Discussion 1,2,3 and 4
What are the key manifestations associated with hyperthyroidism?
Hyperthyroidism (sometimes referred to as Graves Disease) - chart 63-1 in IGGY 9th edition: Emotional instability/manic hyperactive behavior Diaphoretic/moist skin Intolerance to heat Tachycardia and Hypertension Visual changes (photophobia, blurred/double vision) Increased libido Bulging Eyes (exophthalmos) Restlessness and Irritability Goiter Hyper>Thyroid Storm
Remember for transdermal medication in a skin patch for absorption through the skin, producing systemic effects. Teaching should include instructing clients to:
-Apply patches to ensure proper dosing. Do not cut patches. -Wash the skin with soap & water. Dry it thoroughly before applying a new patch. -Place the patch on healthy hairless area, and rotate sites daily to prevent skin irritation. -Showering is permitted and there is no need to cover the patch.
What specific types of injuries would be appropriate for the non-urgent category in regular ED triage?
A simple fracture would be an example of an injury appropriate for the nonurgent category in regular ED triage. Remember disaster triage is not the same as ED triage. You need to know both. For disaster triage: Immediate life-threatening injuries are the emergent category for disaster triage. Any threat to life including airway obstruction and shock are appropriate for the emergent category. The urgent category for disaster triage includes major injuries that require treatment such as open or compound fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours. In normal ER triage, emergent is threat to life, urgent includes major injuries that need treatment, and nonurgent would be appropriate for minor injuries that do not require immediate treatment. Urgent patients have injuries that require quick treatment but are not a threat to life.
What diseases are appropriate for airborne precautions and what is included for airborne precautions?
Airborne precautions are indicated for diseases that are transmitted by air. Varicella (chickenpox), Measles (rubeola), disseminated zoster (shingles) and TB are diseases that require airborne precautions. A special mask is required. The nurse should wear an N95 respirator or high-efficiency particulate air filter respirator. Surgical face masks filter only large particles and do not provide protection needed from airborne diseases. Goggles and shoe covers are not needed for airborne precautions. You should know the type of precautions (airborne, droplet, and contact) required to prevent the spread of specific infections. There is a good table in the IGGY book. Know each disease appropriate for each type of precaution.
What interventions, including medications, are appropriate for a patient experiencing V-fib?
Amiodarone, Lidocaine and Epinephrine -Cardioversion: Elective treatment of atrial dysrhythmias, supraventricular tachycardia, and ventricular tachycardia with a pulse. Cardioversion is the treatment of choice for clients who are symptomatic. -Cardioversion is the delivery of a direct countershock to the heart synchronized to the QRS complex. Defibrillation is the delivery of an unsynchronized, direct countershock to the heart. Defibrillation stops all electrical activity of the heart, allowing the SA node to take over and reestablish a perfusing rhythm. Defibrillation: Indicated for ventricular fibrillation or pulseless ventricular tachycardia. Perform CPR for cardiac asystole or other pulseless rhythms. ● Defibrillate the client immediately for ventricular fibrillation. ● Administer a prescribed antidysrhythmic agent or other prescribed medications.
The registered nurse has received change of shift report. Which of the following patients should the nurse assess first? 1. Client with chest tube inserted due to trauma and has had chest tube drainage of 65mL in the last hour 2. Client s/p cholecystectomy today with t-tube returned to floor 90 minutes ago and due for VS check 3. Client with tumor lysis syndrome, is lethargic and complains of n/v, and has a potassium level of 5.2 4. Client with portal hypertension and a change in BP from 138/82 to 110/60 over the last 2 hours
Answer: #4 All the patients will be assessed but #4 is the priority. Portal hypertension is an increase in pressure within the portal vein. It is a major complication of cirrhosis that can lead to bleeding esophageal varices, a medical emergency. Patients with a change in VS, especially with BP changing at least 20 points (or another significant change over a short timeframe) needs assessed by the RN. This patient could be bleeding from esophageal varices. #1 is not correct as 65mL/hr is considered normal chest tube drainage. #2 is not correct. The patient has been back on the floor for 90 minutes and vital signs (which would not be the first check of VS since the patient returned 90 minutes ago) can be delegated to the CNA. #3 is not correct. Patients with TLS are expected to have high K levels with lethargy and n/v. This patient will need to be assessed but is not the first priority. This patient would be the 2nd priority.
