NCLEX 2

aortic abdominal aneurysm

auscultate over midbelly above umbilicus The nurse should carefully monitor renal status in a client who has had abdominal aortic aneurysm repair. BUN, creatinine, and urine output should be assessed. Urine output of at least 30 mL/hr is expected.

Molar pregnancy wait 6+ mos to get pregnant again

-A molar pregnancy, or hydatidiform mole, is a type of gestational trophoblastic disease that results from abnormal fertilization. It causes rapidly growing trophoblastic tissue that is initially benign but may lead to gestational trophoblastic neoplasia (GTN) (eg, invasive mole, choriocarcinoma). If trophoblastic tissue continues to grow or metastasize after evacuation of a molar pregnancy, levels of human chorionic gonadotropin (hCG), a hormone that is also used to diagnose pregnancy, will continue to increase. Therefore, the nurse should emphasize the importance of avoiding pregnancy during follow-up care to allow health care providers to monitor for rising hCG levels, which may indicate malignant GTN (Option 3). Weekly monitoring of hCG levels is required at first, followed by continued monitoring for 6-12 months postpartum. (Option 1) Uterine evacuation is the recommended treatment option for a molar pregnancy because it is effective and reduces potential complications (eg, hemorrhage, retained trophoblastic tissue). (Option 2) The nurse should help the client understand that the pregnancy was not viable, be available to process emotions with the client, and provide resources for coping with pregnancy loss. (Option 4) Trophoblastic cells may contain genetic material that expresses the Rh factor. Therefore, Rh immune globulin (eg, Rhogam) is required for clients with Rh-negative blood types following a molar pregnancy. Educational objective:Following a molar pregnancy, the nurse should instruct the client to avoid pregnancy during follow-up care while health care providers are monitoring human chorionic gonadotropin levels to ensure that gestational trophoblastic neoplasia (eg, choriocarcinoma) does not develop. Additional Information Health Promotion and Maintenance NCSBN Client Need

Therapeutic communication

-don't defer/refer to other professionals -acknowledge client feelings -help client explore own emotions, values, beliefs -avoid giving advice/influencing decision

PEG tube

A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement (Option 3). (Options 1 and 4) The insertion of a Foley catheter or immediate reinsertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. (Option 2) Small-bore nasointestinal tubes are used for short-term rather than long-term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention. Educational objective:A PEG tube's tract begins to mature in 1-2 weeks and is fully established in 4-6 weeks. Tube dislodgement <7 days from placement requires surgical or endoscopic replacement. Attempting to reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis.

Pleural effusion

A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. It is usually secondary to another disease (eg, heart failure, pneumonia, nephrotic syndrome). Pleural effusions are diagnosed by chest x-ray or CT scan. Thoracentesis can be performed to remove fluid from the pleural space and resolve symptoms. Clients commonly report dyspnea with a nonproductive cough, as well as pleural chest pain with respirations (Options 1 and 3). On assessment, clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and decreased movement over the affected lung (Option 2).

ARF

ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or extrapulmonary (head injury, opioid overdose) in origin. Respiratory failure associated with an alteration in O2 transfer or absorption is type I hypoxemic failure (eg, acute respiratory distress syndrome, pulmonary edema, shock). Respiratory failure associated with carbon dioxide (CO2) retention is type II hypercapnic, or ventilatory failure (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ARF is a potential complication of major surgical procedures, especially those involving the thorax and abdomen, as in this client. ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa) or PaCO2 ≥50 mm Hg (6.67 kPa). ARF occurs quickly over time (minutes to hours), and so there is no physiologic compensation and pH is ≤7.30. Immediate intervention with high O2 concentrations is indicated, and noninvasive or invasive, positive-pressure mechanical ventilation may be necessary.

Abbreviations

Acceptable abbreviations include "ac," "pc," "QID," and "cm." Unacceptable abbreviations include "qd," "q1d," and "qod"; "SSRI" for insulin; and "u" for units. There must be a zero before a decimal dose and no trailing zero after a decimal point.

Addison's vs Cushing's

Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push. Addison disease, or primary adrenocortical insufficiency, is also described as hypofunction of the adrenal cortex. The adrenal gland is responsible for secretion of glucocorticoids, androgens, and mineralocorticoids. Bronze hyperpigmentation of the skin in sun-exposed areas is caused by an increase in adrenocorticotropic hormone (ACTH) by the pituitary in response to low cortisol (ie, glucocorticoid) levels (Option 1). Clients with Addison disease may also have vitiligo, or patchy/blotchy skin, which is usually present when the etiology of the disease is an autoimmune problem. The immune cells are thought to destroy melanocytes which produce melanin (or brown pigment), resulting in a patchy appearance. Other common manifestations of Addison disease include the following: Slow, progressive onset of weakness and fatigue Anorexia and weight loss Orthostatic hypotension Hyponatremia and hyperkalemia Salt cravings Nausea and vomiting Depression and irritability (Options 2, 3, and 4) Purple striae, hirsutism (increased facial and body hair), and a supraclavicular fat pad (ie, buffalo hump) are characteristics of Cushing syndrome, a condition associated with excess corticosteroid production. In contrast, Addison disease is a condition of hyposecretion of glucocorticoids. Educational objective:Hyperpigmentation of the skin is a common characteristic of Addison disease, or primary adrenocortical insufficiency, which can also cause hypotension, hyponatremia, hyperkalemia, and vitiligo.

chest tube air bubbles normal

Air bubbles in the suction control chamber of a chest tube drainage system would be a normal finding. Air bubbles in the water seal chamber may indicate a leak and would require immediate intervention.

PCN allergy

Avoid all "cillins" & "cefs/cephs" (cephalosporins)

Child EEG

An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parent includes the following: Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. Avoid caffeine, stimulants, and central nervous system depressants prior to the test. The test is not painful, and no analgesia is required. (Option 1) Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. (Option 3) This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. (Option 4) A routine EEG is not performed under sedation, and so the child should remember the procedure. Educational objective:An EEG is used to diagnose the presence of a seizure disorder. Electrodes are secured to the scalp to observe for abnormal electrical discharges in the brain. Preprocedure teaching includes avoiding stimulants and CNS depressants and washing the hair.

