Chapter 25- Skin, 13) Chapter 44: Care of Patients with Problems of the Central Nervous System: The Brain, CHAPTER 16 Care of Postoperative Patients, Chapter 14: Care of Preoperative Patients, Chapter 15: Intraop patients, Chapter 40: Care of Patient...

The preoperative patient tells the nurse that she is afraid that she may experience a reaction if she must receive blood during or after her surgery. What is the nurse's best response to the patients concern? -"The likelihood that you will need a blood transfusion for your surgery is minimal, so do not worry about this" -"You could donate your own blood(autologous donation) a few weeks before your surgery" -"With todays technology and procedures, it is very unlikely that you would have a reaction to donated blood." -"The nursing staff follows strict procedures to prevent such an event from ever happening."

-"You could donate your own blood a few weeks before surgery"

The nurse screens a preoperative patient for conditions that may increase risk for complications during the perioperative period. Which conditions are possible risk factors? (Select all that apply) -Emotional status -67 years old -Obesity -Marathon runner -Pulmonary disease

-67 years old -Obesity -Pulmonary disease

A male patient has a scar on his forehead from a third-degree burn. What is the correct classification for this surgery? -Major -Restorative -Cosmetic -Curative

-Cosmetic

An appendectomy is being performed on a patient with appendicitis. What is the correct classification for this surgery? -Curative -Diagnostic -Urgent -Radical

-Curative

A 75 year old patient is having an exploratory laparotomy tomorrow. The wife tells the nurse that at night the patient gets up and walks around his room. What priority action does the nurse take after hearing this information? -Notifies the provider -Develops a plan to keep the patient safe -Obtains an order for sleep medications -Tells the patient not to get out of bed at night

-Develops a plan to keep the patient safe

A female patient is having a biopsy of a nodule found in the right breast. Which classification identifies this surgery? -Urgent -Minor -Cosmetic -Diagnostic

-Diagnostic

A 76 year old patient is having a bilateral cataract removal. What is the correct classification for this surgery? -Major -Cosmetic -Elective -Emergent

-Elective

A patient with an abdominal aortic aneurysm is having a surgical repair. What is the correct classification for this surgery? -Restorative -Emergent -Urgent -Minor

-Emergent

Which client statement indicates that stem cell transplantation that is scheduled to take place in his home is not a viable option?

"I was a nurse, so I can take care of myself." Stem cell transplantation in the home setting requires support, assistance, and coordination from others. The client cannot manage this type of care on his own. The client must be emotionally stable to be a candidate for this type of care.

A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best?

"The donor's cells are actually attacking the client's cells." Graft versus host disease is an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin attacking them.

A client with leukemia is being discharged from the hospital. After hearing the nurse's instructions to keep regularly scheduled follow-up provider appointments, the client says, "I don't have transportation." How does the nurse respond?

"The local American Cancer Society may be able to help."

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information does the nurse include?

"The sickle cell trait will be inherited by your children." The children of the client with sickle cell disease will inherit the sickle cell trait, but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the client's white blood cell count (WBC) is high. What response by the registered nurse is best?

"Those WBCs are abnormal and don't provide protection." In leukemia, the WBCs are abnormal and do not provide protection to the client against infection.

A client with thrombocytopenia is being discharged. What information does the nurse incorporate into the teaching plan for this client?

"Use a soft-bristled toothbrush." Correct Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia

A client with multiple myeloma reports bone pain that is unrelieved by analgesics. How does the nurse respond to this client's problem?

"Would you like to try some relaxation techniques?" Because most clients with multiple myeloma have local or generalized bone pain, analgesics and alternative approaches for pain management, such as relaxation techniques, are used for pain relief. This also offers the client a choice. Before prescribing additional medication, other avenues should be explored to relieve this client's pain.