A nurse is administering an enema to a client who is scheduled for gastrointestinal surgery. What should the nurse do when the client complains of abdominal cramps during the enema? Lower the bag to stop the flow of the infusion Discontinue the enema and try again later Add cool water to the enema bag Tell the client deep breaths will relieve the cramps
Answer: 1 is correct. Lower the bag to stop the flow, which reduces cramping caused by distention of the intestinal lumen. 2 is not correct. There is no need to discontinue the enema. An effective enema must be administered before gastrointestinal surgery. 3 is not correct. We would not add cool water to the bag. 4 is not correct. We would not tell the client deep breaths will relieve the abdominal pain.
The nurse is teaching a mother about car seat safety. The nurse knows the mother correctly understands the teaching when she states: a. "I did not realize that even children between 1 and 2 years old are safer in rear-facing car seats" b. "I should put my car seat in the front so I can watch my baby when I drive" c. "I plan to use the car seat I saved from my last baby 10 years ago" d. "The front-facing car seats do a better job supporting the head and neck of my baby"
Answer: 1 is correct. The other options are not correct. Infants should remain in a rear facing car seat for as long as possible, at least until age 2. All infants and toddlers should ride in a rear-facing seat until they reach the highest weight or height allowed by their car seat manufacturer. Most convertible seats have limits that will allow children to ride rear facing for 2 years or more. Children who have outgrown the rear-facing weight or height limit for their convertible seat should use a forward-facing seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat manufacturer. Many seats can accommodate children up to 65 pounds or more. All children whose weight or height exceeds the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are 8 through 12 years of age. All children younger than 13 years should ride in the back seat. When children are old enough and large enough for the vehicle seat belt to fit them correctly, they should always use lap and shoulder seat belts for the best protection. As noted above, in the back seat is appropriate for all children younger than 13.
The nurse receives a male client from the post-anesthesia care unit (PACU) after the surgeon performed an abdominal repair related to trauma from a knife wound. Which assessment data would warrant immediate intervention? 1. VS T 97, P 108, R 24, BP 80/40 2. Client is sleepy but opens eyes to verbal commands 3. Client complains of pain level 7 on scale of 1-10 4. 25 mL urine in urinary drainage bag
Answer: 1. These VS indicate hypovolemic shock and require immediate intervention. Hypovolemic shock occurs secondary to rapid blood loss. 2 is not correct as clients will be sleepy until the anesthesia wears off. 3 is not correct as pain is expected post-op and this is not a life-threatening complication. 4 is not correct as the bag would have been emptied by the PACU nurse prior to transferring client to the floor.
The charge nurse is assigning patients for care. There are two registered nurses (RNs), an LPN, and a certified nursing assistant (CNA). The charge nurse would assign which of the following patients to the LPN? An older adult who is receiving IV chemotherapy through a central line and will need a central line dressing change An adult patient diagnosed with insulin-dependent diabetes who will need dressing changes on several stasis ulcers on the lower extremities An adult patient with a right fractured femur and right arm in a cast who needs to urinate An older patient with terminal cancer who will be transferred to hospice
Answer: 2 The patient with diabetes will need stasis ulcer care, which is within the scope of practice of the LPN. The patient receiving chemotherapy through a central line would be assigned to the registered nurse. The nursing assistant would help the female patient with the fractures with the bedpan. The RN should facilitate the transfer of the hospice patient.
A nurse on a telemetry unit is caring for a client who was admitted 2 hrs ago and has chest pain. The client becomes angry and tells the nurse there is nothing wrong with him and he is going home immediately. Which of the following actions should the nurse take? (Select all that apply and provide the rationale for your answers) 1. Notify the clients family of his intent to leave the facility 2. Document that the client left the facility against medical advice (AMA). 3. Explain to the client the risks involved if he chooses to leave AMA. 4. Ask the client to sign a form relinquishing responsibility of the facility. 5. Prevent the client from leaving the facility until the provider arrives.
Answer: 2, 3, and 4. 1 is not correct because the client has the right to leave the hospital against medical advice. Notifying the clients family without the client's permission is a violation of HIPAA. 5 is not correct as the nurse should not prevent a client from leaving by any action. Threatening him or refusing to give him his clothes can be false imprisonment or even assault.
