact to know about adenosine post administration?

A brief period of asystole occurs. Client must be monitored for flushing, palpitations, chest pain, and dizziness after the administration.

Client experiencing the "worst headache of my life" could be experiencing what?

A subarachnoid intercerebral bleed.

Pylonephritis is a severe bacterial infection of the kidney and requires what essential treatment?

Continuous IV fluids and IV antibiotics

Burning pain at rest that is worsened by elevating the legs is called?

Critical arterial narrowing - peripheral artery disease.

What test is ordered for clients with suspected pulmonary embolism?

D-dimer

What are the two key findings for a diagnosis of major depressive disorder?

Depressed mood or loss of interest or pleasure.

A client with meningococcal meningitis or Hib should be on what type of precaution?

Droplet precautions Precautions can be discontinued 24 hours after staring antibiotic therapy

What drugs cause serotonin syndrome?

Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs) - (Sertraline, Fluoxetine, Paroxetine, Citalopram) monoamine oxidase inhibitors (MAOIs) - (Phenelzine, Seligilene, Tranylcypromine), also dextromethorphan, ondansetron, St. John's wort, and tramadol.

Treatment for a vaso-occlusive crisis includes?

Fluids, analgesics, oxygen, folic acid, and blood transfusion.

What is the antidote for Benzodiazepines such as midazolam (Versed), diazepam, alprazolam, lorazepam, clonazepam?

Flumazenil

Unexpected and projectile vomiting without feeling nausea can be a sign of what?

Increased ICP

Cramping or pain the leg during exercise that is relieved with rest is called?

Intermittent Claudication

What are the modifiable and nonmodifiable risk factors for breast cancer?

Non-modifiable breast cancer risk factors include: • Female sex and age ≥50 (Options 4 and 5) • First-degree relative (mother or sister) with history of breast cancer (Option 1) • BRCA1 and BRCA2 genetic mutations (Option 2) • Personal history of endometrial or ovarian cancer • Menarche before age 12 or menopause after age 55 Modifiable breast cancer risk factors include: • Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause)(Option 5) • Postmenopausal weight gain and obesity as fat cells store estrogen (Option 4) • History of smoking and alcohol consumption • Dietary fat intake • Sedentary lifestyle

Clients with catatonic schizophrenia are at risk for what?

Risk for deficient fluid volume - dehydration and malnutrition.

Who is at highest risk for suicide and what is the acronym?

SAD PERSONS S Sex (men kill themselves more often than women; women make more attempts) A Age (teenagers/young adults, age >45) D Depression (and hopelessness) P Prior history of suicide attempt E Ethanol and/or drug abuse R Rational thinking loss (hearing voices to harm self) S Support system loss (living alone) O Organized plan; having a method in mind (with lethality and availability) N No significant other S Sickness (terminal illness)

What is the most common treatment for Carpal Tunnel syndrome?

Splinting of the wrist

What are clinical manifestations of serotonin syndrome?

Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (hyperthermia, diaphoresis, tachycardia/hypertension) neuromuscular hyperactivity (tremor, muscle rigidity, clonus, hyperreflexia).

What is the first sign of puberty in boys?

Testicular enlargment This occurs at 9 1/2 - 14 years

How is epistaxis treated and prevented?

The initial step in treatment is to tilt the client's head forward and apply direct, continuous pressure to the nose for 5-10 minutes. Pressure should be applied to the soft, compressible area below the nasal bone (ie, the nasal alae); holding pressure on the nasal bridge does not provide effective relief. Holding a cold cloth or ice pack to the bridge of the nose may also help to induce vasoconstriction. Keeping the child quiet and calm may help provide the adequate time and pressure necessary for clotting. Epistaxis can often be prevented by avoiding local trauma and maintaining hydration of the mucosa with saline nasal spray or a humidifier.

What lab test is used to determine if a client has an MI?

Troponin

What are the diagnostic criteria for SIRS?

include 2 or more of the following manifestations: • Hyperthermia (temperature >100.4 F [38 C]) or hypothermia (temperature <97 F [36.1]) • Heart rate >90/min • Respiratory rate >20 breaths/min or alkalosis (PaCO2 <32 mm Hg) • Leukocytosis (white blood cells >12,000 µL or 10% immature neutrophils [bands])

What is GTPALM?

• G - gravida indicates the number of times a woman has been pregnant • T - indicates a term pregnancy (delivered after at least 37 weeks gestation) • P - indicates a preterm pregnancy (delivered between the beginning of 20 weeks and the end of 37 weeks gestation) • A - indicates an abortion, spontaneous or elective (termination of pregnancy prior to the beginning of 20 weeks gestation) • L - indicates children currently living • M - indicates multiple gestation

Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. What are the 4 classic manifestations of nephrotic syndrome?

• Massive proteinuria - caused by increased glomerular permeability • Hypoalbuminemia - resulting from excess protein loss in the urine • Edema - specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities • Hyperlipidemia - related to increased compensatory protein and lipid production by the liver