Which statement is true regarding the patient who has given consent for a surgical procedure? -Information necessary to understand the nature of and reason for the surgery has been provided -The length of stay in the hospital has been pre-approved by the managed care provider -Information about the surgeons experience provided -The nurse has provided detailed information about the surgical procedure

-Information necessary to understand the nature of and reason for the surgery has been provided

Holding area nurses:

-coordinates and manage his care while the patient weights in this area until the OR is ready -they greet patient upon arrival, review medical record and preop checklist, verify consent forms are signed, and document risk assessment -may answer questions, provide education, and start IV, catheter

Circulating nurse:

-coordinates, overseas, and are involved in the patient's nursing care in the OR -set up the OR, ensure the needed supplies, inspect supplies to ensure safety and function before surgery, makes up operating bed with gel pads, Safety straps, heating pads, warming blankets -positions the patient, protecting brownie areas with padding, assists the anesthesia provider with the induction of anesthesia by positioning the patient and applying cricoid pressure -inserts a foley, applies grounding pad, and prep (scrub) surgical site before patient is draped

Most common ways anesthesia can be induced:

-general -regional -local

Types of OR nurses include:

-holding area nurse -circulating nurse -scrub nurse -specialty nurse

Complications of general anesthesia:

-malignant hyperthermia -overdose of anesthetic -unrecognized hypoventilation -intubation complications

Throughout surgery what does the circulating nurse do?

-protect patients privacy -ensures patient safety -monitors traffic in the room -assesses amount of urine and blood loss -reports findings to surgeon and anesthesia -insurers sterile field/technique -anticipates surgical equipment needed -communicate to family -document care, events, interventions, findings

The OR layout helps prevent infection by:

-reducing contaminants through air exchanges in the room -maintaining recommended temp and humidity levels -and by limiting traffic and activities in the OR

Scrub nurse:

-sets up the sterile table, drapes the patient, and hand sterile supplies/equipment/instruments to the surgeon and assistant -describe, along with the circulating nurse, maintains an accurate count of sponges, sharks, and instruments and amounts of irrigation fluid or drugs used

Who are the members of the surgical team?

-surgeon -One or more surgical assistants -anesthesia provider -OR nursing staff

S&S of MH:

-tachycardia -dysrhythmia -muscle rigidity (jaw and upper chest) -hypotension -tachypnea -skin mottling (lacy red netted skin) -cyanosis -myoglobinuria (muscle proteins in the urine)

What is anesthesia selection influenced by?

-type/duration of procedure -area of body having surgery -safety issues to reduce injury -management of pain postop -how long pt has been PO and or had any drugs -patient position that is needed -if patient must be alert to follow instructions -patient's previous responses to anesthesia

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best?

0.45% normal saline Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline.

A patient is ordered to receive insulin lispro at mealtimes. The nurse will instruct this patient to administer the medication at which time?

5 minutes before eating Lispro acts faster than other insulins, and patients should be taught to give this medication not more than 5 minutes before eating.

A patient has a partial thickness wound. How long does the nurse anticipate the healing by epithelialization?

5-7 days

Which is an age-related change that impacts fluid balance? Loss of skin elasticity Adrenal hypertrophy Increased thirst reflex Increased muscle mass

A

A patient's electrocardiogram demonstrates a heart rate of 52 beats/min, prolonged PR interval with widened QRS complex, and the patient is also hypotensive. The nurse reviews the morning labs for which conditions? Hyperkalemia, hypercalcemia, hypermagnesemia Hypokalemia, hypocalcemia, hypermagnesemia Hypocalcemia, hyperkalemia, hypernatremia Hypernatremia, hypercalcemia, hypophosphatemia

A Cardiovascular changes are consistent with elevated potassium, calcium, and magnesium. These signs and symptoms may progress to life-threatening cardiac emergency. Although hypocalcemia can interfere with cardiac contractility, hypokalemia and hypophosphatemia do not.

What is the preferred diuretic used for patients with hypokalemia? Amiloride Furosemide Bumetanide Chlorthiazide

A Diuretics that increase the kidney excretion of potassium can cause hypokalemia. A potassium sparing diuretic may be prescribed to increase the urine output without increasing potassium loss. Amiloride is an example of potassium sparing diuretic, which is preferred for patients diagnosed with hypokalemia. Furosemide, bumetanide, and chlorthaiazide are examples of high ceiling, loop, or thiazide diuretics. These loop and thiazide diuretics promote excretion of potassium along with water; therefore, they are not used in patients diagnosed with hypokalemia.