The client is a 62-year-old male admitted 2 days ago with traumatic injuries and hypovolemic shock from a car crash. The nurse reviewing the client's daily laboratory test results notices the following values. Which result is most important to report to the health care provider immediately? a. Serum sodium 132 mEq/L b. Serum potassium 6.9 mEq/L c. Blood urea nitrogen 24 mg/dL d. Hematocrit 35% e. Hemoglobin 11.7 g/dL
Answer: B All of the laboratory values listed are out of the normal range. However, the value that has reached or is approaching a critical level is the serum potassium, which shows hyperkalemia. This problem must be addressed immediately. I encourage you all to know normal lab values especially Potassium, Sodium, PT/INR, CBC - platelets, Hct/Hgb, BUN/Creat, and Cholesterol. Remember if Hgb/Hct are low this could be related to blood loss and should be reported.
A company driver is found at the scene of an automobile accident in a state of emotional distress. He tells the paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory rate is rapid at 34/minute. Which primary acid-base disturbance is the young man at risk for if medical attention is not provided? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis
Answer: B. Respiratory Alkalosis Hyperventilation is one cause of respiratory alkalosis. When someone is hyperventilating, they tend to breathe very deeply or very rapidly. Respiratory alkalosis is the excessive loss of carbon dioxide and presents with high pH (above 7.45) and low PaCO2 (less than 35) on ABGs. Be sure you can recognize these ABGs. Hyperventilation from anxiety or a PE can cause this disorder. Sometimes this is the result of mechanical ventilation.
The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the LVN? a. A 68-year-old man with small cell lung cancer receiving chemotherapy via a central vascular access device b. A 50-year-old man with abdominal pain and Type 2 DM prescribed Metformin that needs teaching for a CT scan with contrast c. A 70-year-old woman fresh post-op repair of L hip fracture complaining of pain and is also irritable and agitated d. A 65-year-old woman with retinal detachment complaining of seeing floating dark spots in the affected eye
Answer: D. the patient with retinal detachment complaining of floaters in the affected eye is the most appropriate patient to assign to the LVN as this is an expected manifestation of retinal detachment. The other patients require the care of the RN. The LVN can monitor the patient with a retinal detachment. LVNs cannot administer medication via central lines. The patient scheduled for a CT with contrast needs teaching including withholding metformin 48 hrs before and after the test, NPO for 4 hrs prior, warm sensation when dye is injected, and may need to hold breath at times during the CT scan. Remember, teaching requires an RN. The patient s/p hip repair that is agitated needs the RN to assess as this could be early sign of an embolism.
During an interview at a crisis center, a newly widowed client reveals the wish "to join my husband in Heaven." After the nurse asks the client to sign a no-harm contract, which question is appropriate to use next as a therapeutic response? a. "What feelings have you been experiencing?" b. "Have you considered taking antidepressants?" c. "What was the cause of your husband's death? d. "Do you have children who are willing to help you?"
Answer: a is the most therapeutic response. The nurse needs to focus on the client and address her feelings. Talking about her feelings helps to decrease the risk of self-harm. Doing so takes precedence over questions about the cause of death and her children's level of support. Antidepressant medications may be indicated but more information is needed about the client's emotional state.
Which statement indicates the graduate nurse's understanding of the process at the NCLEX testing site? a. "I will be photographed and have a palm vein scan." b. "I will be placed in a locked testing cubicle." c. "I will answer 300 test questions." d. "I will be given some questions as a paper-and-pencil test."
Answer: a. As noted in the bulletin a palm scan is required for those taking a break during testing, before and after the break. You must provide your digital signature, a palm vein scan and will have your photograph taken. You cannot be tested without having these biometrics taken. For admittance to the NCLEX, you will be required to present one form of acceptable identification. The first and last names printed on your identification must match exactly the first and last names found on your Authorization to Test (ATT) email. Otherwise you have to re-register and pay again. The NCLEX-RN examination can be anywhere from 75 to 265 items. Of these items, 15 are pretest items that are not scored. You will not know which items are the pretest ones.
A patient diagnosed with HTN has received the first dose of lisinopril. Which interventions will the RN delegate to the UAP? Select all that apply. a. restrict the patient to bed rest for at least 12 hours. b. recheck the patient's vital signs every 4-8 hrs c. ensure the call light is within the patients reach d. keep the patient's bed in a supine position with all side rails up e. remind the patient to rise slowly from the bed and sit before standing f. assist the patient to get out of bed and use the bathroom g. assess the patient for signs of dizziness.
