BoardVital cluster #7
For an infant with myelomeningocele, nursing care before surgery to close the defect would include:
Meticulous skin care, especially in the area of the sac -Meticulous skin care, especially in sac and genital areas, is critical. -The baby should not be placed on their exposed spinal cord. A baby with myelomeningocele should be left without a diaper in place to prevent contamination and a saline dressing should be placed over the sac.
What is considered a moderate reaction to iodinated contrast media?
Mild bronchospasm -Moderate contrast reactions are normally non-life threatening but treatment via medication may be required. Moderate contrast reactions are classified as mild bronchospasm, moderate to severe nausea, vasovagal response, tachycardia.
A nurse is teaching a class about cultural and religious influences on food choices to a group of newly licensed nurses. Which statement by a class attendee indicates an understanding of the teaching?
"Clients who practice Orthodox Judaism do not eat meat with dairy products."
A nurse is teaching a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic knee pain. Which of the following statements by the client indicates an understanding of the teaching?
"I'll need to shave the hair off the skin where I place the electrodes." -The nurse should instruct the client to remove any hair or skin preparations prior to affixing the electrodes to promote effective conduction of the cutaneous stimulation.
The nurse is caring for a new mother who is sensitive to certain foods. Knowing that certain foods can pass through the breast milk to the infant, the nurse advises the mother to avoid which foods that have a tendency to cause allergic reactions in infants?
*Eggs *Peanuts *Shellfish -Any food that can cause an allergic reaction in children can also potentially cause a reaction through breast milk. Eggs, peanuts and other nuts, chocolate, and shellfish are all foods that can cause an allergic reaction.
What med is given to a pt with bradycardia?
*Atropine -Dopamine is given for bradycardia if atropine is not successful.
In a client with respiratory problems, a corticosteroid may be prescribed to:
*Decrease edema in the airways -Corticosteroids are used frequently in respiratory illnesses to decrease airway inflammation.
The nurse is to instill ear drops in an adult. To do this properly, the nurse should pull the pinna of the ear:
Back and up -The canal should be pulled up and back. In a child under 3 years of age, the pinna should be pulled back and down
A nurse is giving discharge instructions to a diabetic client, who has to take insulin at home regularly, regarding the storage of insulin. Which of the following instructions is correct?
It should not be kept in direct sunlight -Insulin should not be kept in direct sunlight or a hot car.
A 67-year-old client just had cataract surgery with a right-sided lens implant. The nurse is providing discharge teaching to the client. Which statements from the client indicate an understanding of the proper post-op care after cataract surgery and lens implantation?
*"I will not bend over to tie my shoes." *"I will not lift heavy items." *"I will sleep on my left side." -After cataract surgery and lens implantation, clients should not assume positions or do any activities that would increase intraocular pressure. For example, bending over, heavy lifting, exercises, or actions that require straining the muscles can all increase intraocular pressure, leading to injury of the surgical site and damage to the lens implant. The client should also sleep on the opposite side of the implant to avoid pressure on the affected area.
The nurse is reviewing their client assignment at the start of their shift. Which of the following clients are at risk of developing fluid/circulatory overload?
*A client receiving renal dialysis *A premature infant *A client with heart failure *A 98-year-old client -Clients with renal, cardiac, respiratory, or liver disease and older adults and neonates are at greater risk of fluid or circulatory overload. These clients cannot tolerate excessive fluid volume. Clients on dialysis are no longer able to maintain the correct balance of fluid in their bodies. Neonates have a decreased capacity to concentrate or dilute urine in response to changes in intravascular fluid and are at a greater risk for dehydration or fluid overload.
A nurse is caring for four clients. The nurse should identify that which of the following clients is at risk for developing a dysrhythmia?
*A client who has metabolic alkalosis *A client who has COPD *A client who had a stent placement in a coronary artery -A client who has an acid-base imbalance, such as metabolic alkalosis, is at risk for dysrhythmias, such as atrial tachycardia, and premature ventricular contractions due to depressed respirations and hypokalemia. A client who has a lung disease, such as COPD, is at risk for a dysrhythmia, such as tachycardia, due to hypoxia. A client who has cardiac disease and underwent a stent placement is at risk for dysrhythmias, such as ventricular tachycardia, due to irritation of heart muscle.
The school nurse is teaching high school parents about the warning signs of depression and suicide in teenagers. Which of the following should be included in the teaching?
*Anger *Apathy *Withdrawal *Excessive alcohol use -Signs of depression and suicide go hand-in-hand. Warning signs for depression and suicide, especially in the teenage population, include anger or outbursts, withdrawal from friends and family, apathy or lack of interest, and excessive alcohol or drug use. Research also shows that nine out of ten individuals who attempt suicide have a history of mental illness or substance abuse, making these crucial risk factors.
The nurse is caring for a client scheduled to have surgery the following day, and a low residue diet has been ordered in preparation. Which of the following foods would be acceptable as part of a low residue diet?
*Baked fish *Ground beef -A low residue diet helps rest the digestive system and is often indicated before surgical procedures. A low residue diet allows the body to absorb nutrients efficiently and without much effort since these foods have very little fiber content. -Tender or ground meats and refined carbohydrates are permitted on a low residue diet. Foods with high fiber content, such as bran, nuts, and raw fruits and vegetables, should be avoided.
