PREP U- CLINICAL DECISON MAKING/JUDGEMENT

A client asks the nurse why epoetin alfa is administered during dialysis sessions. Which response by the nurse is accurate?

Epoetin alfa stimulates red blood cell production essential for clients with chronic renal failure. It is not used to eliminate the rise of creatinine, to assist activity levels, or to increase renal output.

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia?

For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection. Reference:

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?

Increase the force of myocardial contraction Explanation: The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.

The nurse is completing the admission assessment on a client with renal failure. The client states, "I was diagnosed with impetigo yesterday." Which is the appropriate nursing intervention?

Initiate contact isolation protocol. Explanation: Impetigo is a bacterial infection transmitted via contact. Therefore, the nurse should initiate contact isolation protocol. The client would not be taking an antiviral medication for impetigo, would not need a negative-pressure room, and would not wear a mask when outside the room.

The clinical finding of pink, frothy sputum may be an indication of which condition?

Pulmonary edema Explanation: Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia?

Sevoflurane is an inhalation anesthetic always combined with oxygen to decrease the risk of coughing and laryngospasm. It would not be combined with alfentanil, rocuronium, or lidocaine. Alfentanil and rocuronium are intravenous anesthetics. Lidocaine is a local anesthetic.

A 32-year-old construction worker is admitted to the emergency department after suffering a heat stroke. Which of the following IV solutions would the nurse expect the physician would order?

A solution of normal saline Explanation: An isotonic solution is helpful for hypotension caused by hypovolemia in dehydration. Examples of an isotonic solution include normal saline (0.9% NaCl) and lactated Ringer's.

While monitoring the patient's eosinophil level, the nurse suspects a definite allergic disorder when seeing an eosinophil value of what percentage of the total leukocyte count?

15% to 40% Explanation: Eosinophils, which are granular leukocytes, normally make up 0% to 3% of the total number of WBCs (Fischbach & Dunning, 2009). A level between 5% and 15% is nonspecific but does suggest allergic reaction. Higher percentages of eosinophils are considered to represent moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and may be found in patients with allergic disorders.

After receiving change-of-shift report about the following four clients, which client should the nurse assess first?

70-year-old returning from PACU following partial thyroidectomy who is extremely agitated, has an irregular pulse rate of 134, and an elevated temperature of 103.2°F (39.6°C) Explanation: Manipulation of a hyperactive thyroid gland during thyroidectomy can cause thyroid storm. It is manifested by very high fever, extreme cardiovascular effects (tachycardia, HF, angina), and severe CNS effects (agitation, restlessness, and delirium). The 22-year-old has normal sodium levels. The 31-year old has a high blood glucose level but not at a critical level. The medication schedule for the 53-year-old is lower priority. It is always preferred to give medications in timely manner; however, thyroid storms are the priority for this group of clients.

The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?

Administration of sodium polystyrene sulfonate [Kayexalate]) Explanation: The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.

When providing care to a newborn with necrotizing enterocolitis (NEC), the nurse would need to report which finding immediately?

An abdomen that appears red and shiny in a newborn with NEC indicates peritonitis and must be reported immediately. A decrease in abdominal girth, stools negative for blood, and active bowel sounds suggest that the condition is resolving.

A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?

An antiviral agent such as acyclovir Explanation: Herpes labialis is an infection that is caused by herpes simplex virus type 1 (HSV-1). It is characterized by an eruption of small, painful blisters on the skin of the lips, mouth, gums, tongue, or the skin around the mouth. The blisters are commonly referred to as cold sores or fever blisters. Medications used in the management of herpes labialis include acyclovir (Zovirax) and valacyclovir (Valtrex), which help to minimize the symptoms and the duration or length of flare-up.

What are important nursing priorities on the first postoperative day for a client who has had an open reduction and internal fixation (ORIF) after a right hip fracture?