Which medication classification does the nurse anticipate being prescribed to help a patient maintain an appropriate fluid balance? Diuretics Anticoagulants Mood stabilizers Opioid analgesics

A Drug therapy for hypertension management may include diuretic drugs that increase the excretion of sodium so that less is present in the blood, resulting in a lower blood volume and increased urine output. Anticoagulants, mood stabilizers, and opioid analgesics do not play a role in maintaining fluid balance within the body

What parameter does the nurse assess for in a postoperative patient to determine perfusion adequacy? Urine output Blood volume Blood pressure Glomerular filtration rate

A Hemorrhage is a risk factor in postoperative patients. The renin-angiotensin II pathway is highly stimulated whenever the patient is in shock or when the stress response occurs, which is why urine output is used to measure the perfusion adequacy after surgery. Blood volume, blood pressure, or glomerular filtration rate are not indicators of perfusion adequacy in postoperative patients.

The nurse is providing care to a patient who is admitted with fluid volume overload. Which electrolyte imbalances does the nurse anticipate for this patient based on the admitting diagnosis? Hyponatremia Hypokalemia Hypercalcemia Hypochloremia Hypermagnesemia

A, B, D A patient admitted with fluid volume overload will often experience hyponatremia, hypokalemia, and hypocholoremia. Hypercalcemia and hypermagnesemia are not anticipated electrolyte imbalances associated with fluid volume overload.

Which drug therapies might be used to manage symptoms of hypocalcemia? Magnesium sulfate Calcium chloride Potassium chloride Vitamin D Zinc sulfate Vitamin E

A, B, D Magnesium sulfate may be used to manage neuromuscular symptoms of hypocalcemia. Calcium supplements are given to restore serum calcium levels. Vitamin D enhances the absorption of oral calcium. Potassium, zinc, and vitamin E are not indicated for the management of hypocalcemia.

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Help the client choose soft foods from the menu. Shave the male client with an electric razor. Use a lift sheet when needed to re-position the client. This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft-bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client.

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best?

Help the client find things to hope for each day of recovery. Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time.

A 32-year-old client is recovering from a sickle cell crisis. His discomfort is controlled with pain medications and he is to be discharged. What medication does the nurse expect to be prescribed for him before his discharge?

Hydroxyurea (Droxia) Hydroxyurea (Droxia) has been used successfully to reduce sickling of cells and pain episodes associated with sickle cell disease (SCD).

Absence of Insulin

Hyperglycemia Polyuria Polydipsia Polyphagia Ketone bodies (Ketones) Dehydration with diabetes leads to---Hemoconcentration, hypovolemia, hyperviscosity, hypoperfusion. and hypoxia Acidosis, Kussmaul respiration

The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What post-transfusion electrolyte imbalance does the nurse want to rule out?

Hyperkalemia During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products.

Alpha-glucosidase inhibitors

acarbose (Precose) and meglitol (Glyset) slow the breakdown of carbohydrates

Glucagon

counterregulatory hormone that has actions opposite of insulin prevents hypoglycemia can be administer by injection in response to severe hypoglycemia

The nurse is performing discharge dietary teaching for a patient with hyperkalemia. Which statement does the nurse include in the teaching? "You may eat avocados, broccoli, and cantaloupe." "You may use salt substitutes." "You may eat apples, strawberries, and peaches." "You don't need to restrict dairy products."

C The patient with hyperkalemia should be instructed to consume foods low in potassium such as apples, strawberries, and peaches. The patient should avoid foods high in potassium, which include avocados, broccoli, cantaloupe, and dairy products. Salt substitutes contain potassium.

On the second day of caring for a patient with generalized edema, which change best reflects that the administered diuretic is effective? Urinary output decrease from 600 mL/8 hr to 200 mL/8 hr Respiratory rate decrease from 24 to 20 Weight loss of 6 pounds Blood pressure decrease from 138/88 to 126/78 mm Hg

C Weight loss and increased urinary output are primary indicators of the effectiveness of a diuretic. In patients with edema, each pound of weight gained after the first pound equates to 500 mL of retained water, so if water loss occurs with diuretic therapy, weight loss will result. The changes in vital signs may reflect volume loss, but are not the best indicators of the effectiveness of a diuretic.

An ECG is ordered for a patient who was placed on IV fluids containing potassium. Which ECG finding is consistent with hyperkalemia? Absent T waves Elevated P waves Prolonged PR intervals Shortened QRS complexes

C When hyperkalemia is present, an individual may show absent P waves, tall T waves, prolonged PR intervals, and widened QRS complexes.

