Risk of Reduction Potential
A multigravid client at 38 weeks' gestation is scheduled to undergo a contraction stress test. What should the nurse include in the explanation as the purpose of this test?
assessment of fetal ability to tolerate labor The purpose of a contraction stress test is to determine fetal response during labor. If late decelerations are noted with the contractions, the test is considered positive or abnormal. Fetal lung maturity is evaluated through amniocentesis to obtain the lecithin-sphingomyelin ratio. The nonstress test is part of the biophysical profile. Determining fetal response during movements is evaluated as part of the nonstress test.
A client with no history of cardiovascular disease comes to the ambulatory clinic with flulike symptoms and a report of chest pain. What question should the nurse ask this client first?
"How would you describe the pain?" Chest pain is assessed by using the standard pain assessment parameters such as characteristics, location, duration, intensity, precipitating factors, and associated symptoms. Beginning with a broader question allows the client to describe the experience with the pain, which directs the nurse on how to clarify this description. Asking if it radiates or increases with taking a deep breath are very specific questions and should be posed only after the client offers interpretation of the pain. The nurse does not offer medication until the pain assessment has been conducted.
The nurse has just received morning change-of-shift report on four clients. In what order from first to last should the nurse perform the actions? All options must be used. Assess the client who has been vomiting according to the report from the night nurse. Notify the health care provider (HCP) about a client who has a serum potassium level of 6.2 mEq/L. Begin discharge paperwork for a client who is eager to go home. Discuss the plan for the day with the unlicensed assistive personnel (UAP), delegating duties as appropriate.
Notify the health care provider (HCP) about a client who has a serum potassium level of 6.2 mEq/L. Assess the client who has been vomiting according to the report from the night nurse. Discuss the plan for the day with the unlicensed assistive personnel (UAP), delegating duties as appropriate. Begin discharge paperwork for a client who is eager to go home. The nurse should first notify the HCP of the high serum potassium level. Normal serum potassium level is 3.5 to 5.0 mEq/L; a level of 6.2 mEq/L must be called to the HCP immediately because hyperkalemia may cause serious cardiac arrhythmias, potentially leading to death if left untreated. The nurse should next assess the client who has been vomiting and if necessary contact the HCP for a prescription for an antiemetic if none has been prescribed. After assessing all clients, the nurse should discuss the plan for the day, with the UAP delegating duties as appropriate. Though the client is eager to go home, the discharge paperwork must wait until all clients have been assessed and immediate needs met.
A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?
Prothrombin time (PT) PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reflects the number of circulating platelets in venous or arterial blood. PTT determines the effectiveness of heparin therapy and helps physicians evaluate bleeding tendencies. Physicians diagnose approximately 99% of bleeding disorders on the basis of PT and PTT values.
When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris?
The pain occurred while I was mowing the lawn." Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
A client had a Mantoux test result of an 8-mm induration. When should the nurse interpret the test as positive? When the client:
is immunocompromised. An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive, and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (e.g., prisons, long-term care facilities, hospitals, homeless shelters), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categories.
Which type of catheter is inserted so that the tip sits in the upper arm at or below the axillary line but is not useful to the nurse for blood draws due to inconsistent blood return?
midline catheter Midline catheters are inserted so that the tip sits in the upper arm at or below the axillary line. These catheters may not be useful to the nurse for blood draws due to inconsistent blood return. All of the other catheter types are inserted centrally to reduce the trauma of repeated venipuncture and can be used for venous blood sampling and laboratory analysis.
The nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed?
petrolatum gauze Gauze saturated with petrolatum is placed over the site to make an airtight seal to prevent air leakage during the healing process. Dry dressings or adhesive strips are not used.
A nurse is caring for a male neonate who has hypospadias. His parents are planning to have the neonate undergo circumcision before discharge. When teaching the parents about the child's condition, the nurse should tell them
the foreskin will be needed at the time of surgical correction. Circumcision is the surgical removal of the foreskin of the penis. In hypospadias, the urethral meatus is on the underside of the penis. A neonate with hypospadias shouldn't be circumcised because the surgeon may need to use the foreskin for surgical repair. The foreskin doesn't block the urethral meatus, which may be located near the glans, along the underside of the penis, or at the base. Circumcision doesn't correct hypospadias because the location of the urethral meatus isn't changed during circumcision.
The nurse is preparing a client for surgery. Although the client can speak English, English is the client's second language. The client has completed high-school level education. When the nurse asks the client what type of surgery is scheduled, the client is unable to provide an answer. What should the nurse do next?
Notify the health care provider that the client cannot explain the scheduled surgery. The nurse should ask the health care provider to explain the surgery to the client again and ensure the client understands the procedure and the risks. If necessary, the nurse can call an interpreter. It is the role of the health care provider to explain the surgical procedure, not the nurse. The nurse cannot continue to prepare the client until the health care provider has explained the surgery and the client agrees to proceed. The nurse should then document the client's response and nurse's action after notifying the health care provider of the need to reexplain the procedure to the client.
Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the health care provider (HCP) immediately?
a 3-cm increase in abdominal circumference Abdominal circumference is measured to monitor for abdominal distention. An increase of 3 cm in 8 hours would require notification of the HCP; it would indicate a substantial degree of abdominal distention, possibly from fluid or gas accumulation. Normally, after surgery, an infant experiences occasional periods of fussiness. However, as long as the infant is able to be quiet by himself or with the aid of a pacifier, the HCP does not need to be contacted. Absence of bowel sounds would be expected after surgery because of the effects of anesthesia. It takes approximately 48 hours for gastric motility to resume. New stomas are typically bright red or pink.
A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, what would the nurse most expect to find?
a history of pelvic inflammatory disease Pelvic inflammatory disease with accompanying salpingitis is commonly implicated in cases of tubal obstruction, the primary cause of ectopic pregnancy. Ectopic pregnancy isn't associated with grand multiparity or hormonal contraceptive use. Ectopic pregnancy is associated with use of an intrauterine device for 2 years or more.
The nurse teaches the parents of a neonate who has undergone corrective surgery for tracheoesophageal fistula about the need for long-term health care. The nurse bases the teaching on the child's high risk for which condition?
esophageal stricture After corrective surgery for repair of tracheoesophageal fistula (TEF), the risk for esophageal stricture is high because scar tissue forms at the site of the esophageal anastomosis, commonly requiring dilation at the anastomosis site during the first years of childhood in about half of such children. Speech problems are likely if other abnormalities are present to produce them. However, the larynx and structures of speech are not affected by TEF. Although dysphagia and strictures may decrease food intake and poor weight gain may result, gastric ulcers are not associated with TEF repair. Recurrent mild diarrhea with dehydration typically does not develop from surgery to correct TEF.