A client is complaining of constipation. The nurse should identify that the following medication could be responsible for constipation:
*Calcium supplements -Intake of calcium preparations will frequently cause constipation. Antibiotics can be associated with diarrhea.
Nursing ethics are based on principles of moral autonomy, beneficence, fidelity, justice, non-maleficence, and veracity. To which of the following do these principles apply?
*Caregiving relationships between nurse and client's family members *Patient's right to self-determination *Nursing responsibilities to dose management -Nursing ethics apply most directly to relationships, responsibilities, and actions of nursing providers with clients. -Incorrect Answer: Nursing ethics do not directly apply to the working relationship between a Doctor and a Nurse
A nurse is providing instructions to a student nurse about administering an intermittent enteral feeding. Which of the following statements indicates understanding of this teaching?
*Change administration set every six hours. *Label the unused portion of the formula. -Feeding equipment, such as the bag holding the formula, should be discarded every 6 hours to prevent bacterial contamination. Extension tubing should be changed every 24 hours. -The unused portion of the formula should be labeled with the time and date the formula was opened and the client's name and room number.
A nurse is providing medication information to a client who has bipolar disorder and a new prescription for lithium. The nurse should instruct the client to report which of the following manifestations of lithium toxicity to the provider?
*Diarrhea *Polyuria *Muscle weakness -Lithium has a narrow therapeutic range of 0.8 to 1.2 mEq/L. -As lithium levels rise, the manifestations become increasingly severe and systemic in nature. Respiratory, cardiovascular, and fluid balance alterations occur. Polyuria is seen at levels greater than 1.2 mEq/L and higher, with increasing amounts of dilute urine being excreted. -Early levels of toxicity can include fine tremors of the hand and muscle weakness. These manifestations can occur when levels are between 1.41 and 1.5 mE/L. As toxicity increases, the hand tremor becomes more pronounced, and incoordination, hyperirritability of muscles, and ataxia occur.
The nurse is reviewing the chart of a 54-year-old male client with renal dysfunction. Which of the following lab results indicate a decrease in renal function?
*Elevated blood urea nitrogen (BUN) level *Elevated serum creatinine level *Decreased hemoglobin level *Decreased red blood cell count -Blood urea nitrogen (BUN) levels and creatinine levels are the most common tests to determine renal function. Both of these will increase when renal function decreases. Hemoglobin and red blood cell counts will decrease if erythropoietin production by the kidneys is affected by renal disease. When the kidneys cannot make enough erythropoietin, this causes red blood cell production to drop, leading to anemia. The kidneys do not have a role in the metabolism of thrombocytes (platelets).
A 53-year-old client is admitted after being found unconscious outside a bar and brought in by his friends. His friends report that he has a habit of heavy drinking multiple times per week. Therefore, the nurse needs to monitor him closely for signs and symptoms of alcohol withdrawal, including which of the following?
*Hallucinations *Tachycardia *Perspiration *Tremors -Symptoms of alcohol withdrawal can start within hours after cessation of drinking. Symptoms include tremors, anorexia, nausea and vomiting, tachycardia, sweating, elevated blood pressure, headache, anxiety, seizures, and transient hallucinations. People with severe withdrawal symptoms remain in the hospital for part or all of the detoxification process to be closely monitored due to blood pressure, breathing, and heart rate changes.
The nurse is caring for a teenage client with a severe latex allergy. Which of the following interventions would the nurse expect to use in caring for this client?
*Keep a latex-free supply cart outside of the client's room *Use non-latex gloves *Make sure the client has a latex allergy band * Place a latex allergy sign on the client's door -A latex-free supply cart should be placed outside the client's room to make it easier to use latex-free supplies. A private room could be used if possible, but it is unnecessary and unrealistic always to get a private room for a latex allergy. Every effort should be made to limit any latex products near the client with the allergy if in a shared room.
The nurse is preparing instructions for a 17-year-old client who just had a plaster cast placed on their forearm. Which of the following instructions would the nurse expect will be included in the client's teaching?
*Keep the cast clean and dry *Keep the cast and extremity elevated when possible -A plaster cast takes 24 to 72 hours to dry. It should always be kept clean and dry and covered or sealed tightly when in the shower. Keeping the extremity and cast elevated when possible will help prevent edema in the extremity. Never stick anything underneath or inside the cast, damaging the skin under the cast. The client must monitor circulation issues such as pain, numbness, swelling, tingling, discoloration, or a diminished pulse and report them immediately.
A nurse working in an outpatient clinic is caring for a client who has rheumatoid arthritis (RA) and reports increased joint tenderness and swelling. Which of the following findings should the nurse expect?
*Recent viral infection *Decreased range of motion *Pain at rest -Exacerbating factors, such as a recent viral illness like influenza, are common in clients who have RA. A decrease in range of motion is common in clients who have RA. Pain at rest is indicative of RA.
A nurse is caring for a client who has chronic cancer pain and has been prescribed fentanyl/bupivacaine to be administered through a permanent epidural catheter. The nurse should monitor the client for which of the following manifestations?
*Respiratory depression *Hypotension *Sedation *Loss of bladder control -Respiratory depression is an adverse effect of epidural analgesics. Other adverse effects include seizures and dura puncture. Hypotension is an adverse effect of that can be corrected by the administration of fluids. Other adverse effects are hematoma and infection. Sedation anaphylaxis and severe headache. Decreases in bowel and bladder control are adverse effects of epidural analgesics.