Assessing the neurovascular status, including circulation and innervation, is very important postoperatively. Control of pain is also a priority. Maintaining the integrity of the skin through frequent turns and ambulation will prevent pressure ulcers. Correct postoperative positioning involves maintaining the leg in a neutral position and preventing adduction. Bed rest can result in immobility consequences. Assessing skin integrity and nutritional status is positive, but maintaining bed rest is incorrect. Reorienting frequently will not prevent disorientation, and the nurse would not restrict pain measures.

A nurse is assessing a patient's nails and observes Beau's lines. Which of the following depicts this condition?

Beau's lines, (option C) are transverse depressions in the nail that may reflect retarded growth of the nail matrix because of severe illness or more commonly local trauma. Option A depicts the normal nail; option B is a spoon nail, which may indicate severe iron-deficiency anemia; option D is late clubbing, which signals hypoxia.

The nurse is caring for a client who is 24 hours after gastric bypass surgery. The client has experienced four episodes of vomiting in the past 12 hours, each producing between 500 and 800 ml of bright yellow-green liquid emesis. What action should the nurse take?

Contact health are provider for a STAT abdominal x-ray prescription. Explanation: The client is producing bilious emesis (bright yellow-green liquid emesis that resembles bile), which is a warning sign of gastrointestinal obstruction. Obstruction is a rare but serious complication of gastric bypass procedures. The nurse should request the prescription for an x-ray to investigate this possibility. The nurse should also keep the client NPO (not on clear fluids) and may increase fluids, but this is dependent on the client's hydration status and current blood pressure and urine output: information that is not provided. While antiemetic medication may be requested, the diagnosis of the bowel obstruction is most important. If an obstruction is present, the client's vomiting will not be well controlled with medication.

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?

Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell. Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell. Diastole is the period of ventricular relaxation resulting in ventricular filling.

An older adult client is being evaluated for suspected pyelonephritis and is ordered kidney, ureter, and bladder (KUB) x-ray. The nurse understands the significance of this order is related to which rationale?

Detects calculi, cysts, or tumors Explanation: Urinary obstruction is the most common cause of pyelonephritis in the older adult. A KUB may reveal obstructions such as calculi, cysts, or tumors. KUB is not indicated for detection of impaired renal function or reveal increased risk for chronic form of the disorder. Urine cultures will reveal causative microorganisms present in the urine.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus. Explanation: The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.

A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage?

Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity.

A client with hereditary angioneurotic edema (HAE) is experiencing an attack. Which priority intervention should the nurse be prepared to administer?

Maintaining a patent airway Explanation: Laryngeal edema is a life-threatening manifestation that can lead to complete airway obstruction and death without intervention. Although vomiting may occur due to the swelling of the structures of the gastrointestinal mucosa, the priority intervention would be maintaining a patent airway.

The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation?

Mean arterial pressure of 70 mm Hg Explanation: The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?

Necrotic tissue prevents wound healing and must be removed. This is accomplished by debridement. Incision and drainage, culture, or irrigation won't remove necrotic tissue. Incision and drainage drain a wound abscess. A wound culture identifies organisms growing in the wound and helps the physician determine appropriate therapy. If the wound is infected, the physician may order irrigation - usually with an antibiotic solution - to treat the infection and clean the wound.

A nurse is caring for a client who is vomiting. The physician has ordered oral dimenhydrinate. What is the most appropriate action by the nurse to help the client?

Notify the physician of the vomiting, and obtain a new medication order. Explanation: Because of the vomiting, the oral medication will be ineffective. The nurse should contact the physician, notify the physician of the vomiting, and obtain a new order for the medication (or an alternate medication) to be given by a different route. Changing the route of the medication without a physician's order is outside the scope of nursing practice. This is also considered prescribing a medication and violates the professional standards for medication administration.

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.

A nurse identifies a nursing diagnosis of spiritual distress for a patient based on assessment of which of the following? Select all that apply.

Spiritually distressed patients may show despair, discouragement, ambivalence, detachment, anger, resentment, or fear. They may question the meaning of suffering or life and express a sense of emptiness.

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?

Tactile agnosia is the inability to identify a familiar object by touch. Visual agnosia is the loss of ability to recognize objects through sight. The Romberg test has to do with balance. Ataxia is defined as incoordination of voluntary muscle action.