Answer: b, c, e, and f Rationale: After the first dose of HTN medication dizziness is a common side effect. Remember dizziness is always a priority to follow up on with any patient. The patient should call for help when getting out of bed and the call light should be within easy reach. The patient should rise slowly, sitting on the side of the bed before standing, and then can be assisted to the bathroom. The UAPs scope of practice includes these actions. Patients are not restricted to bed rest or kept in a supine (flat) position, and side rails are not all kept up for the safety of the patient. Assessment is not within the scope of practice for a UAP. However, the RN can instruct the UAP to ask the patient about dizziness before and during ambulation and then report any dizziness immediately to the RN. It is important to monitor BP sitting and standing. The UAP should also be instructed to report the VS as the RN needs to be aware if there is orthostatic hypotension. Remember the definition of postural hypotension is a decrease in SPB of 20 mm or more and a decrease in DBP of 10 mm or more. If this is noted in any patient it is the RNs responsibility to follow-up.
The nurse is caring for a 25-year-old patient admitted to the acute care unit with an extra strong thirst, and dilute, excessive straw-colored urine output up to 15L/day. What disorder would the nurse suspect? a. SIADH b. Diabetes insipidus (DI) c. Cushing disease d. Addison disease
Answer: b. DI is a disorder where water loss is caused by ADH deficiency or inability of the kidneys to respond to ADH. DI presents with large volume of dilute urine, polyuria and elevated Na levels. Dehydration from massive water loss increases plasma osmolarity and stimulates the thirst sensation. When meds such as DDAVP are administered to treat DI the urine output will decrease. Know the difference in these disorders. SIADH presents with hyponatremia.
The nurse is a client with COPD how to conserve energy. The nurse should teach the client to lift object: a. While inhaling through an open mouth b. While exhaling through purses lips c. After exhaling but before inhaling d. While taking a deep breath and holding it
Answer: b. Exhaling requires less energy than inhaling so lifting while exhaling saves energy and reduced perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva's maneuver, which can stimulate cardiac arrhythmias. It is also helpful for conserving energy if patients with COPD do not talk while performing physical activities.
The nurse is assessing a client who has just had a lumbar puncture. What nursing observation would cause the nurse the most concern? a. The client complains of a headache. b. The nurse observes clear fluid oozing from the puncture site. c. The client states he or she has less strength in the arms. d. The client has difficulty voiding from the supine position
Answer: b. The spinal needle is inserted at lumbar 3 to 4 (L3-L4). If there is any oozing after the procedure, it could be spinal fluid. This would increase the risk of headache and infection. Headache is not uncommon and would be expected. Remaining in the supine position should help prevent the headache. Weakness of the upper muscles is not relevant to the lumbar puncture, and many clients have difficulty voiding while confined to bed.
A nurse is providing teaching to a female client with a sealed radium implant. The nurse knows the client correctly understands the teaching when she states: a. "Visitors can sit at my bedside for 2 hours at a time" b. "Visitors must stay at least 6 feet from me while in the room" c. "Visitors must wear a lead apron while in the room" d. "Visitors may include my 12-year-old niece"
Answer: b. Each visitor is limited to one-half hour per day and should state at least 6 feet from the source of radiation. See page 389 in IGGY care of the patient with a sealed implant. Children under 16 and pregnant women are not allowed to visit. Nurses must wear a lead apron while providing care. Visitors are not required to wear a lead apron.
We may be administering KCL via IV for patients if the K levels drops too low. What are nursing priorities when administering KCL IV?
Good points on drug alert box page 177 in IGGY for potassium guidelines. A NPSG is to never give K by IV push due to cardiac arrest. Recommended dosage is 5-10meq/hr. Never ever exceed 20meq/hr when infusing K. It's important to make sure the patient has adequate urine output before administering K. Also, skeletal muscle weakness is associated with hypokalemia and patients may be too weak to stand. Provide assistance for safety as patients with hypokalemia are at risk for falls. Cardiac monitoring is necessary, we will see PVCs and possibly other dysrhythmias when K level is low. Also, patients with low K levels should not be taking potassium depleting diuretics.
What are the key manifestations associated with hypothyroidism?
Hypothyroidism - chart 63-6 in IGGY 9th edition: Lethargy Intolerance to cold Dry, cool skin and Brittle nails/hair Prolonged menstrual periods or amenorrhea Decreased libido Bradycardia and Hypotension Cold intolerance decreased body temp Facial and eyelid edema, thick tongue Constipation Hypo>Myxedema>Myxedema Coma
RNs care for patients with central venous access devices. What are best practices nurses should implement when caring for a patient with a CVAD?