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
*Rolling the body to the side *Removing environmental hazards to protect the client *Calling the respiratory therapy department -Safety and maintenance of the airway are priority concerns. Rolling the client's whole body to the side facilitates any drainage that may come from the mouth and keeps the airway open. Obiects or situations that could harm the client should be removed. Respiratory therapy can give extra support with the airway.
The nurse works with an RN to care for the following four clients on the medical-surgical floor. How should the nurse prioritize reporting on these clients to the RN?
1)A 61-year-old client with COPD reporting shortness of breath 2)A 75-year-old client who is one day s/p hip replacement surgery requesting assistance to the bathroom 3)A 75-year-old client who is one day s/p hip replacement surgery requesting assistance to the bathroom 4)A 75-year-old client who is one day s/p hip replacement surgery requesting assistance to the bathroom -Prioritize physiological needs and safety over psychosocial needs and safety. The nurse will see the client with shortness of breath because breathing needs to be addressed first based on the ABCs of nursing (airway, breathing, circulation). Elimination is the next priority, as delay in assistance can lead to incontinence. The pain at the incision site only occurs while coughing, which warrants the client's teaching splinting. Reorienting the client with dementia is important but does not prioritize physiological needs
The nurse will don personal protective equipment (PPE) in what order? Drag and drop all options into the appropriate order.
1)Perform hand hygiene 2)Apply a gown 3)Apply a mask 4)Apply a face shield 5)Apply gloves
The nurse rounds on clients when they discover a client unresponsive in bed. The nurse ensures the space is safe, checks for a pulse, and finds that the client is pulseless with no respirations. In what order would the nurse initiate cardiopulmonary resuscitation (CPR)?
1)Press the call bell to ask for additional help and the AED 2)Place hands mid-chest and begin 30 compressions at least 2 inches deep at a rate of 100 compressions/minute 3)Deliver two rescue breaths using the head tilt chin lift method and resuscitation bag with a mask 4)When the AED arrives, apply pads and shock as instructed by the AED -Code teams include members who are both basic and advanced life support certified. However, the first responder, typically the nurse, makes the biggest difference by initiating basic life support (BLS) skills.
The nurse ambulates with a client who is status post (s/p) appendectomy. While ambulating, the client reports lightheadedness and begins to fall. How would the nurse safely guide the client to the floor?
1)Put both arms around the client's waist 2)Stand with feet apart to provide a wide base of support 3)Extend one leg to provide support and allow the client to slide against it 4)Bend knees and lower body as the client slides to the floor 5)Call for assistance -During a fall, proper body mechanics will eliminate or minimize the risk of injury to yourself and the client. Once the client is safe, the nurse should call for assistance.
Nurses are rounding when they smell and see smoke coming from a client's room. Upon entering the room, the nurse discovers an electrical fire in an electrical outlet. The client is sleeping in bed. What is the appropriate course of action for the nurse in this situation?
1)Rescue the client by removing them from the room or shielding them from fire to avoid burns 2)Activate the fire alarm and alert staff 3)Contain the fire by closing doors, turning off oxygen, and placing wet towels along the base of the doors 4)Evacuate other clients near the fire (per facility protocol) -Remember to RACE- *Rescue the client from danger *Activate the alarm *Contain the fire, and *Evacuate the remaining clients.
How long should you wash your hands for?
20 seconds
If the nurse is giving an enema to an adult client, how far should the enema tip be inserted into the anal canal?
3 to 4 inches The tip of the enema tubing is inserted approximately 3 to 4 inches when giving an enema to an adult client. This allows the tubing to enter the anal canal and pass the internal sphincter, where the solution is instilled.
intermittent tube feedings are generally administered
4 to 6 times a day, with each feeding infusing 30 to 45 min. -The feedings can be infused without a pump as long as care is taken to monitor carefully. Gastric residuals should be measured before each feeding is started.
A nurse is positioning a client who will undergo lumbar puncture. The nurse understands that a lumbar puncture is usually performed at which of the sites?
A lumbar puncture is performed at L4-L5 because damage to the spinal cord is less likely to occur at this level. -The nurse will assist the client into the lateral recumbent position, with knees flexed and chin flexed to the chest, which widens the space between the vertebrae to facilitate insertion of the needle. The client's back is positioned at the edge of the bed or table.
Which of the following is a relatively low risk entry site for inoculation with HIV?
Accidental needlestick -An accidental needlestick is considered a low risk entry method for HIV inoculation. Other low-risk sites of entry include conjunctiva and oral and nasal mucosa. Perinatal exposure, transmission through infected blood products, needle sharing, and broken skin are all considered high-risk entry sites.
A nurse in the emergency department is caring for a child who has severe lead toxicity. Which of the following actions should the nurse plan to take?
Administer chelation therapy. -Chelation therapy is the administration of a chelating agent, such as deferoxamine mesylate (IM), along with calcium EDTA IV or IM. Chelation therapy is indicated for severe lead poisoning and toxicity. It removes lead from the bloodstream by excreting it through the urine
The nurse should understand that the mechanism of action of docusate sodium (Colace) is to:
Allow fluid to enter the stool and soften it -Docusate sodium allows fats and fluids to enter the stool thereby softening it.