Criteria for rapid response

Any provider worried about client's condition OR HR <40 or >130 BP <90 (systolic) RR <8 or >28 O2 <90 (w/O2) Urine <50 mL/4h (<12.5/h) LOC

Hypoglycemia S/S

BG <70 -diaphoresis -pallor -trembling -palpitations -anxiety/arousal -late: CNS

Droplet precautions

Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet (1.8 meters) away from the client. Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets (Option 5). Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care (eg, suctioning, wound care) (Options 1, 2, and 3). Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of infection. (Option 4) For client care involving airborne precautions, a class N95 or higher respirator must be used instead of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated only for barrier protection from droplet splashing and for filtration of large respiratory particles. Educational objective:When caring for clients on droplet precautions, a surgical mask is needed for routine care, such as assessment or medication administration. If there is risk of contact with body fluids during procedures (eg, wound care, suctioning), gloves, gown, and face shield are used.

Degrees of heart block

Blocking of electrical signal communication b/w atria & ventricles 1st: slowed conduction (still reaches ventricles) 2nd: skipped beats 3rd: no communication (atria & ventricles beat independently)

CVC occlusion

Catheter occlusion is the most common complication of central venous access devices. Kinked tubing, catheter malposition, medication precipitate, or thrombus can occlude the lumen, preventing the ability to flush or aspirate blood. The nurse should first assess for mechanical, nonthrombotic problems by: Repositioning the client (eg, head, arm) as the catheter tip may be resting against a vessel wall (Option 4) Assessing IV tubing for clamps, kinks, and precipitate The nurse should then attempt to flush the device again. If the occlusion remains, the nurse should not flush against resistance as applying force may damage the catheter or dislodge a thrombus. Instead, the nurse should contact the health care provider (HCP), who may prescribe medication (ie, alteplase) to dissolve a thrombus or fibrin sheath.

Reye's syndrome

Children who develop Reye syndrome often have had a recent viral infection, especially varicella (chicken pox) or influenza. Clinical manifestations include fever, lethargy, acute encephalopathy, and altered hepatic function. Elevated serum ammonia levels are an expected laboratory finding. Acute encephalopathy manifests with vomiting and a severely altered level of consciousness; it can rapidly progress to seizures and/or coma. The risk of developing Reye syndrome increases if aspirin therapy is used to treat the fever associated with varicella or influenza. As a result of this awareness, there has been a significant increase in the use of acetaminophen or ibuprofen for fever management in children. (Option 1) Although a child who has not received the varicella vaccine may have an increased risk of developing chicken pox, this evidence alone is not enough to substantiate suspected Reye syndrome. (Option 2) Recent exposure to bats would place the child at risk for rabies, a severe infection affecting the nervous system. This finding would not be indicative of Reye syndrome. (Option 4) The use of aspirin to treat fever, especially in clients with Kawasaki disease, can be associated with Reye syndrome. Acetaminophen is an appropriate antipyretic choice to reduce the risk of Reye syndrome. Educational objective: Reye syndrome is characterized by fever, acute encephalopathy, and altered hepatic function. It often develops following a viral infection, especially varicella or influenza. The risk of developing Reye syndrome increases if aspirin therapy is used to treat fever.

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first?

Client post-cholecystectomy reporting increased nausea: Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit.

Borderline personality disorder

Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other. All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to assess whether it involved suicidal intent. Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a suicide. Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior.

open radical prostatectomy

Clients who have had an open radical prostatectomy for prostate cancer should avoid anything that could cause strain on the rectal area. Straining, suppositories, and enemas are contraindicated in these clients, and interventions should be implemented to prevent constipation.

SVT

Clients with paroxysmal supraventricular tachycardia (SVT) (regular, narrow QRS complex tachycardia) are initially treated with vagal maneuvers. The act of "bearing down" as if having a bowel movement (Valsalva) is an example of these maneuvers and may need to be attempted more than once. Vagal maneuvers work by increasing intra-thoracic pressure and stimulating the vagus nerve, which supplies parasympathetic nerve fibers to the heart, resulting in slowed electrical conduction through the atrioventricular node. (Option 2) Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Cardioversion delivers a synchronized electrical current to the heart. This works by stopping the electrical activity to the heart and briefly allowing a normal heartbeat to return. (Option 3) An ECG is used to diagnose SVT and can be obtained while or after the client is asked to perform the vagal maneuvers as it is not therapeutic. (Option 4) Adenosine is the drug of choice to treat SVT and has a 5- to 6-second half-life (the time it takes for the drug to be reduced to half of its original concentration). Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect. Adenosine is given rapidly over 1-2 seconds and then followed by a rapid 20-mL normal saline flush. Transient asystole is common, and clients often experience flushing and dizziness. Educational objective: Supraventricular tachycardia is a regular, narrow QRS complex tachycardia with a rate of around 150-220/min. The best treatment is vagal maneuvers and adenosine IV push.

Nephrotic syndrome

Collection of symptoms resulting from glomerular injury. 4 characteristic manifestations: -proteinuria -hypoalbuminemia (b/c losing proteins in urine) -edema (periorbital, peripheral, ascites) -hyperlipidemia (compensatory protein/lipid production by liver)

Catatonia

Common w/schizophrenia, etc. -immobility (ex: fixed stupor) -bizarre postures -fast or strange mvmts -staring -lack of speech -limbs stay where another person puts them -negativism (resists mvmt or instructions) Priority: -fluids & food -then: elimination needs, skin integrity, impaired communication, etc.

Tet spell use knee-chest position

Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect. This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect.

A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions?

Continuous suction can be applied to decompress the stomach if a double lumen Salem sump tube is in place. The larger lumen is attached to suction and the smaller lumen (within the larger one) is open to the atmosphere. Checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous suction for decompression and is not being used to administer enteral feeding (Option 1). The air vent (blue pigtail) must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa. If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level of the client's stomach to prevent reflux (Option 3). General interventions to maintain gastric suction using a Salem sump tube include: Place the client in semi-Fowler's position to help keep the tube from lying against the stomach wall; this is done to help prevent gastric reflux (Option 2). Provide mouth care every 4 hours as this helps to maintain moisture of oral mucosa and promote client comfort (Option 4). Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds (Option 5). Inspect the drainage system for patency (eg, tubing kink or blockage). Educational objective: General interventions to maintain gastric suction when using a Salem sump tube include: Maintaining client in semi-Fowler's position Accurate assessment of bowel sounds Keeping the air vent (blue pigtail) open and above the level of the client's stomach Providing mouth care every 4 hours to maintain moisture of oral mucosa and promote comfort Inspecting the drainage system for patency

Cushing's triad

Cushing's triad/reflex indicates increased intercerebral pressure. Classic signs include bradycardia, rising systolic blood pressure, widening pulse pressure, and irregular respirations (such as Cheyne-Stokes).