A patient is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect? Hypernatremia Hypomagnesemia Hypercalcemia Hyperphosphatemia

Hypernatremia These symptoms are indicative of hypernatremia. Clinical manifestations of hypomagnesemia are seen in the neuromuscular, central nervous, and intestinal systems. Hypercalcemia manifests with an altered level of consciousness that can range from confusion and lethargy to coma, and severe hypercalcemia depresses electrical conduction, slowing heart rate. Hyperphosphatemia causes few direct problems with body function (although hypocalcemia is usually also present).

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?

Double-checking the client and blood product identification This client had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type.

An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? (Select all that apply.)

Hypertension Hypotension Rapid, bounding pulse an older adult receiving a transfusion, hypertension is a sign of overload, low blood pressure is a sign of a transfusion reaction, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic

Less common ways anesthesia can be induced:

Hypnosis, cryothermia (use of cold), and acupuncture

Which intervention most effectively protects a client with thrombocytopenia?

Encouraging the use of an electric shaver The client with thrombocytopenia should be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time

A nurse is preparing to administer a blood transfusion. What action is most important?

Ensuring informed consent is obtained if required If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent.

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first?

Examine the client's feet for signs of injury.

A late sign of MH:

Extremely elevated temp as high as 111.2 degrees F

Insulin Side Effects

Hypoglycemia, insulin shock Nervousness, tremors Lack of coordination Cold, clammy skin Headache, confusion Somogyi effect Occurs in predawn hours Rapid decrease in blood glucose during night stimulates hormonal release to increase blood glucose Lipodystrophy (failure to rotate sites - fat metabolism) Lipoatrophy Lipohypertrophy Dawn phenomenon Hyperglycemia upon awakening Symptoms: Headache, night sweats, nightmares Diabetic ketoacidosis Hyperglycemia

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

I should decrease my intake of protein and eliminate carbohydrates from my diet

After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?

I should look into swimming or water aerobics to get my exercise Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury.

Which statement indicates to the nurse that the patient needs additional teaching on oral hypoglycemic agents?

I will take the medication only when I need it.

Which statement by a patient taking glipizide indicates that more teaching is indicated?

I will use a new needle every time I take the medication (Glipizide (Glucotrol) is an oral antidiabetic agent. It is well absorbed from the GI tract and is highly protein-bound.)

A patient diagnosed with Stevens-Johnson syndrome. What is the priority action for the health care team?

Identify the offending drug and discontinue it

Management of Dehiscence: Preventing Wound Infection and Delayed Healing

If dehiscence (wound opening) occurs, apply a sterile nonadherent (e.g., Telfa) or saline dressing to the wound and notify the surgeon. Instruct the patient to bend the knees and to avoid coughing. A wound that becomes infected dehisces by itself, or it may be opened by the surgeon through an incision and drainage (I&D) procedure. In either case, the wound is left open and is treated as described previously.

Critical Rescue: Ox Sat

If the oxygen saturation drops below 95% (or below the patient's presurgery baseline), notify the surgeon or anesthesia provider. If it drops by 10 percentage points and you are certain it is an accurate measure, call the Rapid Response Team.

Home Care Management.

If the patient is discharged directly to home, assess information about the home environment for safety, patient accessibility, cleanliness, and availability of caregivers. Collaborate with the social worker or discharge planner to identify needs related to care after surgery, including meal preparation, dressing changes, drain management, drug administration, equipment rental, physical therapy, and personal hygiene. Support the patient and family members as they make discharge plans. The patient with visible scars after surgery may need more emotional support from and acceptance by his or her family. The patient may be angry about the surgical outcome or about role changes. He or she may be concerned about financial matters and work. The surgical outcome may not have met the patient's expectations, and further interventions may be needed to assist in resolving his or her feelings.

The nurse is providing patient teaching for the drug miglitol for the patient with a diagnosis of type 2 diabetes. Which group of side effects should the nurse include in the patient teaching?

Flatulence, hypoglycemia and diarrhea

Complications: HHNS Hyperglycemic hyperosmolar nonketotic syndrome

Happens mainly in Type 2 diabetics This presents with hyperglycemia without the breakdown of ketones...so there isn't acidosis/ketosis because there is just enough insulin present in the body to prevent the breakdown of fats Signs and Symptoms of HHNS: very dehydrated, thirsty, hyperglycemic, mental status changes

Complications: Organ Problems

Hardens the vessel (atherosclerotic....makes vessels hard from all the glucose that sticks on the proteins of the vessels and it forms plaques). So the patient can develop heart disease, strokes, hypertension, neuropathy, poor wound healing (FROM DECREASE circulation), eye trouble, infection.