The nurse is caring for a client who has just been told she is pregnant for the first time. The nurse knows that the woman should anticipate which emotion during the first trimester?
Ambivalence about the pregnancy -During the first trimester, it is not uncommon for a woman to be ambivalent about a pregnancy, particularly if the pregnancy was not planned
A nurse in the emergency department is caring for a client who has sustained a pelvic fracture in a motor vehicle collision. Which of the following would be a sign of hypovolemic shock in this client?
An apical pulse rate of 140 BPM -Tachycardia is a compensatory mechanism in the early stages of hypovolemic shock in which the body attempts to increase blood flow to the organs.
A nurse is caring for a 67-year-old client who is scheduled for cardiac surgery. The nurse assesses the patient for disorders that could complicate or affect the postoperative course. Which of the following conditions are least likely to affect outcomes of postoperative recovery?
Arthritis -Arthritis is a long-term chronic condition that is less likely to affect postoperative recovery. -One of the primary responsibilities of the surgical team is to determine the client's risk of poor outcomes before they undergo surgical procedures to avoid or help prevent postoperative complications. Certain conditions such as hypertension, diabetes, and alcohol or drug dependence can have deleterious outcomes for recovery and cause complications that can postpone optimal recovery.
A nurse is caring for a child who has cerebral palsy who is experiencing painful muscle spasms. Which of the following medications should the nurse expect to administer?
Baclofen -Baclofen is a centrally acting skeletal muscle relaxant that decreases muscle spasms and severe spasticity. Cerebral palsy is a neuromuscular disorder characterized by abnormal muscle tone, seizures, and alterations in vision, hearing, or speech, as well as cognitive and behavioral deficits. The abnormal muscle tone can manifest as painful muscle spasms and the development of contractures. -Diazepam is a skeletal muscle relaxant that decreases muscle spasms and severe spasticity; however, it should not be administered to younger children.
A nurse is caring for a 48-year-old client who is terminally ill. The client states they regret not coming in for cancer screenings sooner, and they are praying that they can live long enough to see their daughter get married. In which of the following stages of grief is this client?
Bargaining -This client is in the bargaining stage of grief as they feel guilt for not getting screened for cancer sooner and are praying to live to see their daughter get married. -The bargaining stage of grief usually results in the client making a deal with a higher power or praying for a few more months to live to postpone the loss. The bargaining stage deals with grief as a type of negotiation, and it is a false sense of hope.
The nurse is preparing to administer the daily dose of digoxin to an adult client. What is the essential action for the nurse to take prior to administering this medication?
Check the client's apical pulse -Before administering digoxin, the nurse should always check the client's apical pulse. -If the adult client's pulse is below 60 BPM the nurse should hold the digoxin and notify the physician.
The nurse is caring for a client with a laryngectomy. The nurse knows that the client should do all of the following EXCEPT: A. Shield the stoma when showering B. Increase fluid intake to 2-3 liters each day C. Consume a low fiber diet D. Humidify the air
Consume a low fiber diet -The client does not need to consume a low-fiber diet. A diet that includes fiber in at least normal levels is most beneficial
A nurse is assessing an 86-year-old elderly client who was admitted with cholecystitis. The nurse knows that the client may not exhibit the typical symptoms of this disease, given his age. Which of the following symptoms might an older adult with cholecystitis exhibit?
Hypotension and oliguria -Symptoms of cholecystitis in elderly clients may be accompanied or preceded by those of septic shock, which include oliguria, hypotension, change in mental status, tachycardia, and tachypnea.
A client had a hysterectomy 10 hours ago. The nurse assesses the client and finds that her blood pressure has abruptly fallen. What action by the nurse is most appropriate at this time?
Inform the surgeon about the client's condition The nurse's ultimate responsibility is for the client's safety. A change in vital signs is a sign of systemic complications, such as hemorrhage and shock, and should be reported immediately.
When a client receives a permanent prosthesis, the nurse should teach the client to:
Inspect the prosthesis daily for loose or worn parts -The prosthesis should be maintained in good working order. All other options are False.
A 67-year-old client hospitalized for 2 days has a history of hypertension, diabetes, and hyperlipidemia. The client is scheduled for a surgical procedure in the morning. The nurse administering the morning medications at 8:00 am should question which of the following medication orders?
Low molecular weight heparin (LMWH) via subcutaneous injection -Doses of heparin and low molecular weight heparin should be held 12 to 24 hours before surgery because of the risk of postoperative bleeding. This order should be clarified with the ordering provider.
A nurse is caring for a 70-year-old client in a rehabilitation facility who has just had a stroke. The nurse recognizes that the client is having difficulty swallowing. The nurse knows that which of the following areas of the brain regulates the ability to swallow?
Medulla oblongata -Swallowing is a voluntary act regulated by the swallowing center in the medulla oblongata.
A nurse is documenting information about a client's bladder irrigation. Which information is most important to include in the documentation of the procedure?
Date and time of catheter insertion -The nurse should document the date and time of the catheter insertion to keep track of how long it is in place, and to monitor for factors that could increase risk of a catheter-associated infection. -Documentation after bladder irrigation includes date and time of procedure; indication for the irrigation including the clients clinical symptoms; the result of irrigation, including volume of return, description of output, clots, or debris and urine color. The volume infused and the volume returned should be entered on the fluid balance chart. The difference between the two is the urine volume.
