Pain , Fluid & Electrolyte - medsurg1

moral distress

conflict that arises within oneself when a person is aware of the correct course of action but institutional constraints stand in the way of pursuing the correct action. (how i feel)

evaluation

determination of the patients responses to the nursing interventions and the extent to which the outcomes have been achieved (also called the reassessment in the nursing process)

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?

Daily weight

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client?

-Tetany -Hypotension -Prolonged QT interval -Positive Chvostek's sign (CATS HIDDEN)

Which clients are most likely to be at risk for the development of third spacing?

-The client with cirrhosis -The client with liver failure -The client with chronic kidney disease Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac.

critical thinking

metacognition- the examination of one's own reasoning or thought processes to help refine thinking skills

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure and increased respirations

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited?

Areflexia means Deep tendon reflex decrease.

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia?

A client admitted 6 hours ago with a 40% burn injury

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A client with an ileostomy

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved?

A urine specific gravity of 1.043 Normal values for urine specific gravity are 1.005 to 1.03

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed?

Asks the athletes to take a salt tablet before football practice. Salt tablets contribute to dehydration.

A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child?

Assess the child's physical status.

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

Attempt to arouse the client. The nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs.

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply.

Bounding pulse Difficulty breathing Presence of dependent edema Neck vein distention in the upright position

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level?

Depressed ST segment

what is critical thinking used for?

It is used for clinical reasoning which is the process used to gather and analyze client information, evaluate the relevance of the info, and decide on possible nursing actions to improve the clients physiological and psychosocial outcomes.

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?

Loss of deep tendon reflexes

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level?

Malnutrition

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client?

Monitor the client for dysrhythmias.

The nurse is caring for a client who had a cholecystectomy 1 day ago. The nurse plans pain-management techniques, knowing that the severity of the client's pain can be related to which factor?

Positioning of the client during surgery The duration of the operation, and the degree of tissue trauma also contribute to the presence and severity of postoperative pain.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L (3.0 mmol/L)

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

U waves Inverted T waves Depressed ST segment

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?

Urine specific gravity of 1.032 urine specific gravity range 1.005 to 1.030

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications?

Warfarin Glimepiride Amlodipine

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

Weight loss and poor skin turgor

nursing diagnosis

a clinical judgement

implementation

actualization or carrying out of the plan of care through nursing interventions

moral dilemma

circumstances in which a clear conflict exists between two or more moral principles or competing moral claims that are incompatable

moral problem

competing moral claim or principle: one claim or principle is clearly dominant

moral uncertainty

conflict that arises within a person when he or she cannot accurately define what the moral situation is or what moral principles apply but has a strong feeling (gut) that something is not right

planning

development of measurable goals and outcomes, as well as a plan of care

utilitarianism

is based on the concept of the greatest good for the greatest number.

ADPIE

nursing process

morals

specific beliefs or actions whose outcomes are often examined through a systematic ethical analysis

morality

the adherence to informal personal values

ethics

the formal systematic approach used to understand, analyze , and evaluate matter of right and wrong as they relate to well-being.

assessment

the systematic collection of data

moral integrity

virtue composed of honesty, truthfulness, benevolence, wisdom, and moral courage

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic?

-10% dextrose in water -5% dextrose in 0.9% saline -5% dextrose in 0.45% saline -5% dextrose in lactated Ringer's solution

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)?

-Dehydration -Physiological stress -Decreased blood volume

The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care?

-Ensure adequate fluid intake. -Implement safety measures to prevent falls. -Instruct the client about foods that contain potassium. -Encourage the client to obtain assistance to ambulate.

The clinic nurse is caring for a client who has been prescribed fentanyl, a potent opioid, for chronic pain. In what forms is it available for chronic pain administration in the at-home setting?

-Intranasal spray -Oral transmucosal lozenge -72-hour transdermal patch -Effervescent buccal oralets

The nurse is caring for a client with a back injury sustained 1 year ago. To obtain the most complete assessment data about the client's chronic pain pattern, what should the nurse ask the client?

Can you describe your daily activities in relation to your pain

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?

Changes in mental status

The nurse is discussing pain management with a student who is caring for a 1-day postoperative abdominal surgery client who is a known opioid substance abuser. What comment by the student indicates a need for further education?

Opioid substance abusers are less tolerant to opioids and require decreased doses. Rationale: They developed a tolerance to opioids and require higher

The nurse is assessing the status of pain in an alert elderly client who was recently admitted to the hospital with a diagnosis of ruptured lumbar disc. What are some of the beliefs and concerns older adults have about pain?

Pain is something that must be lived with. Nurses are too busy to listen to reports of pain. Pain signifies a serious illness or impending death. Reporting pain will result in being labeled as a "bad" client.

A client with a fractured femur who has had an open reduction-internal fixation is receiving ketorolac. Which assessment measurement will assist the nurse in determining the effectiveness of this medication?

Pain rating. Ketorolac is a nonopioid analgesic and nonsteroidal antiinflammatory agent.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume?

Peas Nuts Cauliflower. They are Low Sodium

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value?

Prolonged QT interval Prolonged ST segment

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?

Prolonged bed rest. End-stage renal disease

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by taking which action?