Preventing hip dysplasia in infants

Developmental dysplasia of the hip (DDH) is a range of various hip abnormalities that may be present at birth or develop during the first few years of life. There are many risk factors, including breech birth, large infant size, and family history. Although all cases cannot be prevented, several interventions have been shown to help reduce the risk of DDH development. Key measures include: Proper swaddling technique - infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room for hip movement (Option 3) Choosing infant carriers orcar seats with wide bases - infant seats should allow for proper hip positioning in an abducted manner Avoiding any positioning device, seat, or carrier that causes hip extension with the knees straight and together (Option 1) Narrow infant carriers prevent proper hip abduction, putting a strain on the hip ligaments and possibly leading to DDH. (Option 2) Double/triple diapering is no longer recommended as a preventive measure for DDH. This practice can cause extension of the hip, leading to abnormal development. (Option 4) Infant swings, bouncers, wraps, and other similar items can cause the legs to be positioned straight and together, which can increase the risk for DDH. Educational objective:DDH is a range of hip abnormalities that may be present at birth or develop in early childhood. Preventive measures include proper swaddling with hips bent up and out, and avoiding seats or carriers that hold the legs straight and together.

Digoxin

Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate). The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin. The early symptoms of toxicity are nausea and vomiting. Later signs of toxicity are arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment.

coup-contrecoup injury

Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds. Coup-contrecoup head injuries are common in motor vehicle accidents and shaken baby syndrome. Damage to the occipital lobe of the brain during coup-contrecoup head injury will result in visual disturbances.

Controlling Epistaxis

Epistaxis (nosebleed) is a common and rarely serious nasal condition that can be caused by dry mucous membranes, local injury (eg, nose-picking), insertion of a foreign body, or rhinitis. Epistaxis usually involves the anterior nasal septum and often resolves spontaneously or with simple home management. Home management of epistaxis includes: Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 5-15 minutes to promote clot formation (Option 2) Holding a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding (Option 1) Attempting to keep the client with epistaxis quiet and calm as emotional outbursts and noncooperation create a challenge to implementing interventions and stopping bleeding (Option 3) (Option 4) Positioning a child with epistaxis in a horizontal position or with the head tilted backward promotes drainage of blood into the throat, which increases the risk of swallowing or aspirating blood. Clients with epistaxis should sit upright and tilt the head forward.

Nursing ethics

Ethical principles guide decision making and appropriate behavior. Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Option 4). Accountability refers to accepting responsibility for one's actions and admitting errors (Option 1). Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia (Option 5). (Option 2) Autonomy is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can provide information and should respect the client's decisions. (Option 3) Confidentiality means that information shared with the nurse is kept in confidence unless permission is given to share or it is required by law to be shared to protect the client and/or community (eg, reportable infectious diseases). If a client discusses suicidal ideation with the nurse, it must be appropriately reported to protect the client from self-harm. Educational objective:Accountability is accepting responsibility for one's actions. Autonomy is making an informed decision about treatment for oneself. Confidentiality is not sharing information unless permission is given or required by law. Justice is treating every client equally. Nonmaleficence is doing no harm.

Liver biopsy risks

The liver is very vascular, which places it at risk for internal bleeding after a tissue sample is removed for biopsy. Liver dysfunction typically results in coagulopathy as many coagulation factors are synthesized in the liver, thereby increasing the risk for bleeding. Early signs of blood loss/shock are tachypnea, tachycardia, and agitation. A later sign is hypotension.

Ringworm not a worm (a fungus)

Highly contagious but not dangerous. Child will be uncomfortable from itching.

Extravasation

Extravasation is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: Stop the infusion immediately and disconnect the IV tubing (Option 5). Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. Elevate the extremity above the heart to reduce edema (Option 2). Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine) (Option 4). (Options 1 and 3) The nurse should not flush the infiltrated IV site or use it for further drug administration. Although new IV access must be obtained, access should be established ideally through a central line or on an unaffected extremity. Educational objective:If extravasation of IV norepinephrine occurs, the nurse should stop the infusion immediately, aspirate the drug, remove the IV catheter, elevate the extremity, and administer the antidote phentolamine into affected tissues as prescribed. IV access is reestablished on an unaffected extremity or through a central line.

HIV lower risk cx

Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells, resulting in progressive immune system impairment. Clients with HIV are susceptible to opportunistic infections that typically occur during periods of low CD4+ counts. To reduce the risk of infection, nurses should educate clients with HIV to: Obtain and remain up to date on vaccinations, including the annual influenza vaccination (Option 2). Avoid eating undercooked meats (eg, steak that is pink) and having contact with cat feces (eg, cat litter box) because both are sources of Toxoplasma gondii, an opportunistic parasite that causes encephalitis (Options 1 and 3). Avoid drinking water from poorly sanitized (eg, developing countries) or potentially contaminated (eg, rivers, wells) sources because it may contain infectious pathogens (eg, Cryptosporidium, Isospora, Giardia). Instead, use bottled or purified water when drinking and brushing teeth (Option 4). (Option 5) Educate clients with HIV to always use synthetic barriers (eg, condoms) during sex to reduce the risk of transmitting HIV and being infected with additional HIV strains or other sexually transmitted infections. Clients with an undetectable viral load have a lower risk of transmitting HIV to a sexual partner but should still use barrier contraception. Educational objective:Clients with HIV should take precautions to prevent opportunistic infections, including: staying up to date on vaccinations, eating thoroughly cooked meat, avoiding changing cat litter boxes, and using bottled water to brush teeth when traveling to developing countries. Clients with HIV, even those with a low viral load, should always use condoms.