A nurse is reviewing the laboratory findings of a client who has acute pancreatitis. Which of the following findings is the priority to report?
Decreased calcium -Calcium is vital for cardiac function, neural transmission, blood clotting, and muscle contractility. Decreased levels of calcium occur with acute pancreatitis and can remain low for 7 to 10 days following the onset of the disorder. -Manifestations of hypocalcemia include tetany, paresthesia, muscle cramps, increased peristalsis, diarrhea, and cardiovascular changes. The greatest risk to the client is ECG changes and hypotension from hypocalcemia. Therefore, the client's calcium level is the priority finding for the nurse to report to the provider.
A nurse is monitoring a client newly diagnosed with diabetes mellitus. Which of the following symptoms, if exhibited in the client, would indicate hypoglycemia and requires physician notification?
Diaphoresis -Hypoglycemia symptoms include: shakiness, dizziness, sweating (diaphoresis). Classic symptoms of diabetes include polydipsia, polyphagia, and polyuria.
Which of the following describes hypochlorite bleach (Clorox)?
Disinfectant -Clorox and other hypochlorite bleaches are disinfectants, used to clean surfaces and equipment in the hospital. A bacteriostatic compound is an antibiotic compound and they may be topical or systemic.
A 36-year-old client came to the clinic reporting chronic constipation, irregular bowel movements, decreased appetite, and bloating. The client's vital signs are all stable, and they are febrile. What condition would the nurse suspect this client has
Diverticulosis -Since this client is not exhibiting signs of an infection, they most likely have diverticulosis, not diverticulitis. Clients with inflammatory bowel disorders report drastic changes in their stool, involving blood or mucus, typically accompanied by cramping abdominal pain. -Diverticulosis is when multiple small pouches or pockets form in the digestive tract lining, without any signs of infection or inflammation. Generally, these pockets do not cause symptoms, but constipation, bloating, and loss of appetite can occur.
Clonidine (Catapres) is a central acting adrenergic agonist. It reduces sympathetic outflow from the central nervous system.
Dry mouth, impotence, and sedation are all possible side effects. -Hyperkalemia and pancreatitis are not side effects of this drug.
A nurse is caring for a 66-year-old client in the cardiac unit who reports dyspnea on exertion and fatigue. What diagnostic test is likely to be ordered to confirm a diagnosis of heart failure in this client?
Echocardiogram -An echocardiogram uses sound waves to produce images of the heart's size and structure along with blood flow. An echo measures the ejection fraction, which shows how well the heart is pumping.
A 28-year-old female client is at the clinic reporting vaginal spotting and sharp colicky pain. She informs the nurse that her period is two weeks late. The client should be investigated for which of the following?
Ectopic pregnancy -These pregnancies cannot proceed normally since the fertilized egg cannot survive. The symptoms seen are normally a delay in the menstruation of up to two weeks, vaginal spotting, and sharp colicky pain
When scheduling an endoscopic procedure, which of the following is correct?
Endoscopic procedures should be performed first if a series of procedures is to be performed. -Tests should be scheduled so they do not interfere with on another. Barium studies should be scheduled last and those radiographic examinations that do not require contrast should be scheduled first. Patients who are undergoing any study of the Gl system should be NPO for 8 to 12 hours before the procedure.
A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should recognize that discontinuing this medication demonstrates which of the following ethical principles?
Nonmaleficence -Nonmaleficence is the obligation to do no harm to the client. Intentionally exposing clients to serious or permanent harm is unacceptable. Should such a situation emerge during the conduct of a study, the study should be terminated immediately.
The nurse is assessing an 87-year-old client's skin turgor. Which of the following statements about skin turgor is correct?
Older adults normally have inelastic skin turgor -Understanding skin in older adults is important for skin assessments. Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal Skin turgor is dry and firm.
Which of the following is not a cause of mechanical obstruction of the intestine? A. Meconium ileus B. Carcinoma C Volvalus D. Paralyticileus E. Intussusception
Paralytic ileus -Paralytic ileus refers to a loss of peristalsis that results in functional, not mechanical, obstruction. -Meconium ileus is a mechanical obstruction in the neonate that is caused by impaction of the meconium, which is the first feces of a neonate. -Carcinoma is a frequent cause of intestinal obstruction. -Volvulus is a mechanical obstruction that occurs when the intestine twists upon itself. -Intussusception is a mechanical obstruction that occurs when the bowel invaginates or telescopes back upon itself.
A nurse is caring for a 35-year-old client who has had transsphenoidal surgery. The nurse understands that this surgery is generally done to correct an underlying dysfunction of which gland?
Pituitary gland Transsphenoidal surgery is a surgical approach to operate on the pituitary gland via the sphenoid sinuses to reach the base of the brain. Transsphenoidal surgeries are typically performed by a neurosurgeon and an ENT surgeon collaboratively.
A nurse is assisting with planning care for a client who is having a vertebroplasty of the thoracic spine. Which of the following interventions should the nurse recommend to include in the plan of care?
