ADN 140
Which potential side effect would the nurse include when teaching a patient about the administration of ferrous gluconate? Hypotension Constipation Clay-colored stool Abdominal swelling
Constipation Iron supplements, such as ferrous gluconate, reduce peristalsis and result in constipation. Ferrous gluconate does not reduce BP and does not result in hypotension. Ferrous gluconate can cause gastrointestinal bleeding and black, tarry stools. Ferrous gluconate does not cause fluid accumulation in the peritoneal cavity or abdominal swelling.
The nurse is teaching a patient about the administration of liquid iron supplements. Which response by the patient indicates the need for additional teaching? "I will take my iron supplement with a straw." "I will take my iron supplement at bedtime." "I will take my iron supplement along with meals." "I will take my iron supplement along with orange juice."
"I will take my iron supplement along with meals." Iron is mostly absorbed in the form of ferrous sulfate. Ferrous sulfate chelates with food, impairing iron absorption. Iron supplements should be taken one hour before meals to ensure effective absorption. Iron supplements may stain the teeth, so they may be taken with a straw. The patient can take iron supplements at bedtime if he or she experiences abdominal discomfort. Orange juice is rich in vitamin C, which enhances iron absorption.
Which client is at greatest risk for the development of a venous thrombosis? A 76-year-old female with a 100-pack-per-year smoking history and hypertension A 68-year-old male on bed rest following a left hip fracture A 59-year-old male who is an intravenous drug user with hyperlipidemia A 42-year-old female with Factor V Leiden mutation on warfarin
A 68-year old male on bed rest following a left hip fracture Venous thrombosis is the result of inflammation to a vein, hyper-coagulability, venous stasis, or a combination of the three, known as Virchow triad. Bed rest and hip fracture are two major risk factors for the development of a thrombosis. While the other options present risk factors (cigarette smoking, drug abuse, and clotting disorders), the combination of the two (venous stasis and vessel injury) results in greatest risk for thrombus development.
A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? An obese client with leg trauma A pregnant client with acute asthma A client with diabetes who has cholecystitis A client with pneumonia who is immunocompromised
An obese client with leg trauma An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for the development of pulmonary embolism.
Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. Arrange for a supply of heparin for the client to take to the rehab center. Explain to the client that anticoagulant therapy will no longer be needed. Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.
Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. Failure to clarify this omission can be life threatening because of the potential for an embolus. Waiting until the client is in the new facility to discuss the administration of an anticoagulant may jeopardize the client's status. Because anticoagulant therapy was not included in the transfer prescriptions, the nurse cannot legally supply the client with medications to take to the rehabilitation center. It is unclear what the anticoagulant needs are for this client; it is unsafe to tell the client that anticoagulants are no longer required. It is the nurse's, not the client's, responsibility to discuss this situation with the healthcare provider.
The nurse would place the highest priority on initiating interventions that will reduce which symptom in a patient with a gastrointestinal bleed, a hemoglobin of 8.7%, and a hematocrit of 26%? Nausea Dizziness Headache Constipation
Dizziness The patient with a low hemoglobin and hematocrit (normal values 13.5% to 17% and 40% to 54%, respectively, for males) is anemic and would be most likely to experience fatigue and dizziness. This symptom develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Nausea, constipation, and headache are not associated with decreased hemoglobin and hematocrit levels.
What should the nurse do to prevent thrombus formation after most surgeries? Keep the client's bed gatched to elevate the knees. Have the client dangle the legs off the side of the bed. Have the client use an incentive spirometer every hour. Encourage the client to ambulate with assistance every few hours.
Encourage the client to ambulate with assistance every few hours. Ambulation is essential to promote venous return and prevent thrombus formation. Keeping the client's bed gatched to elevate the knees or having the client dangle the legs off the side of the bed cause increased popliteal pressure and impair venous return. Having the client use an incentive spirometer every hour helps prevent atelectasis, not thrombi.
A nurse receives a shift report on four adult clients who are between the ages of 25 and 55. Which client should the nurse assess first? Male client with a hemoglobin of 15.9 (160 mmol/L) Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5 Female client taking daily calcium supplements with a serum calcium level of 9.4 (2.35 mmol/L) Male client with a blood urea nitrogen (BUN) of 20 (7.1 mmol/L) and a creatinine of 1 (96 mcmol/L)
Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5 The client on warfarin (Coumadin) with an INR of 7.5 should be assessed first by the nurse because this is an elevated result. Normal is considered between 2 and 3. This result is not therapeutic, and the nurse should assess for bleeding and hemodynamic stability. The nurse should report the result to the physician and implement bleeding precautions. The other results are within normal ranges: hemoglobin for a male is 14 to 18 g/dL (140 to 180 mmol/L); serum calcium is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L); BUN is 5 to 20 mg/dL (3.6 to 7.1 mmol/L); and creatinine is 0.7 to 1.5 mg/dL (53 to 106 mcmol/L).