Peritoneal dialysis

In peritoneal dialysis (PD), the abdominal lining (peritoneum) is used as a semipermeable membrane to dialyze clients with decreased kidney function. A catheter is placed in the peritoneal cavity for infusing and draining dialysate (dialysis fluid). Dialysate is infused and dwells in the abdomen, which allows waste products and electrolytes to cross the peritoneum into the dialysate for removal. After the prescribed dwell time, the dialysate, electrolytes, and wastes are drained via gravity. When administering PD, it is essential to use sterile technique when spiking and attaching bags of dialysate to the client's PD catheter to prevent contamination and infection (Option 4). Bacterial peritonitis, an infection of the peritoneum, is a potential complication of PD that may lead to sepsis. Signs of peritonitis should be reported to the health care provider. (Options 1 and 2) Proper positioning of the catheter drainage bag (ie, below the abdomen) and the client (eg, Fowler or semi-Fowler position) promotes effluent outflow but is not a priority over infection prevention. (Option 3) Cloudy effluent may indicate infection, whereas bloody or brown effluent may indicate bowel perforation. Documenting effluent characteristics is important but not a priority over maintaining asepsis. Educational objective: Peritoneal dialysis (PD) uses the peritoneum as a semipermeable membrane to dialyze clients with decreased kidney function. Bacterial peritonitis is a potential complication of PD. Using sterile technique when spiking or changing bags of dialysate is a priority to avoid contamination and reduce the risk of peritonitis. Additional Information Physiological Adaptation NCSBN Client Need

Stress incontinence

Nursing interventions related to stress incontinence include bladder training (eg, voiding every 2 hours), pelvic floor exercises (eg, Kegel exercises), lifestyle modifications (weight loss, reduction of dietary bladder irritants, smoking cessation), and incontinence products. The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks (Option 2). Pelvic floor exercises (eg, Kegel exercises), which strengthen the sphincter and structural supports of the bladder, are an essential part of the teaching plan but are not the priority for this client (Option 1). It will take approximately 6 weeks for pelvic floor muscle strength to improve. Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated but are not the priority in this client (Option 3).

Most dangerous steroid side effect

Infection Addison disease (primary adrenocortical insufficiency) is characterized by a deficiency in all three types of adrenal steroids (ie, glucocorticoids, androgens, mineralocorticoids), most commonly caused by an autoimmune response. Corticosteroid therapy (eg, hydrocortisone, dexamethasone, prednisone) is the primary treatment for Addison disease. Long-term use of corticosteroids can cause immunosuppression, and the anti-inflammatory effects may also mask signs of infection (eg, inflammation, redness, tenderness, heat, fever, edema). Signs and symptoms of infection (eg, low-grade fever) should be reported to the health care provider immediately as infection can develop quickly and spread rapidly (Option 2). In addition, physiological stress such as infection can trigger Addisonian crisis, a life-threatening complication of Addison disease that would require an increase in the corticosteroid dose. (Options 1, 3, and 4) Side effects of long-term corticosteroid therapy mimic the signs and symptoms of Cushing syndrome, including buffalo hump, moon-shaped face, and hypokalemia. Increased weight, blood pressure, and blood glucose levels can also occur; however, these effects are not as life-threatening as infection. Educational objective: In clients taking corticosteroids, it is imperative to notify the health care provider of signs and symptoms of infection, even a low-grade fever. The anti-inflammatory properties of corticosteroids can mask signs of infection, and their immunosuppressive effects can cause the infection to develop and spread quickly.

Orthopedic priority: joint dislocation (ex: pain, deformity, ↓ ROM, paresthesia)

Joint dislocations dangerous b/c can compress vasculature = ischemia = lose limb

Flail chest

Life-threatening: segment of rib cage breaks d/t trauma & becomes detached from rest of chest wall. Risks: abc, pneumothorax, hemothorax

mastectomy

Lymphedema is the accumulation of lymph fluid in the soft tissue. It can occur as a result of lymph node removal or radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid can accumulate in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor function may be impaired. The presence of lymphedema increases the client's risk for infection or injury of the affected limb. Interventions to manage lymphedema include: Decongestive therapy (massage technique to mobilize fluid) Compression sleeves or intermittent pneumatic compression sleeve (Option 5)Compression sleeves are graduated with increased distal pressure and less proximal pressure.Clothing should also be less constrictive at the proximal arm and over the chest. Elevation of arm above the heart (Option 3) Isometric exercises (Option 4) Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure measurements, and injections (eg, vaccinations) on the affected limb (Option 2) Injury prevention (limb less sensitive to temperature changes)Infection prevention (limb more prone to infection through skin breaks) (Option 1) Clients often learn massage techniques (ie, decongestive therapy) from physical therapists to increase lymphatic drainage and promote circulation of the extremity. Educational objective:Management for lymphedema includes decongestive massage therapy, compression bandages or sleeves, elevation of the arm above heart level, isometric exercises, and avoidance of venipuncture or blood pressure measurements on the affected limb. Additional Information Physiological Adaptation NCSBN Client Need

Delirium

Major predisposing factors for the development of delirium in hospitalized clients include: Advanced age Underlying neurodegenerative disease (stroke, dementia) Polypharmacy Coexisting medical conditions (eg, infection) Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) Metabolic and electrolyte disturbances Impaired mobility - early ambulation prevents delirium Surgery (postoperative setting) Untreated pain and inadequate analgesia

Sleep apnea

Obstructive sleep apnea (OSA) is the most common type of breathing disorder during sleep and is characterized by repeated periods of apnea (>10 seconds) and diminished airflow (hypopnea). A partial or complete obstruction occurs due to upper airway narrowing that results from relaxation of the pharyngeal muscles or from the tongue falling back on the posterior pharynx due to gravity. During periods of apnea, desaturation (hypoxemia) and hypercapnia occur; these stimulate the client to arouse and breathe momentarily to restore airflow. These cycles of apnea and restored airflow can occur several hundred times per night, resulting in restless and fragmented sleep. Partners of clients with OSA witness loud snoring, apnea episodes, and waking with gasping or a choking sensation (Options 5 and 6). During the day, clients experience morning headaches, irritability, and excessive sleepiness. Excessive daytime sleepiness can lead to poor work performance, motor vehicle crashes, and increased mortality (Options 2 and 3). (Option 1) Frequent (not difficult) arousal from sleep is associated with OSA. (Option 4) Cataplexy is a brief loss of skeletal muscle tone or weakness that can result in a client falling down. It is associated with narcolepsy, a chronic neurologic sleep disorder. Educational objective: At night, clients with obstructive sleep apnea experience repeated periods of apnea, loud snoring, and interrupted sleep. During the day, morning headaches, irritability, and excessive sleepiness are common.