Nursing implications for vascular access devices include: Flushing: Routine flushing may be required unless there is a continuous IV infusion. This may be done with normal saline solution, heparin, or fibrinolytics. Type of solution, frequency, and volume depend on IV therapy and whether blood was drawn from the line, as well as institution policy. Excessive force should never be used to irrigate the line. Syringes smaller than 10 mL should not be used because the smaller the syringe, the greater the pressure exerted. The push-pause technique is a flushing method used to possibly remove debris from ports or catheter lumens. Do not flush a PICC catheter if there is resistance or if catheter is occluded; increased pressure may cause catheter to rupture and/or produce a catheter emboli. Hand hygiene is important before manipulation of the IV system Catheter access/manipulation. Aseptic techniques are used for all access to the line. Catheter site care is performed with chlorhexidine at dressing changes. In the absence of chlorhexidine, use povidone iodine. Ports or hubs are cleaned using "Scrub the Hub" protocol prior to catheter access. Dressing changes: Implanted sites require cleansing after exit but do not require a dressing. External sites (PICCs and ports) require dressings, either gauze or transparent. Gauze dressings are changed if they are contaminated or if observation of the site is required; dressing is routinely changed every 48 hours. Transparent dressings may not be changed for 5 to 7 days.
Sometimes violent patients must be secluded and/or restrained if they are a danger to self or others. What are best practices and priorities when caring for a violent patient in restraints?
Per the mental health textbook once a violent person is in restraints, the priority is direct observation of the patient. There should also be a formal assessment at frequent, regular intervals for safety and needs. Guidelines for use of mechanical restraints are noted in box 27-3 for the 7th edition mental health textbook. Staff must be in constant attendance for these patients if they are restrained and documentation every 15 minutes is required.
Where would you place the stethoscope to auscultate the pulmonic valve and what are considered normal breath sounds?
Place the stethoscope on the second intercostal space, LEFT of the sternal notch, to auscultate opening and closing sounds of the pulmonic valve. This is the opposite side of the sternal notch for auscultating the aorta opening and closing, which would be second intercostal space, right sternal notch. Normal breath sounds include bronchial, bronchovesicular, and vesicular depending on the areas auscultated. See pages 505/506 in 8th edition or pages 520/521 in 9th edition of IGGY. You need to know normal vs abnormal breath sounds.
What are the priorities for routine newborn care after an uncomplicated vaginal birth?
Priorities for newborn care after an uncomplicated vaginal delivery include stabilization of the infant. Airway is a priority as is temperature regulation. Babies born vaginally do not usually have issues with too much fluid in the lungs. Establish a patent airway by cleaning the nasopharynx and maintaining adequate oxygenation. Thermoregulation for the maintenance of body temperature is also important. Preheat a radiant warmer, warm a stethoscope and other instruments, and pad a scale before weighing the newborn. The newborn should be placed directly on the mother's chest and covered with a warm blanket. Stable infants are placed on the mother's bare chest or abdomen as a preferred method of thermoregulation. A hat may also be added to prevent heat loss from the head. A physical assessment with APGAR score, measurements, and lab studies will also be done but these are not the first priority.
We are learning about negligence in this unit. What are the basic elements of negligence for malpractice?
See page 457. The basic elements of negligence include: you must have a duty (professional nurse-patient relationship) you must have breached that duty (did not meet standard of care) your breach of duty must have been a foreseeable cause of the injury injury must have occurred These elements must be present and proven by the plaintiff for negligence to be determined. Having another nurse testify what a reasonable nurse in the same situation would do is the most common way to establish the duty owed by a nurse.
We are learning about incident reports in the legal unit. What does the Nursing Today textbook note about this tool that is used by the risk management department?
See page 475. Regarding incident reports: Person identifying the event completes report within 24 hrs of incident Confidential - not shared with clients, do not add a copy of incident report to medical record Do not chart that an incident report was completed Document incident factually in medical record Injuries, actions taken, objectively Report goes to Risk Management Dept Before an action plan is developed to address incidents on a unit all reports should be reviewed as well as interviewing staff regarding contributing factors
Transmission-based precautions will be tested in 280 and on NCLEX. What diseases are transmitted by droplet and what is required for droplet precautions?