Place the client in a supine position. -The nurse should apply cold therapy to the puncture site to decrease bleeding and swelling, and to relieve pain following the procedure. -The nurse should remove the dressings the day following the procedure. Client should have someone check the site for signs of redness, swelling, or drainage and report these findings to the provider. -The nurse should have the client remain in a supine position with the bed flat for 1 to 2 hr following the procedure. The client can resume the usual activities of daily living, especially walking, the next day.
A nurse is caring for a client with diarrhea. Which of the following diets would the nurse advise?
Potassium-containing diet -Diarrhea may result in potassium loss. This should be replenished through foods rich in potassium.
The nurse correctly identifies that the most important need for the client with left hemisphere infarction is:
Prevention of injury -It is important to maintain nutritional status but, impaired judgment makes safety the most important need. This puts the client at high risk for injury.
A client who is receiving hydantoin (Dilantin) reports to the nurse that his urine is very dark. What action should be taken by the nurse?
Report this serious side effect to the physician immediately Dark urine can indicate serious adverse effects associated with the use of Dilantin. The cause of the dark urine should be investigated. -Pink-colored urine occurs frequently in persons who are taking hydantoin(Dilantin). It is not a serious side effect. The nurse should make a note of the information.
The client is receiving valproic acid (Depakene) for seizures. The nurse knows that one of the common side effects of this medication is:
Scleral yellowing -A side effect of valproic acid is liver toxicity which can result in scleral and mucosal yellowing and abdominal pain. This medication can also cause increased appetite. It does not usually cause diarrhea or sore throat.
The nurse is caring for a client with Grave's disease. Which finding would indicate a complication of the client's disease?
Shortness of breath -Clients with Grave's disease, or hyperthyroidism, who experience shortness of breath are most likely experiencing cardiac and lung complications of their disease.
A nurse is caring for a client who is on a mechanical ventilator and who receives nutrition through a feeding tube. Which position would most likely reduce the risk of this client developing aspiration pneumonia?
Supine with the head of the bed elevated 30 to 45 degrees
A nurse is teaching a client about the intake of the drug levothyroxine. Which of the following instruction is correct?
Take the drug on an empty stomach -Intake of levothyroxine in the empty stomach helps in absorption and also it mimics the normal hormone release.
A client is admitted for an elective cholecystectomy the next morning. She takes no routine medication. The nurse should prioritize notification of which of the following assessment data to the healthcare provider before surgery?
Temperature of 100.8°F with a productive cough -This is the most concerning. Although it is a low-grade fever, it is accompanied by a cough, and both findings are important to communicate to the healthcare provider prior to administration of anesthesia and elective surgery. -Decreased respirations secondary to pain, the stress associated with surgery, and potential exacerbation of an existing but diagnosed infection, whether viral or bacterial, increases both the risk of pulmonary complications and wound healing complications.
The nurse is collecting preoperative vital signs and an electrocardiogram (ECG) on a 56-year-old client who is scheduled for a cardiac catheterization. The cardiologist is planning a right-sided cardiac catheterization. Through which vein is a right-sided cardiac catheterization typically performed?
The cardiologist typically inserts a catheter through the femoral vein for right-sided cardiac catheterization. -Left-sided heart catheterization can be performed through the femoral, brachial, or radial arteries.
A 45-year-old client is prescribed a short course of corticosteroid therapy. What would be important information for the nurse to give this client?
The client may be at increased risk for infection -Corticosteroid therapy reduces inflammation and suppresses the immune system. Therefore, a client who is on corticosteroid therapy is at increased risk of infection. -Clients should never abruptly discontinue medications due to unpleasant side effects without consulting with the prescriber.
A 67-year-old client in the cardiac unit is undergoing telemetry monitoring, which indicates ventricular fibrillation. The rapid response team is called immediately, and the client is converted back into a normal sinus rhythm within a few minutes. The nurse knows which of the following interventions by the rapid response team was responsible for converting the client back to normal sinus rhythm?
The electrical shock administered to reset the electrical conductivity of the heart -Ventricular fibrillation results in rapid and erratic heartbeats that prevent the heart from pumping blood to the rest of the body. The first line of treatment is cardiopulmonary resuscitation while a defibrillator is obtained to deliver an electrical shock to reset the electrical conductivity of the heart.
The nurse is preparing to perform a routine venipuncture with a butterfly needle. The nurse gathers the supplies and performs hand hygiene. The nurse chooses the median cubital vein for venipuncture. Identify the median cubital vein.
The median cubital vein is the superficial vein that joins the median antebrachial, basilic, and cephalic veins. It has an H or M pattern. -Choosing the appropriate vein for a routine venipuncture can minimize injury to the client and allow for a brisk blood flow, decreasing the incidence of sample clotting or hemolysis. The median cubital vein is typically chosen for venipuncture because of its H or M pattern and easy visibility and palpability.
A female client is currently being prepared for surgery, and you have been monitoring her vital signs. You observe that her hemoglobin levels are 9 g/dl. Which of the following should be told to the healthcare provider?
The patient is anemic -A client with anemia is at risk for bleeding episodes during or after surgery. It has been associated with poorer surgical outcomes. Anemia may be corrected for using erythropoesis-stimulating drugs, before during and after surgery. When possible, candidates preparing for elective surgical procedures should have their hemoglobin levels measured a minimum of 30 days prior to surgery.
A nursing team consists of a registered nurse (RN), a Licensed Practical Nurse (LPN), and a certified nurse aid (CNA). Which of the following clients would be appropriate to assign to the LPN?