Measles

Measles (ie, rubeola) is a highly contagious viral illness that affects people of all ages. Measles spreads when infected individuals cough or sneeze, sending the virus through the air, where it remains suspended for up to 2 hours. Widespread vaccination with the measles, mumps, and rubella (MMR) vaccine, such as in the United States, has reduced measles incidence by 99%. However, an increase in international travel and unvaccinated children have caused a resurgence of the disease. For hospitalized clients with measles, the plan of care should include the following: Recommendation of postexposure prophylaxis (ie, MMR vaccine) for eligible, susceptible (eg, unvaccinated) family members within 72 hours of exposure to decrease the severity and duration of symptoms in case they contract the disease (Option 1) Implementation of airborne precautions, including a negative-pressure isolation room and use of an N95 respirator mask, during contact with the client by health care staff (Options 4 and 5) Administration of vitamin A supplements to prevent severe, measles-induced vitamin A deficiency, which can cause blindness, particularly in clients in low-resource areas (Option 2) An erythematous, maculopapular, morbilliform rash is characteristic of measles, but it is not typically pruritic. Calamine lotion is effective for soothing pruritic rashes (eg, varicella [chickenpox]). (Option 3) A tracheostomy tray is not required for this client with measles because respiratory paralysis or emergency intubation is not expected. Educational objective:Clients with measles are highly contagious and require airborne precautions (eg, negative-pressure isolation room, N95 respirator). Susceptible family members should receive postexposure prophylaxis (eg, measles, mumps, and rubella vaccine). Additional Information Physiological Adaptation NCSBN Client Need

Thiazide diuretics side effects

Most dangerous: -low potassium (dysrhythmias, muscle cramps) -low sodium (CNS/seizures) Others: -high blood sugar -orthostatic hypotension -gout (increases uric acid) -photosensitivity

To leave against medical advice (AMA)

Must be legally competent to make educated decision to stop treatment. Disqualifications (can't leave) -altered consciousness -mental illness (danger to self or others - ex: manic & hasn't eaten in 5d) -intoxicated (drugs or alcohol) HCP explains risks Nurse witnesses & documents Discharge instructions & option to return at any time

Nitroglycerin patches

Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12-14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation. (Option 1) Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined use can result in severe hypotension. (Option 2) Patches may be worn in the shower. (Option 3) Headaches are common with the use of nitrates. The client may need to take an analgesic. Educational objective: Nursing education about transdermal nitroglycerin includes application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing.

Stop tube feedings for phenytoin

Phenytoin (Dilantin) is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. The nurse's priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing calcium (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the absorption and the serum level of this drug. (Option 1) Unless clients have renal insufficiency, renal function tests are not routinely monitored during prescribed phenytoin therapy. Phenytoin is metabolized in the liver and can cause liver damage. Monitoring of liver function test during therapy is recommended. (Option 2) Flushing the tube with 30-50 mL of water before and after administering phenytoin is recommended to minimize drug loss and drug-drug incompatibility. Flushing with normal saline before and after drug administration is recommended in clients receiving intravenous (IV) phenytoin. (Option 4) BP is not usually affected in clients prescribed oral phenytoin therapy for seizure disorders. However, IV phenytoin can cause hypotension and arrhythmias. Educational objective:Phenytoin is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. Administration of phenytoin concurrent with certain drugs (eg, antacids, calcium) and/or enteral feedings can affect the absorption of phenytoin.

Pneumonia vs pneumothorax

Pneumonia is an acute infection of the lungs. Findings in a client with pneumonia include: Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus (Option 1) Fever, chills, productive cough, dyspnea, and pleuritic chest pain (Options 3 and 4) Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be an early sign of pneumonia. Unequal chest expansion - Decreased expansion of affected lung on palpation Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia) (Option 2) Hyperresonance is percussed over a hyperinflated lung (eg, asthma, emphysema) or air in the pleural space (eg, pneumothorax). (Option 5) A trachea deviating from midline is not a symptom of pneumonia but instead indicates a tension pneumothorax where the trachea deviates away from the tension. Educational objective:Physical examination of a client with pneumonia can reveal crackles, increased vocal/tactile fremitus, unequal chest expansion, and bronchial breath sounds in peripheral areas. Clients often report fever, chills, productive cough, dyspnea, and pleuritic chest pain. Additional Information Physiological Adaptation NCSBN Client Need

Postpartum hemorrhage interventions

Postpartum vaginal bleeding that saturates aperineal pad in <1 hour is considered excessive. This client saturated a perineal pad in 20 minutes. Based on the nurse's assessment, the boggy fundus indicates uterine atony. The fundus is also elevated above the umbilicus and deviated to the right, indicating a distended bladder. Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the previous placental site. The client should be assisted to void to correct the bladder distension (Option 1). The nurse should then perform fundal massage. (Option 2) Oxytocin is a uterotonic that increases contraction of the myometrium, constricting vessels at the previous placental implantation site. An oxytocin infusion should be initiated if initial attempts to control postpartum bleeding (relief of bladder distention and fundal massage) have failed. The usual postpartum oxytocin IV dosage is 125-200 milliunits/min. (Option 3) A complete blood count is needed to determine hematocrit and hemoglobin levels following excessive postpartum bleeding. However, this is not the immediate priority. (Option 4) Oxygen delivery at 10 L/min via a nonrebreather facemask may be initiated if the client becomes symptomatic following excessive blood loss. However, the first priority is to control the bleeding. Educational objective:Excessive postpartum bleeding is most commonly caused by uterine atony. The nursing priority for uterine atony associated with bladder distension is to assist the client with voiding and then perform fundal massage and other interventions as needed to control excessive bleeding.

Caring for intubated patient whose O2 sat drops.

Priority: auscultate lung sounds to make sure ET tube not displaced.

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the health care provider?

Serum glucocse of 68 in client receiving TPN he recommended target serum glucose range for clients receiving nutritional support is 140-180 mg/dL (7.8-10.0 mmol/L). The nurse should monitor a client receiving TPN for hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) and hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]). Hypoglycemia places the client at risk for life-threatening complications (eg, seizures, nervous system damage).

Sputum collection

Sputum culture and sensitivity testing is used to identify infectious organisms in the respiratory tract and determine which antimicrobials are most effective at treating the identified organism. Nurses assisting a client to collect sputum should instruct the client to: Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora (Option 1) Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin (Option 2) Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume (Option 3) Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection (Option 5) (Option 4) Sputum specimens should be collected early in the morning after awakening, which improves the quality of the sample because secretions accumulate overnight due to cough inhibition. A nebulizer treatment may be prescribed to help mobilize thick secretions.

Statins

Statin medications (eg, rosuvastatin, atorvastatin) can cause hepatotoxicity and muscle aches. Liver function tests should be assessed prior to the start of therapy.