See table 23-3 in IGGY. Diseases known to be transmitted by droplets include: Streptococcal pharyngitis Pneumonia Influenza Rubella Meningitis causes by H influenzae type B or Neisseria Meningitidis Mumps Pertussis Droplet precautions include a private room if available and the nurse must wear a mask if working within 3 feet of patient. The patient should only leave the room for essential reasons and needs to wear a surgical mask if transported out of the room.
You learned about multiple sclerosis (MS) in the first med/surg course. What teaching is appropriate for these patients on how to prevent an exacerbation?
Teach patients with MS about energy conservation and to avoid overexertion, stress, extremes of temperatures, humidity, and people with infections.
One of the areas students often forget is AKI, from NUR265 week 1 content. What are important considerations with these patients?
Thanks for responding to another student's follow-up question. I wait until the week is over to respond if someone else answers a follow-up question. This allows the student who I posted the question to time to respond. Severe volume depletion can lead to kidney injury even in people who have never had any kidney problems. Page 1393 in our IGGY book has a critical rescue box that notes details about volume depletion and AKI. Systolic BP will decrease as well as the pulse pressure. Patients will have orthostatic hypotension, low urine output, and likely complain of thirst. Blood osmolarity will also increase. Prompt intervention with fluids can prevent permanent kidney damage.
A client who has had a stroke is aphasic. It has been a week since the stroke. The client is beginning to show functional improvement and demonstrates an ability to follow verbal directions. What will the rehabilitation include to address the aphasia? A leg brace Ambulation training Speech training Vocational retraining
That is correct. Answer: 3. When a stroke occurs in the dominant hemisphere, the client experiences communication difficulties or aphasia. Speech retraining cannot begin until the client understands and can follow directions. Part of speech therapy includes determining how well the patient can communicate, this should be included in the rehab plan. The question is focusing on the client's ability to speak and the current problem with aphasia. Although wearing a leg brace and ambulation training will begin when the client has stabilized, the question is focusing on the client's aphasia. Vocational retraining would not be appropriate one week after a stroke.
The nurse is instructing a student nurse about proper donning and doffing of personal protective equipment (PPE). Which statement by the student nurse indicates a correct understanding of donning and doffing of PPE? "When removing PPE, gloves are removed last" "When removing PPE, goggles are removed after gloves" "The PPE should be applied just inside the door of the client's room" "The gown is put on first, then the gloves, then eye protection, and the mask last"
The correct answer is B. For this question when removing PPE, gloves are removed first, then eye protection, gown, and mask. Hand hygiene is performed last. PPE should be applied before entering the room. When donning PPE, hand hygiene is first, followed by the gown, mask, eye protection, and lastly gloves.
There are often other misconceptions around contraindications for vaccines with pediatric patients. What are the contraindications for pediatric vaccines?
The peds presentation includes contraindications for vaccines, which are: Condition which increases the risk for a serious adverse reaction (e.g., not administering a live virus vaccine to a severely compromised child). The general contraindication for all immunizations is a severe febrile illness. (not mild fever) In general, live virus vaccines such as varicella and MMR should not be administered to persons who are severely immunocompromised. Multiplication of the virus may be enhanced, causing a severe vaccine-induced illness. Another contraindication to live virus vaccines (e.g., MMR and varicella) is the presence of recently acquired passive immunity through blood transfusions, immunoglobulin, or maternal antibodies. Administration of MMR and varicella vaccines should be postponed for a minimum of 3 months after passive immunization with immunoglobulins and blood transfusions (except washed red blood cells (RBCs), which do not interfere with the immune response). A known allergic response to the vaccine. Only a history of anaphylactic reaction to neomycin, gelatin, or the vaccine itself is considered a contraindication to their use. Although not related to peds content, pregnancy is a contraindication to MMR vaccines. Minor illnesses such as the common cold is not a contraindication. Misconceptions are a concern. Issues that have surfaced regarding vaccines include the misconception that administering combination vaccines may overload the child's immune system. This is not correct as the combined vaccines have undergone rigorous study in relation to side effects and immunogenicity rates following administration.
As a nurse you may care for patients receiving TPN or PPN. What is the difference with administration of PPN versus administration of TPN?