The postoperative client requiring twice-daily sterile dressing changes -The LP should be assigned stable clients who are unlikely to experience changes in status -The client requiring the sterile dressing change would be most appropriate to be assigned to the LPN The certified nurse aid would be capable of assisting with voiding and ambulating. Complicated discharge teaching would best be performed by the registered nurse.
The nurse rounds on clients and finds a 78-year-old client unresponsive and pulseless with no respirations. The nurse calls for help and initiates CPR. Assistance arrives with an automated external defibrillator (AED). The nurse places the first adhesive pad on the upper right sternal border below the clavicle. Where will the nurse place the second adhesive AED pad?
The second AED pad should be placed lateral to the left nipple with the top of the pad a few inches below the axilla. -Proper placement of both pads allows for proper delivery of a shock on an axis through the heart. -Alternative placement may prevent the AED from analyzing a heart rhythm, thus rendering the AED incapable of determining if a shock is necessary.
A nurse is administering vancomycin to a client with methicillin resistant Staphylococcus aureus. Which of the following is an adverse effect of vancomycin (Vancocin) that should be reported immediately to the healthcare provider?
Tinnitus -The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved.
Most breast tumors are found in the:
Upper outer quadrant. Most breast tumors are found in the upper outer quadrant of the breast but can be found in any area.
The nurse is preparing a 70-year-old client diagnosed with benign prostatic hypertrophy (BPH) for a lower urinary tract cystoscopy. The nurse informs the client that which of the following is the most common, temporary complication that can occur after this procedure?
Urinary retention -Urinary retention is the most common complication experienced after a cystoscopy. Cystoscopy procedures can create scar tissue, which can create a narrowing in the urethra that causes temporary difficulty urinating. A client might have mild hematuria after a cystoscopy, but a hemorrhage or bladder perforation is extremely rare.
A transcutaneous electrical nerve stimulation (TENS) unit is a portable device used to treat
acute, emergent, chronic, and postsurgical pain. It uses cutaneous stimulation through mild electrical current to activate opioid and serotonin receptors. -The client should remove any hair or skin preparations prior to affixing the electrodes near or at the area of pain to promote effective conduction of the cutaneous stimulation. The client can adjust the frequency and intensity of the current until pain relief is effective. The TENS unit is contraindicated for clients who have areas of skin breakdown, a pacemaker, or dysrhythmias.
All clients undergoing tonsillectomy should undergo a
basic coagulation workup to check for abnormal bleeding. -The tonsillar area is very vascular, which can increase the chances of bleeding. If the prothrombin time is not therapeutic, the client could bleed excessively. -To reduce the risk of bleeding, the client should avoid aspirin, aspirin containing compounds, Advil, or Ibuprofen for two weeks prior to surgery. Acetaminophen (Tylenol) can be used instead
The nurse should monitor a client who is experiencing dysrhythmias for manifestations of decreased..
cardiac output can include a change in level of consciousness and cool skin. Manifestations of fluid retention can include neck vein distention and crackles or wheezes in the lungs. -Treatment for dysrhythmias include medications, elective cardioversion, defibrillation, and insertion of a pacemaker or implantable cardioverter-defibrillator.
Lead poisoning is the accumulation of lead in the body. Risk factors include
children less than 6 years of age, living in older homes built prior to 1978, and exposure to environmental elements such as soil, dust, and water that can contain lead. Children can be exposed to lead by ingesting lead-based paint. -Blood lead levels greater than 5mcg/dL can cause improper function of the client's RBCs. For high blood lead levels of 20 mcg/dL or greater, chelation is recommended. -Precaution should be used during the administration of chelation because it can cause hypocalcemia and death. -Prevention of lead toxicity is aimed at educating parents about lead exposure from paint and window sills, proper handwashing techniques, and to wet mop floors to prevent airborne particles.
The major cause of coronary artery disease is atherosclerosis. This refers to focal deposits of
cholesterol and lipids within the intima of arteries. Although atherosclerosis can affect any artery, it occurs most commonly in the coronary arteries. -Atherosclerotic coronary artery disease begins as fatty streaks in the wall of the artery. This progresses to a raised fibrous plaque composed of lipids, primarily cholesterol. Platelets aggregate at the site of damage in the arterial wall and can create a thrombus. As the plaque progresses, it incorporates lipids, thrombi, damaged tissue, and calcium. Obstruction of arterial flow by plaques results in ischemia and angina. Total occlusion results in myocardial infarction.
Chronic cancer pain can be treated with medications delivered through an
epidural catheter. -The nurse should monitor the client for manifestations of overmedication. The manifestations could include hypotension, decreased level of consciousness, decreased rate of respiration, gastrointestinal upset, and constipation.
Vancomycin is used intravenously for treatment for
gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA). Adverse effects include ototoxicity, nephrotoxicity, and Red Man Syndrome. -If a client develops ototoxicity, the drug should be discontinued. Ototoxicity due to vancomycin is characterized by high frequency hearing loss. Risk is increased with higher doses and when vancomycin is administered with aminoglycoside antibiotics (gentamicin.) It is more common in older clients and those with preexisting renal insufficiency.