Why enteral over TPN

Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. The enteral route is preferred for feeding. Enteral feedings maintain the integrity of the gut, prevent stress ulcers, and help prevent the translocation of bacteria into the bloodstream.

Signs of pregnancy

Subjective/presumptive: -amenorrhea -N/V -urinary freq -breast tenderness -fatigue -quickening Objective/probable: -positive pregnancy test -Goodell (soft cervix)/Chadwick (blue cervix)/Hagar (soft lower uterus) -Braxton Hicks -Ballottement (finger in vagina feels rebound of unengaged fetus) -fetal outline palpation -uterine & funic souffle (steth on uterus = blowing sound in sync w/fetal/maternal HR) -chloasma (brown patches/face)/linea nigra/areola darkening -stria gravidarum Positive/diagnostic: -fetal heartbeat on doppler -fetal mvmt palpated by HCP -visible fetal mvmts -ultrasound

Boys puberty

Testicular enlargement, including scrotal changes, is the first manifestation of puberty and sexual maturation. This typically occurs at age 9½-14. It is followed by the appearance of pubic, axillary, facial, and body hair. The penis increases in size and the voice changes. Some boys also experience an increase in breast size. Growth spurt changes of increased height and weight may not be apparent until mid-puberty. Educational objective:Sexual maturation in boys begins with an increase in testicular size, followed by changes in the scrotum, appearance of pubic, axillary, facial, and body hair, and voice changes.

SIADH

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is often caused by the ectopic production of ADH by a malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium drops below 120 mEq/L (120 mmol/L) (normal: 135-145 mEq/L [135-145 mmol/L]). Therefore, hyponatremia is the highest priority to report as it poses the greatest threat to survival. Hyponatremia requires immediate evaluation and treatment (eg, seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider. Malignant lung tumors are a common cause of syndrome of inappropriate antidiuretic hormone secretion (SIADH). When serum sodium drops below 120 mEq/L (120 mmol/L), immediate intervention is necessary to prevent severe neurologic dysfunction. Fluid restriction is recommended for clients with SIADH.

Orthostatic Hypotension

Take BP supine then sitting then standing Orthostatic hypotension: if any position changes => -systolic ↓ by >20 -diastolic ↓ by >10 -HR ↑ 10% If OH when sit up, don't need to proceed to standing. Lie back down (recumbent) & notify HCP.

A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation?

Take capillary glucose him/herself then compare to recorded result. When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally and comparing it to what has been documented.

Cirrhosis labs

The chronic, progressive destruction characteristic of cirrhosis causes bilirubin, ammonia, and coagulation studies (PT/INR and aPTT) to become elevated. Hyponatremia and hypoalbuminemia are to be expected. Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes alter blood flow through the liver and decrease the liver's functionality. Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin (Option 3). Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated partial thromboplastin time [aPTT]) are usually elevated (Option 4). Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy (Option 2). (Options 1 and 5) Albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of vascular spaces into interstitial spaces (eg, edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb (conserve) both sodium and water. The large amount of water in the body results in a dilutional effect (low sodium).

FOBT

The guaiac fecal occult blood test is used to assess for microscopic blood in the stool as a screening tool for colorectal cancer. The steps for collecting a sample include: Assess for recent ingestion (within last 3 days) of red meat or medications (eg, vitamin C, aspirin, anticoagulants, iron, ibuprofen, corticosteroids) that may interfere and produce false test results. Obtain supplies (Hemoccult test paper, wooden applicator, Hemoccult developer), wash hands, and apply nonsterile gloves (Option 2). Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. Collect from 2 different areas of the specimen as some portions of the stool may not contain microscopic blood (Option 4). Close the slide cover and allow the stool specimen to dry for 3-5 minutes. Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide (Option 3). Assess the color of the Hemoccult slide paper within 30-60 seconds. A positive guaiac result will turn the test paper blue, indicating presence of microscopic blood in the stool (Option 5). Dispose of used gloves and the wooden applicator and perform hand hygiene. Document the results (Option 1). The guaiac fecal occult blood test is used to assess for microscopic blood in the stool as a screening tool for colorectal cancer. The steps for collecting a sample include: Assess for recent ingestion (within last 3 days) of red meat or medications (eg, vitamin C, aspirin, anticoagulants, iron, ibuprofen, corticosteroids) that may interfere and produce false test results. Obtain supplies (Hemoccult test paper, wooden applicator, Hemoccult developer), wash hands, and apply nonsterile gloves (Option 2). Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. Collect from 2 different areas of the specimen as some portions of the stool may not contain microscopic blood (Option 4). Close the slide cover and allow the stool specimen to dry for 3-5 minutes. Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide (Option 3). Assess the color of the Hemoccult slide paper within 30-60 seconds. A positive guaiac result will turn the test paper blue, indicating presence of microscopic blood in the stool (Option 5). Dispose of used gloves and the wooden applicator and perform hand hygiene. Document the results (Option 1). Educational objective: The guaiac fecal occult blood test detects microscopic blood in the stool and is used to screen for colorectal cancer. A blue color on the Hemoccult slide paper within 30-60 seconds indicates a positive result.

Normal FHR

The normal FHR tracing include baseline rate between 110-160 beats per minute (bpm), moderate variability (6-25 bpm), presence of accelerations and no decelerations.

COPD

The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, "I can't breathe." The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time? Anxiety is an emotional reaction to a perceived threat. For the client with COPD, the fear of having difficulty breathing can actually trigger difficulty breathing, which worsens as the client's anxiety increases. This client is stable, with no obvious cause of shortness of breath. The nurse should intervene by calmly coaching the client through breathing exercises, which will promote relaxation and help alleviate the anxiety that is causing the client to feel short of breath. (Option 1) The client's lung sounds are clear bilaterally and so albuterol, a bronchodilator used for wheezing, will not be helpful. Its action as an adrenergic agonist may cause tachycardia and tremulousness and actually worsen the client's anxiety. (Option 2) Trigger avoidance and problem solving are appropriate strategies for long-term control of anxiety and shortness of breath. However, these are not appropriate at this time as the client has acute symptoms that need to be controlled. (Option 4) This client has normal oxygen saturation. Constant monitoring is not likely to alleviate the symptoms unless the client is reassured by this knowledge. However, the client's anxiety may actually be worsened by worrying about the saturation results and the alarms that are likely to be triggered by monitoring. Educational objective: Anxiety is common in clients with COPD and can contribute to difficulty breathing. In the client with acute shortness of breath and normal assessment findings, appropriate interventions are controlled breathing and relaxation.