Total parenteral nutrition (TPN) is a hypertonic IV solution. The purpose of TPN administration is to prevent or correct nutritional deficiencies and minimize the adverse effects of malnourishment. TPN administration is usually through a central line, such as a tunneled triple lumen catheter or a single‑ or double‑lumen peripherally inserted central (PICC) line. TPN contains complete nutrition, including calories in a high concentration (10% to 50%) of dextrose, lipids/essential fatty acids, protein, electrolytes, vitamins, and trace elements. Partial parenteral nutrition (PPN) is less hypertonic, intended for short‑term use, and administered in a large peripheral vein. Usual dextrose concentration is 10% or less and can include lipid emulsion, which may be administered as an IVPB. Risks include phlebitis and elevated triglyceride levels. Monitor lab values and report abnormal with any patient receiving TPN or PPN. See my supplemental lecture for more information.
A client is admitted to the ED with full-thickness burn to the R arm. On assessment the nurse notes the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states pain level is 8 on a scale of 1-10. The nurse should: Administer morphine sulfate IV push for the severe pain Call the provider to report the loss of a radial pulse Continue to assess the arm every hour for any additional changes Instruct the client to perform ROM for fingers and wrist
Yes answer: 2. Circulation can be impaired by circumferential burns and edema, causing compartment syndrome. Early recognition and treatment of impaired blood supply is key. The provider should be informed since an escharotomy (incision through full-thickness eschar) is frequently performed to restore circulation. Pain management is important for burn clients, but restoration of circulation is the priority. Assessments should be performed every 15 minutes while there is absence of the radial pulse. Exercise will not restore the obstructed circulation.
A nurse is completing discharge teaching for a client who has a new prescription for transdermal patches. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will clean the site with an alcohol swab before I apply the patch." "I will rotate the application sites weekly." "I will apply the patch to an area of skin with no hair." "I will place the new patch on the site of the old patch."
Yes, answer: 3. 1 is not correct. The client should wash his skin with soap and water and dry it thoroughly before applying a transdermal patch. 2 is not correct. The client should rotate application sites daily to prevent skin irritation. 3 is correct. The client should apply the patch to a hairless area of skin to promote absorption of the medication. 4 is not correct. The client should rotate application sites daily to prevent skin irritation.
The nurse assesses the client's burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. What should be the nurse's priority response? a. Document findings and recheck in 1 hour. b. Elevate extremity on one pillow. c. Implement passive range-of-motion exercises. d. Notify the physician immediately.
Yes, answer: d The absence of a pulse, decreased sensation in the extremity, and increasing edema are all indicative of compromised neurovascular status due to compartment syndrome. Loss of pulse or sensation must be reported immediately to the physician. An escharotomy or fasciotomy may need to be performed to release pressure in the extremity. Other assessments to note include the temperature, capillary refill time, and movement or increasing pain of the affected extremity.
The nurse is caring for a client who has just returned from surgery for a descending colostomy. The nurse plans to include reinforcement teaching for the client and spouse. Which statements should the nurse include in the teaching? Select all that apply. "The colostomy will begin functioning within 24 hours" "A large amount of bleeding may be present at the stoma site" "Stools will become more solid after a few days" "A healthy stoma is reddish-pink, moist, and protrudes about 2 cm from the abdominal wall."
Yes. Answer: Statements 3 and 4 are correct. Rationale: For a colostomy in the descending colon the stools are more solid. See page 1132 in IGGY 9th edition. A healthy stoma is reddish-pink, moist, and protrudes about 2 cm from the abdominal wall. The action alert box on page 1132 notes problems that should be reported to the surgeon. Only a small amount of bleeding should be present at the stoma site. The colostomy will begin functioning in 2-3 days. A colostomy is a surgical procedure to create an opening from the colon (the longest part of the large intestine) to the outside of the body through the abdominal wall. An ileostomy creates an opening from the ileum (the last part of the small intestine) to the outside of the body through the abdominal wall. The opening created by colostomy or ileostomy is called a stoma.
A nursing professor is preparing students for the NCLEX-RN®. Which of the following items should the professor inform the students to expect on the exam? Select all that apply. a) Multiple-choice questions with one correct answer b) Drag and drop questions into an ordered response c) True/false questions d) Graphic questions with a hot spot to identify an area e) Questions with an audio component where you need to wear a headset to listen f) Questions where you select the correct answer from the graphics presented at the end of the question
Yes. Answer: a, b, d, e, f All the above except true/false questions may be on the NCLEX.
