physiological
A client with peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish with the client immediately after surgery? Maintain circulation. Prevent infection. Relieve pain. Provide education.
Maintain circulation. Explanation: Maintaining circulation in the affected extremity after surgery is the focus of care. The graft can become occluded, and the client must be assessed frequently to determine whether the graft is patent. Preventing infection and relieving pain are important but are secondary to maintaining graft patency. Education should have taken place in the preoperative phase and then continued during the recovery phase.
The nurse in an outpatient clinic is conducting a follow-up assessment on a child who had a severe streptococcal infection 1 week ago. The client is doing better, and the nurse is providing teaching to the parents about continuing to monitor the client for possible complications of the infection. Which information is most important for the nurse to discuss with the parents? "Return immediately if acute flank or mid-abdominal pain occurs." "Expect the child's weight to decrease over the next 2 weeks." "Fevers may continue to occur as the body recovers from the infection." "The infection may cause the child to have some burning with urination."
"Return immediately if acute flank or mid-abdominal pain occurs." Explanation: Acute glomerulonephritis is a major complication of streptococcal infections in children. The onset is often marked by a sudden occurrence of acute flank or mid-abdominal pain. The child may show signs of fluid retention, such as weight gain and edema. Hypertension also commonly occurs.
A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in his left chest. The client tells the nurse how excited he is because he's planning to go rifle hunting with his grandson. How should the nurse respond? "Enjoy your time with your grandson." "You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." "Being that close to a rifle might make your ICD fire." "You'll need to take an extra dose of your antiarrhythmic before you shoot."
"You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." Explanation: The recoil from the rifle can damage the ICD, so the client should be warned against shooting a rifle with his left hand. Close proximity to a rifle won't cause the ICD to fire inadvertently. The client shouldn't take an extra dose of his antiarrhythmic.
When bandaging a client's ankle, the nurse should use which technique? Figure-eight Circular Recurrent Spiral reverse
Figure-eight Explanation: The nurse uses a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee. The nurse uses the circular bandaging technique to anchor a bandage; the recurrent technique to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique to accommodate the increasing circumference of a body part such as when in a cast.
Which intervention is the most critical for a client with myxedema coma? Administering an oral dose of levothyroxine Warming the client with a warming blanket Measuring and recording accurate intake and output Maintaining a patent airway
Maintaining a patent airway Explanation: Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing intervention. Ventilatory support is usually needed. Although myxedema coma is associated with severe hypothermia, a warming blanket shouldn't be used because it may cause vasodilation and shock. Gradual warming with blankets is appropriate. Thyroid replacement is administered I.V., not orally. Although recording intake and output is important, these interventions aren't critical at this time.
A child is in the emergency department with suspected epiglottitis and has been ordered an X-ray to confirm the diagnosis. The nurse would prepare the child for X-ray by which methods? in radiology, transported by wheelchair, accompanied by a nurse in radiology, transported by stretcher, accompanied by a nurse in surgery, by portable X-ray in the emergency department, by portable X-ray
in the emergency department, by portable X-ray Explanation: The child is at risk for obstruction related to the swollen epiglottis. The nurse should not move the child, keep a careful watch, and get a portable X-ray in the emergency department.
A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? pulse rate of 112 bpm blood pressure of 94/64 mm Hg urine output of 30 mL/h serum sodium level of 136 mEq/L (136 mmol/L)
urine output of 30 mL/h Explanation: Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.
A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? Sweating, tremors, and tachycardia Dry skin, bradycardia, and somnolence Bradycardia, thirst, and anxiety Polyuria, polydipsia, and polyphagia
Sweating, tremors, and tachycardia Explanation: Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus.
Which nursing diagnosis takes highest priority for a client with hyperthyroidism? Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing Disturbed body image related to weight gain and edema Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
Imbalanced nutrition: Less than body requirements related to thyroid hormone excess Explanation: In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. These changes put the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements related to thyroid hormone excess the most important nursing diagnosis. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing and Disturbed body image related to weight gain and edema may be appropriate for a client with hypothyroidism, which slows the metabolic rate.
A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do? Count the rate to be sure that ventilations are deep enough to be sufficient. Notify the health care provider (HCP) of the client's breathing pattern. Increase the rate of ventilation. Increase the tidal volume on the ventilator.
Notify the health care provider (HCP) of the client's breathing pattern. Explanation: Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the HCP immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen, and the depth of breathing is assisted by the ventilator. The HCP will determine changes in the ventilator settings.
When assessing an infant with colic, the nurse should specifically determine if the infant has:
expulsion of flatus. Explanation: Infants with colic have paroxysmal abdominal pain or cramping caused by the production and accumulation of gas. This causes pain and abdominal distention. They may expel flatus or burp, but they do not vomit. Despite their pain, infants with colic typically tolerate formula well, gain weight, and thrive.
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. The appendix may develop gangrene and rupture, especially in a middle-aged client. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. Explanation: A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.
