Reduction of Risk Potential

Stage 3 dysphagia diet

Advanced: soft bread or baked goods pasta and casseroles soft or ripe fruits fish and baked potatoes

A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should implement which action to prepare the client for this test? 1. Shave the groin for insertion of a femoral catheter. 2. Remove all metal-containing objects from the client. 3. Keep the client NPO (nothing by mouth) for 6 hours before the test. 4. Instruct the client in inhalation techniques for the administration of the radioisotope.

2. Remove all metal-containing objects from the client. Focus on the subject, preparing a client for an MRI. In an MRI study, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a history should be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, or shrapnel. A femoral catheter is not used for this diagnostic test. An intravenous (IV) catheter may be inserted if a contrast agent is prescribed. Also, shaving is not a common practice because of the risk for microabrasions and infection. If needed, hair may be clipped away from a surgical or insertion site. NPO status is not necessary for an MRI study of the head. Inhalation of the radioisotope may be prescribed with other types of scans but is not a part of the procedures for an MRI.

14. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for IMMEDIATE action by the nurse? Breath sounds can be heard bilaterally Mist is visible in the T-Piece Pulse oximetery of 88 Client is unable to speak

Answer C. Pulse oximetry should not be lower than 90.

The nurse is developing a plan of care for a client who has epilepsy and is undergoing an electroencephalogram. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Provide padding to the side rails B. Verify suction is at bedside and working properly. C. Keep bite block at bedside in case of seizure. D. Ensure nasal cannula is available and working at the bedside. E. Establish peripheral vascular access

A, B, and E are correct. Ensuring the side rails are raised and padded will provide a safe environment for the client in case of a seizure. It is imperative to have suction ready at the bedside should the client vomit during a seizure. Timely clearing of the airway will prevent aspiration, maintain a patent airway, and keep your patient safe. Suctioning the client should only occur once the seizure has terminated as it is contraindicated to put objects in the client's mouth. Ensuring that peripheral vascular access is essential because if the client has a seizure, parenteral benzodiazepines (diazepam/lorazepam) are necessary.

Lumbar puncture was performed on a client for a myelogram. After the procedure, he complains of severe headache. The most appropriate nursing intervention is: A. Increase the client's oral fluid intake B. Administer the prescribed antihypertensives to this client C. Give the patient roll lenses D. Place a cool pack over the lumbar puncture site

A. Increase the client's oral fluid intake Choice A is correct. A headache following a lumbar puncture is usually caused by leakage of cerebrospinal fluid (CSF). Increasing fluid intake would facilitate the restoration of CSF volume. Choices B, C, and D are incorrect. Administering antihypertensives will not address the problem. Roll lenses reduce light irritation to the eyes and cold packs will help reduce pain on the site, but neither action solves the problem of reduced CSF.

6. A four year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do FIRST? Notify the physician Readjust the traction Administer the ordered prn medication Reassess the foot in fifteen minutes

Answer A. The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately.

20. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? Increased blood pressure Increased heart rate Loss of pulse in the extremity Decreased urine output

Answer C. Loss of the pulse in the extremity would indicate impaired circulation.

19. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? "I can't lie in one position for more than thirty minutes." "I am allergic to shrimp." "I suffer from claustrophobia." "I developed a severe headache after a spinal tap."

Answer B. A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures

9. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform? Disconnect the client from the ventilator and use a manual resuscitation bag Perform a quick assessment of the client's condition Call the respiratory therapist for help Press the alarm re-set button on the ventilator

Answer B. A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.

15. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care? Esophagitis Leukopenia Fatigue Skin irritation

Answer B. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.

17. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a PRIORITY? Blanch nail beds for color and refill Assess for post operative arrhythmias Auscultate for pulmonary congestion Monitor equality of peripheral pulses

Answer B. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

4. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? Blanch nail beds for color and refill Assess for post operative arrhythmias Auscultate for pulmonary congestion Monitor equality of peripheral pulses

Answer B. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

1. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote: Relaxation and sleep Deep breathing and coughing Incisional healing Range of motion exercises

Answer B. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.

12. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote: Relaxation and sleep Coughing and deep breathing Incisional healing Range of motion exercises

Answer B. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.

16. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client? "The tube will drain fluid from your chest." "The tube will remove excess air from your chest." "The tube controls the amount of air that enters your chest." "The tube will seal the hole in your lung."

Answer B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space

5. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? "The tube will drain fluid from your chest." "The tube will remove excess air from your chest." "The tube controls the amount of air that enters your chest." "The tube will seal the hole in your lung."

Answer B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

7. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 L/min, his color is flushed and his respirations are 8/min. What should the nurse do FIRST? Obtain a 12-lead EKG Place client in high Fowler's position Lower the oxygen rate Take baseline vital signs

Answer C. A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client's death.

13. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management. Pallor Increased temperature Dyspnea Involuntary muscle spasms

Answer C. Client's having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.

8. The nurse is assessing a client two hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's FIRST action should be to: Wrap the leg with elastic bandages Apply pressure at the bleeding site Reinforce the dressing and elevate the leg Remove the dressings and re-dress the incision

Answer C. Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation.

10. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY? Blood urea nitrogen 50 mg/dl Hemoglobin of 10.3 mg/dl Venous blood pH 7.30 Serum potassium 6 mEq/L

Answer D. Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.

3. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? Blood urea nitrogen 50 mg/dl Hemoglobin of 10.3 mg/dl Venous blood pH 7.30 Serum potassium 6 mEq/L

Answer D. Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.

2. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? Clamp the chest tube Call the surgeon immediately Prepare for blood transfusion Continue to monitor the rate of drainage

Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest

11. A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action? Clamp the chest tube Call the surgeon immediately Prepare for blood transfusion Continue to monitor the rate of drainage

Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.

The nurse is caring for a patient in the emergency department who has just received a head injury following a car accident. After a hyphema has been noted, which position should the nurse encourage this patient to be in? A. Supine B. Semi-Fowler's C. Lateral on the affected side D. Lateral on the unaffected side

B. Semi-Fowler's Semi Fowler's position is the most appropriate position after a hyphema, or blood in the anterior chamber has been diagnosed. This position works with gravity to keep blood accumulation away from the optical center of the cornea.

The nurse is caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up? A. Active range of motion in both arms B. Scant drainage on the dressing C. Difficulty swallowing liquids D. Soreness at the operative site

C. Difficulty swallowing liquids Choice C is correct. Difficulty swallowing liquids indicates nerve damage that requires immediate follow-up. Following cervical spinal surgery, the client is likely placed in a cervical collar for a prescribed period. Manifestations that need to be reported following cervical spinal surgery include numbness and tingling in the upper extremities, difficulty swallowing, decreased motor strength, and respiratory depression.

The nurse is assessing a client with a chest tube for a pneumothorax. The nurse assesses a crackling sensation beneath the fingertips around the chest tube insertion site. The nurse should take which action? A. Document the finding as normal B. Clamp the chest tube C. Notify the primary healthcare provider (PHCP) D. Apply nasal cannula oxygen

C. Notify the primary healthcare provider (PHCP) This assessment indicates crepitus which is air trapped in and under the skin, known as subcutaneous emphysema. The PHCP needs to be notified because this is a complication, and measures such as increasing the suction on the chest tube need to be considered

The nurse in charge of a patient with iron deficiency anemia is documenting care. Which nursing diagnosis is the most appropriate in the plan of care? A. Impaired gas exchange B. Ineffective airway clearance C. Deficient fluid volume D. Ineffective breathing pattern

Choice A is correct. The hemoglobin in blood is the component responsible for oxygen transport in the body. Iron is an essential substance for hemoglobin synthesis. In iron deficiency anemia, the hemoglobin drops to subnormal levels, leading to impaired tissue oxygenation and reducing gas exchange

The nurse is assisting with monitoring a client that has a chest tube and documents the appropriate assessments. Which of these assessments are expected findings? Select all that apply. A. Drainage system at a level below the patient's chest. B. Vigorous bubbling in the water-seal chamber. C. Stable water in the tube of the water-seal chamber during inhalation and exhalation. D. Occlusive dressing over the chest tube.