Pulling up and releasing the skin on the sternal area

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client?

R = Where is the pain located? Q = What does the pain feel like? U = How does the pain affect you? P = What makes your pain better or worse?

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods?

Raisins Potatoes Cantaloupe Strawberries

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?

Requires nasogastric suction

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client?

Respiratory depression

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?

Resume full activity level.

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation?

Sodium chloride. Because it's low.

The nurse works in a long-term care facility, caring for older clients. The nurse should make which interpretation when an older client complains of pain?

Something is wrong, and an assessment should be made.

A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soapsuds enemas until clear to a client. The UAP reports that three enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the UAP to do?

Stop administering the enemas until the health care provider (HCP) is notified.

The nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The client complains of discomfort at the intravenous (IV) site, and the nurse notes that the site is cool, pale, and swollen and that the solution is infusing slowly. What action should the nurse take first?

Stop the IV infusion. because it has infiltrated

nursing process

Systematic problem-solving method by which nurses individualize care for each client. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action should the nurse take?

Take no action. the normal range for potassium for a client with chronic kidney disease receiving hemodialysis is 4 to 6.5 mEq/L

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value?

Tall peaked T waves. Widened QRS complexes

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Twitching

identify the priorities that will determine the nurses plan of pt centered care -gather data from pt chart -validate info presented and confirm accuracy -analyze the info to determine significance -utilize logical thinking, past experiences, intuitive thinking - maintain a flexible attitude - utilize inductive and deductive reasoning to id available options - formulate decisions that reflect creativity and independent decision making -demonstrate personal humility in terms of ones knowldedge deficits and willingly seek additional info to assist with decision making -exhibit the courage to seek new, innovative approaches to pt-centered care. Look at things objectively (bracketing)

components of critical thinking

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next?

Check skin turgor over the client's sternum.

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid?

Client with an ischemic stroke.

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?

Client with diabetes insipidus

To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what should the nurse do first?

Ensure that the client is experiencing adequate pain control.

Ethics vs morals

Ethics is the formal, systematic study of moral beliefs to understand, analyze, and evaluate matters of right and wrong: whereas, morality includes specific values, characters, or actions whose outcomes are often examined through systematic ethical analysis.

The health care provider (HCP) writes a prescription for acetylsalicylic acid, or aspirin, for a client who was admitted to the hospital with joint pain from rheumatoid arthritis. The nurse contacts the HCP to verify the prescription if which finding is noted in the assessment data?

Gastric ulceration

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?

Heparin

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

Hyperactive bowel sounds

The nurse is administering a dose of triamterene to an assigned client. What is the most significant adverse effect of this medication for which the client should be monitored?

Hyperkalemia

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?

Hypotension

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

I will be sure to cue in to any indicators that the client may be exaggerating their pain. Pain is a highly individual experience. should not assume that the client is exaggerating his pain

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels?

-Blood transfusions -Bleeding or hemorrhage -Ingestion of potassium in medications -Failure to restrict dietary potassium

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube?

0.9% sodium chloride

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

Integumentary output

The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the health care provider at standard doses and frequencies would the nurse question?

Meperidine hydrochloride by intramuscular route. it should be used only short term and is not recommended for use in older clients.

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?

Muscle weakness

The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate?

Naloxone (Protamine sulfate is the antidote for heparin)

The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank.

tea 4*30 = 120 orange juice 4*30 = 120 water at 1200 4*30 = 120 water at 1700 4*30 = 120 ice tea at lunch 4*30 = 120 ice tea at supper 4*30 = 120 IV med at 0800 & 1400 50+50 = 100 Total intake = 820 Urine output = 100 820-100 = 720 Fluid restrict at 750 So pt has fluid left to drink = 750 - 720 = 30 ml

The nursing instructor is discussing the topic of pain with a student nurse who is assessing the status of pain in a cognitively impaired older adult. What comment by the student implies that further education is needed?

Clients in this age group are less sensitive to pain and have a greater pain tolerance. Rationale: They are not less sensitive to pain and do not necessarily have a greater pain tolerance.

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first?

Contact the health care provider (HCP).

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?

Dehydration

A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy?

Dislodgment of the epidural catheter because the catheter is not sutured in place

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include?

Ensure adequate oxygenation. Provide assistance to prevent falls. Monitor medication administration of diuretics. Prevent complications during potassium administration.

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate?

Pour the aspirate into the NG tube through a syringe with the plunger removed.

The nurse is instructing a client about receiving patient-controlled analgesia to control postoperative pain. What comment by the client indicates that further instruction is needed?

That's great that overdosing can't happen.

A client is being started on tramadol therapy for pain management after a back injury. When educating this client on tramadol therapy, what is the priority?

The client cannot drink alcohol while taking tramadol.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

The client who has sustained a traumatic burn

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

The client who is taking diuretics

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

The client with kidney disease and a 12-year history of diabetes mellitus

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

The client's pain rating

The nurse is setting up a transcutaneous electrical nerve stimulation unit on a client with chronic pain. As the nurse turns up the level of stimulation, the client complains of discomfort. Based on this finding, the nurse should make which interpretation?

The maximal stimulation has been reached, and it should be decreased slightly.