After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? Tell the client to drink more fluids. Instruct the client to remain in bed. Gently rub the client's legs for circulation. Tell the client about the dangers of prolonged bed rest.
Instruct the client to remain in bed Localized sensory changes may indicate nerve damage, impaired circulation, or thrombophlebitis. Activity should be limited. Bed rest is indicated to prevent the possibility of further damage. Symptoms indicate a possible problem with thrombus formation. While fluids may be helpful to prevent hemoconcentration and the resulting risk of thrombus formation, fluids should be held in case a surgical procedure or diagnostic test is performed that requires the client to refrain from oral intake. Rubbing or massaging the legs is contraindicated because of possible dislodging of a thrombus if present.
A patient that has sickle cell disease has developed cellulitis above the left ankle. Which action is the nurse's priority for this patient? Maintain oxygenation. Administer antibiotics. Assess pain every 4 hours. Start IV fluids.
Maintain oxygenation. Maintaining oxygenation is a priority because sickling episodes frequently are triggered by low oxygen tension in the blood, which commonly is caused by an infection. Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity also will be used, but oxygenation is the priority.
Which hemoglobin level would the nurse identify as most likely to have an increased heart rate? Patient A: 80 g/dL Patient B: 50 g/dL Patient C: 100 g/dL Patient D: 110 g/dL
Patient B: 50 g/dL Hemoglobin content of less than 60 g/dL indicates severe anemia, which can result in tachycardia, or increased heart rate. Patient B is showing symptoms of tachycardia and increased pulse pressure. Patient A has a hemoglobin content between 60 and 100 g/dL, which indicates moderate anemia but is not associated with an increased heart rate. Patients C and D have a hemoglobin content between 100 and 120 g/dL, which indicates mild anemia.
While caring for a client who had an open reduction and internal fixation of the hip, the nurse encourages active leg and foot exercises of the unaffected leg every 2 hours. What does the nurse explain that these exercises will help to do? Prevent clot formation Reduce leg discomfort Maintain muscle strength Limit venous inflammation
Prevent clot formation Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. These isotonic exercises are being performed on the unaffected extremity; there should be no discomfort. Although isotonic exercises do promote muscle strength, that is not the purpose of these exercises at this time. Active ROM exercises help prevent, not limit, venous inflammation.
What should the nurse teach a client who is taking warfarin? Report episodes of spontaneous bleeding. Increase the dose with prolonged inactivity. Take antibiotics, if injured, to prevent infection. Eat a diet with an increased quantity of green vegetables.
Report episodes of spontaneous bleeding. Warfarin is an anticoagulant; therefore, excessive bleeding, especially that which occurs spontaneously and unrelated to injury, may require a dosage adjustment for safety reasons. Activity or inactivity is unrelated to the need to alter the dose of warfarin. The dose should not be altered without healthcare supervision. The problem of bleeding is more significant than infection when a client is taking warfarin. Green vegetables that contain vitamin K, which is necessary for the synthesis of clotting factors VII, IX, and X, should be kept consistent in the diet from week to week; increased consumption will decrease the action of warfarin, and a decreased consumption will increase the action of warfarin.
A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? Poached eggs Spinach salad Sweet potatoes Cheese sandwich
Spinach salad Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet.
Which instructions would the nurse include when teaching a patient about the administration of iron capsules? Select all that apply. Take laxatives if needed. Take the medication with orange juice. Take the medication about one hour after meals. The medication may cause the stools to become black. Stop therapy when hemoglobin level returns to normal.
Take laxatives if needed. Take the medication with orange juice. The medication may cause the stools to become black. Constipation is a common side effect, and the patient should be started on stool softeners or laxatives. The nurse should teach the patient to take iron capsules with orange juice or vitamin C to enhance iron absorption. The patient should be informed that use of iron preparations will make the stool appear black because the gastrointestinal (GI) tract excretes excess iron. Iron should be taken at least one hour before meals, when the duodenal mucosa is most acidic to enhance absorption; however, gastric side effects may necessitate ingesting iron with meals. To replenish the body's stores, the patient needs to take iron therapy for two to three months after the hemoglobin level returns to normal.
The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" How should the nurse explain the primary purpose of early ambulation? To promote healing of the incision To decrease the incidence of urinary tract infections To use energy to help the client sleep better at night To keep blood from pooling in the legs to prevent clots
To keep blood from pooling in the legs to prevent clots The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although activity during the day may promote sleeping at night, it is not the reason for ambulating after surgery.