A vertebroplasty is a diagnostic procedure that is performed in the surgical or radiology department under moderate sedation. During the procedure, bone cement is injected percutaneously into the fractured vertebrae to stabilize the injured site and relieve pain. The procedure is not recommended for clients who
have an infection, taking anticoagulants, or have multiple old fractures. The client should remain supine for 1 to 2 hr after the procedure with an ice pack applied to the puncture site to decrease swelling, bleeding, and discomfort. -The nurse should monitor the site for bleeding, check for shortness of breath, and report any changes to the provider. After discharge, the client should have a family member or friend remove the dressing the next day and check the site for signs of infection. The client can resume the usual activities of daily living, especially walking, the next day.
Ventilator-associated pneumonia (VAP) occurs in 10-30 percent of intubated patients. Good nursing care can prevent ventilator-associated pneumonia in patients who are receiving tube feedings. It is important to..
keep the head elevated at least 30 degrees and check for residuals every 4 hours to prevent aspiration. -A client who uses a mechanical ventilator and/or a feeding tube for nutrition is at high risk of developing aspiration pneumonia. Unless otherwise contraindicated, the nurse should position the client supine with the head of the bed elevated 30 to 45 degrees to reduce the risk of aspiration while maintaining a comfortable position.
Causes of atelectasis include hypoventilation, abdominal compression of the lungs, and airway obstruction. Nonpharmacologic therapies are useful to prevent atelectasis in clients with
limited mobility or weakness. These therapies are targeted at improving cough and clearance of secretions from airways and include chest physiotherapy, postural drainage, chest wall percussion and vibration, and a forced expiration technique known as huffing. -The nurse can evaluate the efficacy of therapy by assessing characteristics of the client's sputum, including volume, weight, and viscosity. When atelectasis develops, the underlying cause must be determined and treated.
Clonidine is a central acting adrenergic agonist used to treat
mild to moderate hypertension,(ADHD). It is also used off-label for management of opioid withdrawal and treatment of neuropathic pain. Clonidine stimulates alpha-adrenergic receptors in the central nervous system to decrease sympathetic outflow. -These actions inhibit vasoconstriction and acceleration of the heart rate and prevent transmission of pain signals to the central nervous system. Therapeutic effects include decreased blood pressure, decreased pain and Improvement in ADHD symptoms
Hypovolemic shock usually occurs as a result of rapid blood loss (hemorrhage.) It refers to a condition in which
rapid fluid loss results in multiple organ failure due to inadequate circulating blood volume and inadequate perfusion. -Tachycardia occurs early, as a compensatory measure to increase cardiac output and to improve perfusion. When compensatory mechanisms are overwhelmed, blood pressure and urine output decrease. The client will have signs and symptoms that reflect organ dysfunction, including mental status change due to decreased perfusion of the brain.
In the event of a fire, the nurse should first
rescue the client, then set off and alarm. -Next, the nurse will confine the fire by closing doors, or other access to the fire and if possible extinguish the fire.
Acute pancreatitis is the inflammation and autodigestion of the pancreas, which can be fatal. It is caused by chronic alcohol use disorder, gallstones, abdominal trauma such as surgical manipulation or blunt trauma, drug use, or infection. Manifestations of acute pancreatitis include
severe abdominal pain with radiation to the back, left flank, or left shoulder, abdominal guarding, nausea, vomiting, fever, confusion, agitation, hypotension, tachycardia, cyanosis, and hypoxia. -The client who has acute pancreatitis is at risk for developing sepsis, shock, and alterations in the cardiovascular, neurologic, renal, and respiratory systems. The nurse should closely monitor laboratory results as well as complete frequent assessments of cardiac, respiratory, neurologic, and renal systems.
Diverticulosis is a condition where
small pouches or pockets form in the lining of the digestive tract. They occur as the inner layer of the digestive tract pushes out from a weak spot in the outer layer. -Clients with chronic constipation have a higher risk of developing diverticulosis. Signs and symptoms of diverticulosis are relatively mild and include bowel irregularity, constipation, anorexia, and bloating. Diverticulitis occurs when one of these pouches becomes infected or inflamed. This is evidenced by abdominal pain, tenderness, chills, nausea, vomiting, or a fever.
Rheumatoid arthritis (RA) is a chronic and progressive systemic inflammatory autoimmune disease of the
synovial joints that can have an altered effect on any body system. -The nurse should recognize that the manifestations might initially resemble those of a viral infection. Manifestations of A also include decreased range of motion of joints, especially those in the upper extremities, and is an extremely painful condition.
Ventricular fibrillation is caused by a problem in the heart's electrical properties or a disruption of the blood supply to the heart muscle. This rhythm is a result of rapid and erratic heartbeats that prevent
the heart from pumping blood to the rest of the body. -Ventricular fibrillation is a medical emergency, and if it is not immediately treated, it could result in death within minutes. The goal is to restore blood flow as quickly as possible to prevent any damage. Defibrillation, also known as cardioversion, uses an automated external defibrillator (AED) to deliver a shock to the heart to help correct the heart rhythm.
Magnesium is administered for
ventricular tachycardia with prolonged QT intervals -Defibrillation should be attempted first before using magnesium.
Heart failure can cause the kidney to retain sodium, which can cause
water retention resulting in volume overload. -Normal aging also increases the risk of fluid imbalance and dehydration because older adults are less capable of maintaining fluid balance than younger clients.