Choices A and D are correct. It is expected that the drainage system will be at a level below the client's chest. This is what allows gravity to help drain fluid from the pleural space. If the drainage system was above the client's chest, the chest tube would not work properly (Choice A). An occlusive dressing placed over the chest tube is appropriate. This is important to ensure that air does not enter the pleural space causing a pneumothorax. The nurse should check the dressing to ensure that it is airtight (Choice D).

The nurse provides oral care to clients in the ICU. What are the benefits of providing oral care to a client in critical care? Select all that apply. A. It promotes the patient's sense of well-being. B. It prevents deterioration of the oral cavity. C. It decreases the incidence of aspiration pneumonia. D. It eliminates the need for regular flossing. E. It decreases oropharyngeal secretions. F. It compensates for an inadequate diet.

Choices A, B, and C are correct. Adequate oral hygiene is essential for promoting a client's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of both aspiration pneumonia and ventilator associate pneumonia (VAP).

Which of the following are potential complications of cleft lip and cleft palate in the infant? Select all that apply. A. Ear infections B. Feeding difficulties C. Weight gain D. Speech delay

Choices A, B, and D are correct. Choice A is correct. When a child has a cleft lip and cleft palate, the tissue and bone inside their mouth are not appropriately fused, which means there is a space between their upper lip and their palate. Ear infections will be a frequent complication for these patients due to the dysfunction of the eustachian tube, which connects the middle ear and the throat. Choice B is correct. Feeding issues are a common complication of cleft lip and cleft palate because it is harder for these infants to eat with the abnormality in their palate. The space in the roof of the mouth makes it very hard to suck and make a good seal around the bottle or nipple. Choice D is correct. Speech delays and language delays are both common complications of cleft lip and cleft palate. The roof of the mouth and lip have spaces, which decrease muscle function and lead to delayed or abnormal speech. Eventually, many of these patients will require consultation with a speech-language pathologist.

Which of the following clients, receiving normal saline via IV infusion, is at the highest risk for bloodstream infections? A. A client who has a midline IV catheter in the left antecubital fossa. B. A client with a peripherally inserted central catheter (PICC) line in the right upper arm. C. A client with an implanted port in the right subclavian vein. D. A client who has a non-tunneled central line in the left internal jugular vein.

D. A client who has a non-tunneled central line in the left internal jugular vein. Several factors increase the risk of infection for this client. Central lines are associated with a higher risk of infection because the neck and chest skin harbor a high number of microorganisms. Additionally, because the line is non-tunneled, the risk for infection is higher. Non-tunneled catheters are mostly used for short-term access in indications requiring rapid resuscitation or pressure monitoring. Such non-tunneled catheters are good for about 5 to 7 days. They carry a higher risk of infection and are inappropriate for patients who require central venous access for longer than 2 weeks.

The nurse walks into the room and finds her client complaining of severe shortness of breath and chest pain. She suspects a pulmonary embolism. After notifying the rapid response team, the nurse's priority action is which of the following? A. Obtain vital signs and place the client in left-sided, Trendelenburg position. B. Administer heparin. C. Check lung sounds. D. Elevate the head of the bed.

D. Elevate the head of the bed. The first action following the notification of the rapid response team when a pulmonary embolism is suspected is "elevating the head of the bed" to about 30 degrees. This is a quick action that does not require a doctor's order. A pulmonary embolism causes ventilation and perfusion mismatch. In a position with the head of the bed elevated, gravity pulls the diaphragm downward, allowing for lung expansion and improved ventilation.