Warfarin

The nurse should hold a dose of warfarin for an INR over 4 and notify the HCP. Vitamin K may need to be administered for INRs of 5 or greater.

Pulses documentation

The nurse should palpate and compare the characteristic and quality of the pulses on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated as 0, absent; 1+, weak; 2+, normal; and 3+, increased, full, bounding. These descriptions should be documented in the client's record.

Phlebostatic axis

The phlebostatic axis (fourth intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest) is an external reference point on the thorax used to determine proper placement of the pressure monitoring system transducer when measuring direct BP, CVP, and/or cardiopulmonary pressures invasively. It is also used as a reference point for the upper arm when measuring BP indirectly.

Tracheostomy suctioning

The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia (Option 1). The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia (Option 4). In addition, deep rebreathing should be encouraged. (Option 2) The suction catheter should be no more than half the width of the artificial airway and inserted without suction. (Option 3) The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as excess pressure will traumatize the mucosa and can cause hypoxia. (Option 5) Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction. Educational objective:Proper airway suctioning technique includes preoxygenation, limiting a suction pass to 10 seconds, and allowing 1-2 minutes between passes to prevent hypoxia. Medium suction pressure should be set at 100-120 mm Hg for adults, with the catheter inserted without suction.

Rule of 9s

The rule of nines is used to estimate quickly the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client. Superficial (first-degree) burns are not included in the calculation of affected TBSA. For a client who has sustained partial-thickness burns to the back and to the anterior and posterior surfaces of the right arm and leg, TBSA is calculated as follows: TBSA = [back] + [anterior and posterior of right arm] + [anterior and posterior of right leg]TBSA = [18] + [4.5 + 4.5] + [9 + 9]TBSA = 18 + 9 + 18 = 45% Once the affected TBSA has been estimated, the volume of necessary fluid resuscitation can be calculated (ie, Parkland formula [4 mL x kg of body weight x TBSA]). TBSA also determines the required level of care. In general, clients require transfer to a burn center for specialty care for: Full-thickness burns Partial-thickness burns >10% TBSA Electrical or chemical burns Inhalation injuries Educational objective:The rule of nines provides a quick estimate of the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client. TBSA determines the volume of necessary fluid resuscitation and the required level of care. The rule of nines assigns 9% per arm, 18% per leg, 36% for the torso, 1% for the perineum, and 9% for the head and neck. Additional Information Reduction of Risk Potential NCSBN Client Need

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action?

This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to ensure the client's safety and offer support. Additional nursing actions while the client is experiencing panic symptoms include: Maintaining a calm, matter-of-fact approach Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures Placing the client in a room with as few stimuli as possible Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription) Having the client take slow, deep breaths if hyperventilation is a problem

Status epilepticus

This client is in status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer. Grunting and a dazed appearance are 2 common signs. A client with hydrocephalus (abnormal collection of cerebrospinal fluid in the head) and a ventriculoperitoneal (VP) shunt is at a higher risk for seizures. Stopping seizure activity is the first nursing priority. IV benzodiazepines (diazepam or lorazepam) are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department. (Option 2) Stopping the status epilepticus is a priority over determining its cause through a neurologic assessment. Quickly obtaining the oxygen saturation level and managing the airway are priority assessments. (Option 3) Blood draw is needed for laboratory studies but is not a priority over stopping the seizure. (Option 4) A VP shunt drains excess fluid in the brain down to the abdomen, where it is absorbed by the body. A CT scan can accurately assess shunt malfunction. Any malfunction would need to be treated promptly to prevent future seizures and damage. Finding the cause of the seizure is important and should be done as soon as seizing has stopped. Educational objective: Status epilepticus is a serious condition that could result in brain damage and death. Quickly stopping the seizure is the first nursing priority as long as there is an adequate airway and the client is breathing. IV or rectal benzodiazepines (lorazepam or diazepam) are used to rapidly control seizures.

Desmopressin

Treats diabetes insipidus (pee out too much, thirsty) Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration (Option 3). ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP). Danger: water intoxication/overhydration (overshooting & holding too much water, diluting electrolytes like Na+) -CNS changes -muscle weakness -N/V

A 2-year-old child is brought to the emergency department for a severe sore throat and fever of 102.9 F (39.4 C). The nurse notes that the child is drooling with distressed respirations and inspiratory stridor. What action should the nurse take first?

This is a classic description of epiglottitis (supraglottitis). It is an inflammation by bacteria of the tissues surrounding the epiglottis, a long, narrow structure that closes off the glottis during swallowing. Edema can develop rapidly (as quickly as a few minutes) and obstruct the airway by occluding the trachea. There has been a 10-fold decrease in its incidence due to the widespread use of the Hib (Haemophilus influenzae type B) vaccine. The classic symptoms include a high-grade fever with toxic appearance, severe sore throat, and the 4 Ds—dysphonia (muffled voice), dysphagia (difficulty swallowing), drooling, and distressed respiratory effort. The tripod position opens the airway and helps air flow. The child should be allowed to assume a position of comfort (usually sitting rather than lying down). The priority nursing response is to protect the airway. (Option 1) No invasive procedure should be done that could cause the child to cry until the airway is secure. Knowing the temperature is not a priority. (Options 2 and 3) When drooling is present, the airway becomes the primary concern. No visual inspection, invasive procedure, or anxiety-provoking activity should be done until the airway is secure due to the risk of laryngospasm and respiratory arrest. Educational objective:Children with potential epiglottitis should be allowed a position of comfort without any invasive or anxiety-provoking procedures (eg, phlebotomy, pharyngeal examination, epiglottal cultures) until the airway is secure with intubation or a surgical airway. Additional Information Physiological Adaptation NCSBN Client Need

TPN

Total parenteral nutrition (TPN) is administered via a central venous catheter to meet the nutritional needs (eg, glucose, amino acids, vitamins, minerals) of clients who cannot digest nutrients via the gastrointestinal tract. The nurse should hang 10% dextrose in water at the same infusion rate of 75 mL/hr until the new bag arrives. If the 20% dextrose solution is temporarily replaced with an infusion lacking dextrose (eg, normal saline, lactated Ringer's [LR]), the pancreas will continue to produce insulin in response to the residual glucose, which may cause hypoglycemia (Option 2). (Option 1) The infusion of 0.9% saline solution without dextrose can lead to hypoglycemia. Rapid infusion (150 mL/hr) of the hypertonic TPN solution can increase the risk for fluid overload and hyperglycemia. The nurse should never increase the rate of central TPN to make up for volume lost during previous hours. (Option 3) Dextran in saline solution is a colloid used to expand intravascular volume in clients with hypovolemia. It can cause fluid overload and so is not an appropriate action. (Option 4) LR contains electrolytes but no glucose; hypoglycemia may result. Educational objective: Abrupt cessation of central total parenteral nutrition (TPN), which usually contains 20%-50% dextrose, increases the risk for hypoglycemia, as the pancreas will continue to produce insulin in response to the residual glucose. When TPN is discontinued, the infusion rate is gradually reduced and then replaced with a solution containing dextrose.

aPTT (activated partial thromboplastin time)

Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 25-35 seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5-2 times the normal value. Therapeutic value for aPTT is 46-70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed.