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects:

The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma. Squamous cell carcinoma commonly develops on the skin of the face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas. Early lesions appear as opaque, firm nodules with indistinct borders, scaling, and ulceration. Actinic keratosis is a premalignant skin lesion. Basal cell carcinoma presents as lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated.

The nurse is preparing to administer an I.V. medication through a tunneled venous access device. Prior to administering an I.V. medication, the nurse meets resistance when attempting to flush the line with saline. What is the best action by the nurse?

The best action by the nurse is to assess for external kinks and/or other exterior blockages of the line such as clamping of the line. Alteplase may be appropriate if the line is clotted but requires a physician's order and the nurse should first assess for external blockage. Heparin is utilized to maintain patency of the line after flushing or medication administration. Obtaining a larger syringe may increase the pressure of the flush and rupture the central line.

The nurse is assisting a client who had a myocardial infarction 2 days ago during a bath. The client suddenly lost consciousness and the nurse was unable to feel a pulse. Cardiopulmonary resuscitation was begun and the client was connected to the monitor with a gross disorganization without identifiable waveforms or intervals observed. What is a priority intervention at this time?

The classic electrocardiographic pattern of ventricular fibrillation is that of gross distortion without identifiable waveforms or intervals. When the ventricles do not contract, there is no cardiac output, and there are no palpable or audible pulses. Immediate defibrillation using a nonsynchronized, direct-current electrical shock is mandatory for ventricular fibrillation and for ventricular flutter that has caused loss of consciousness.

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:

The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.

The nurse asks the client to hold her left wrist in complete flexion for approximately 1 minute. The client states she feels tingling and numbness when she does this, pointing to the medial nerve. What does the nurse anticipate the client will be prepared for after this assessment?

The client will be prepared for further diagnostic tests such as an electromyogram (EMG). Explanation: The Phalen maneuver is performed by having the person hold the wrist in complete flexion for approximately a minute. If numbness and paresthesia along the median nerve are reproduced or exaggerated, the test result is considered to be positive. EMG and nerve conduction studies often are done to confirm the diagnosis and exclude other causes of the disorder. Treatment includes avoidance of movements that cause nerve compression; splinting; and anti-inflammatory medications. Measures to decrease the causative repetitive movements should be initiated. Splints may be confined to nighttime use. When splinting is ineffective, corticosteroids may be injected into the carpal tunnel.

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?

The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.

When determining the volume of replacement fluid that is to be administered during continuous renal replacement therapy (CRRT), what should the nurse subtract from the total fluid loss? Select all that apply.

The nurse determines the total fluid loss by adding together fluid in the collection device from the previous hours and any blood loss, emesis, or nasogastric drainage in the past hour. This is the total fluid loss. From this the nurse should subtract the client's prescribed net fluid loss and fluid intake in the past hour. This gives the volume of replacement fluid to infuse.

When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first?

The nurse should check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge any clots that are present. Elevating the I.V. fluid bag may help if the nurse finds no kinks and if repositioning doesn't resolve the problem.

A client in an acute care mental health program refuses a morning dose of an oral antipsychotic medication and believes it contains poison. The nurse should respond by taking which action?

To determine a care plan for clients who are noncompliant with medications, the nurse should consult with the physician. Unless there is a danger to self or others, the client can't be forced to take medications. Crushing the medication and putting it in food might make the client suspicious. The nurse shouldn't omit the dose and try again the next day. The nurse should instead make another attempt to administer the drug to avoid decreased drug levels.

A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?

Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an overdistended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that the client has no active gag reflex. What is the next action by the nurse?

Withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse would withhold food and fluid until the client's gag reflex returns. The client would be placed in an upright position. There is no indication that oral airway placement would be appropriate or that an NG tube is needed.

The nurse is caring for four clients who have come to the clinic for eye exams. The nurse would know that which client is visually impaired?

lient B - eyes test at 20/100 and 20/200 Explanation: The term visually impaired is used to describe a BCVA between 20/70 and 20/200 in the better eye with the use of glasses. Options A, C, and D do not meet the criteria for visual impairment.