Which of the following is helpful in reducing a patient's post-surgical pain and anxiety? A. Preoperative anxiety medications B. Psychological counseling C. Prepare a preoperative checklist D. Preoperative teaching

D. Preoperative teaching Choice D is correct. Patient teaching before surgery not only helps to reduce a patient's anxiety and postsurgical pain, but it also decreases the amount of anesthesia needed, and a lack of concern additionally speeds up wound healing. Choice A is incorrect. Preoperative medication can decrease the amount of anesthetic needed and respiratory tract secretions, but it does not help with postoperative pain. Choice B is incorrect. Psychological counseling is typically unnecessary except under highly unusual circumstances. Choice C is incorrect. Preoperative checklists are a form of nursing documentation that is used to guide and document the care of the patient before surgery.

The nurse is caring for a client at the first prenatal visit. The primary healthcare provider (PHCP) has prescribed testing for syphilis. The nurse anticipates which laboratory testing? A. Brain Natriuretic Peptide (BNP) B. Comprehensive Metabolic Panel (CMP) C. Complete Blood Count (CBC) D. Rapid Plasma Reagin (RPR)

D. Rapid Plasma Reagin (RPR) Choice D is correct. An RPR is a common screening test for syphilis infections. This test is often confirmed with a fluorescent treponemal antibody absorption (FTA-ABS) test. Choices A, B, and C are incorrect. A BNP test is utilized to assist in the diagnosis of heart failure. A CMP may detect problems with the liver or any other electrolyte abnormalities. A CBC may reveal disorders associated with blood dyscrasias.

The nurse is on her way to the hospital for her shift when she encounters a roadside traffic accident. The nurse assists in responding to the victim and notes that the victim suffered a traumatic amputation of her fingers. Which intervention should the nurse implement when dealing with traumatic amputations? A. Apply direct pressure to the site using wet gauze. B. Remove the pressure dressing when emergency personnel arrive. C. Place the amputated fingers in a container with ice. D. Wrap the fingers in a clean cloth, put it in a plastic bag, and then place the bag in ice water.

D. Wrap the fingers in a clean cloth, put it in a plastic bag, and then place the bag in ice water. Placing fingers directly on ice can cause ice burns.

18. The MOST effective nursing intervention to prevent atelectasis from developing in a post operative client is to: Maintain adequate hydration Assist client to turn, cough and deep breathe Ambulate client within 12 hours Splint incision

Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.

You are assigned to take care of a client who just underwent a cholecystectomy. Which of the following would decrease the risk of developing atelectasis in this client? Select all that apply . A. Deep inspiration. B. Supine position with the head end of the bed elevated. C. Change position every 2 hours. D. Encourage the patient to cough at least 10 times/hr.

Encouraging clients to take deep inspirations (Choice A) and use incentive spirometry. An incentive spirometer encourages the client to pursue deep breathing. Deep breathing aids in gas exchange and promotes the full expansion of the alveoli. Keeping the client in the supine position with the head end of the bed elevated (Choice B) or semi-recumbent area (head of the bed raised 30 to 45 degrees). This allows for maximum thoracic expansion by lowering the abdominal pressure on the diaphragm. Encouraging the client to change position at least every 2 hours (Choice C). This increases mobility and allows full chest expansion and increases perfusion to both lungs. Encouraging the client to cough at least ten times per hour (Choice D) when awake. This helps promote alveolar expansion.

Stage 2 dysphagia diet

Mechanical soft : Mashed potatoes, meatloaf, canned or soft fruits, scrambled eggs

Compartment Syndrome S/S 5Ps

Pain Pallor Pulseless Parasthesia Pressure

Stage 1 dysphagia diet

Pureed

Cellulitis

an infection in the soft tissue. Although it is typically unilateral, it would not be as urgent as a blood clot.

Osteomyelitis

an infection of the bone, caused by an external pathogen that usually enters the blood or tissue via an open wound