Phlebotomy

When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema. (Option 3) An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. (Option 5) The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A heel stick collection on an infant should be done on the plantar surface. Educational objective:When obtaining blood from a client, insert the needle at 15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion.

Dabigatran

blood thinner Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic atrial fibrillation. The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor). Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture contamination (Option 3). (Option 1) Red urine or blood in the stool may indicate internal bleeding caused by thrombin inhibitors. The client should report these symptoms to the health care provider. (Option 2) Thrombin inhibitors should only be stopped under the direction of the health care provider. The nurse should educate the client that stopping dabigatran will increase the risk for stroke. Taking the medication with food will not affect how much is absorbed, and food or a full glass of water may prevent gastrointestinal side effects (eg, nausea, indigestion). (Option 4) Thrombin inhibitor capsules should not be crushed or opened as crushing pills increases absorption and risk of bleeding. Educational objective:Thrombin inhibitors such as dabigatran reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use.

Dilitiazem

calcium channel blocker tx HTN, afib, angina Atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. The dosage needs to be adjusted to achieve a goal heart rate of <100/min. Atrial fibrillation is usually not immediately life-threatening.

Can give hydromorphone or strong opioid to OUD pt who reports pain

he client with opioid abuse history would be experiencing the same type and degree of pain as other clients with a fractured femur. However, a higher dose or a stronger opioid analgesic (eg, hydromorphone) is needed for pain relief due to the client's increased opioid tolerance.

Jugular venous distension

he nurse should position the client with the head of the bed at a 30- to 45-degree angle to assess for the presence of JVD.

thyroid storm

hyroid storm is a serious and potentially life-threatening emergency for clients with Graves disease. This condition occurs when the thyroid gland releases large amounts of thyroid hormone in response to stress (eg, trauma, surgery, infection). Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 104-106 F (40-41 C). Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures. (Option 2) Heat intolerance is an expected symptom in hyperthyroidism, including Graves disease. (Option 3) Tachycardia and arrhythmias (eg, atrial fibrillation) are commonly seen with hyperthyroidism of any cause, including Graves disease. These alone cannot differentiate whether the client has simple hyperthyroidism or life-threatening thyroid storm. (Option 4) Exophthalmos (protruding eyeball) is commonly seen in Graves disease. The eyelids do not close over the eyeballs properly, leading to excessive dryness and resultant corneal damage (exposure keratitis). Although it is important to treat exophthalmos, it is not immediately life-threatening.

Babinski

infant - fanning and curling toes when foot is stroked adult - The Babinski sign can indicate an upper motor neuron lesion from damage to the corticospinal tract. A normal finding for an adult is for the toes to point downward.

Immunosensce

mmunosenescence is an age-related decrease in the immune and inflammatory responses that increases older adult clients' risk of infection and sepsis and causes atypical signs of infection (eg, hypothermia, altered mental status, leukopenia). Atypical signs of infection should be immediately reported to increase the client's chance of survival.

A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery bypass (MIDCAB) grafting. The client thought that this surgery was supposed to have a much easier recovery and asks the nurse why it is so painful to take deep breaths. What is the best response by the nurse?

overall recovery time shorter but initial pain may be greater b/c incisions b/w ribs MIDCAB does not involve a sternotomy incision or placement on cardiopulmonary bypass. Several small incisions are made between the ribs. A thoracotomy scope or robot is used to dissect the internal mammary artery (IMA) that is used as a bypass graft. Radial artery or saphenous veins may be used if the IMA is not available. Recovery time is typically shorter with these procedures and clients are able to resume activities sooner than with traditional open chest coronary artery bypass graft surgery. However, clients may report higher levels of pain with MIDCAB due to the thoracotomy incisions made between the ribs.

Normal ABGs

pH 7.35-7.45 PaO2 80-100 mm Hg (10.7-13.3 kPa) PaCO2 35-45 mm Hg (4.66-5.98) Bicarbonate (HCO3-) 22-26 mEq/L (22-26 mmol/L) O2 Saturation (SaO2) 95%-99%

Avoid suctioning ventilated patient prior to drawing ABGs

rterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results. (Option 2) Pre-oxygenation should occur prior to suctioning and possibly before position changes. It will affect ABG results. (Option 3) The head of the bed should be maintained at 30 degrees or higher in an intubated client to prevent aspiration and allow for adequate chest expansion. This position will not affect ABG results. (Option 4) If a client is being weaned from the ventilator, sedation may be reduced. A client with reduced sedation may become anxious and have an increased activity level; these could affect the ABG results. Educational objective:If the client's condition allows, the nurse should avoid suctioning or changing activity or oxygenation levels prior to drawing of ABGs. These actions can result in inaccurate ABG results.

Hiatal hernia

upper part of the stomach protrudes upward through the diaphragm Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to a weakness in the diaphragm. Although hiatal hernias may be asymptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess weight by performing light activities (eg, short walks) because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining (eg, weight lifting), which increases abdominal pressure (Option 4). (Options 1 and 2) Sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches (15 cm) reduces upward movement of the hernia and decreases the risk of gastric reflux. (Option 3) If symptoms of hiatal hernias are uncontrolled with home management (eg, weight loss, diet modification, positioning after meals), surgical revision of the diaphragm may be required to prevent organ movement. Educational objective:Hiatal hernia is characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to diaphragmatic weakness. Nurses educating clients with hiatal hernias about symptom management should instruct them to avoid activities that increase abdominal pressure (eg, weight lifting), sleep with the head of the bed elevated, and remain upright for several hours after meals.