In order to assist the HCP in determining if avoidance therapy is appropriate for a patient, which question would the nurse ask?

Have you used any new soaps, detergents, or personal care products?

A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, "My cousin has depression and is taking this drug. Do you think I'm depressed?" How should the nurse respond?

It's for peripheral neuropathy. Do you have burning pain in your feet or hands? Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy.

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?

Keep the lower extremities warm. During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the client's legs will be cool or cold. The UAP can attempt to keep the client's legs warm

A patient diagnosed with a primary herpetic infection. The nurse would question an order for which drug?

Ketoconazole (Nizoral)

Phase III

Known as the extended-care environment, most often occurs on a hospital unit or in the home. For patients who have continuing care needs that cannot be met at home, discharge may be from the hospital unit to an extended-care facility. Although vital signs continue to be monitored in this type of environment, the frequency ranges from several times daily to just once daily.

The nurse hears in report that a patient admitted for an elective surgery also has herpes zoster. The nurse initiates contact isolation for which factor?

Lesions are present as fluid filled blisters

Most anesthetics are metabolized in the _______ and excreted by the ________.

Liver Kidneys

Chronic complications

Macrovascular/microvascular disease Retinopathy Nephropathy Neuropathy

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications?

Maintain tight glycemic control and prevent hyperglycemia Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications.

The nurse administers NPH insulin at 8 AM. What intervention is essential for the nurse to perform?

Make sure patient eats by 5 PM.

A patient with type 1 diabetes mellitus has been ordered insulin aspart 10 units at 7:00 AM. What nursing intervention will the nurse perform after administering this medication?

Make sure the patient eats breakfast immediately

Specialty nurse:

May be in charge during some types of specialty surgery; they provide specific nursing care during surgery, assesses, maintains, and recommends equipment and supplies used

Surgical assistant

Maybe another surgeon, physician, resident, in turn, advanced practice nurse, physician assistant, CRNFA (certified registered nurse first assistant), or surgical technologist; The assistant may hold retractors, suction the wound, cut tissue, suture, and dress wounds

An older adult patient is admitted with dehydration. Which nursing assessment data identify that the patient is at risk for falling? Dry oral mucous membranes Orthostatic blood pressure changes Pulse rate of 72 beats/min and bounding Serum potassium level of 4.0 mEq/L

Orthostatic blood pressure changes Blood pressure decreases when changing positions. The patient may not have sufficient blood flow to the brain, causing sensations of lightheadedness and dizziness. This problem increases the risk for falling, especially in older adults. Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does not assess for fall risk.

Physical status ranking of a patient (used to estimate potential risks):

P1 ranking- totally healthy P6- brain dead

A nurse cares for a client who has type 1 diabetes mellitus. The client asks, "Is it okay for me to have an occasional glass of wine?" How should the nurse respond?

One glass of wine is okay with a meal and is counted as two fat exchanges

Rapid acting insulin

Onset: 15 minutesPeak: 1 hourDuration: 3

Intermediate-Acting insulin

Onset: 2 hours Peak: 8 hours Duration: 16 hours

Long-acting insulin

Onset: 2 hours Peak: NONE Duration: 24 hours

Short-Acting insulin

Onset: 30 minutes Peak: 2 hours Duration: 8 hours

In addition to being used for examination and obtaining specimens for biopsy, endoscopes can be used for:

Organ removal, reconstruction, blood vessel grafting, cutting, suturing, stapling, cautery, and laser surgery

TABLE 16-1 General Potential Complications of Surgery

PG 257!!

Chart 16-2 Focused Assessment The Patient on Arrival at the Medical-Surgical Unit After Discharge from the Postanesthesia Care Unit

PG 258

TABLE 16-2 Immediate Postoperative Neurologic Assessment: Return to Preoperative Level

PG 260!!

Chart 16-3 Recognizing Serious Complications of Spinal and Epidural Anesthesia

PG 261!!

TABLE 16-3 Calculating Nasogastric Tube Drainage

PG 262!!

Chart 16-4 Emergency Care of the Patient Experiencing a Benzodiazepine Overdose

PG 266!!

Chart 16-5 Best Practice in Postoperative Skin Care

PG 267!!

Chart 16-6 Emergency Care of the Patient with Surgical Wound Evisceration

PG 268!!

Chart 16-8 Emergency Care of the Patient Experiencing an Opioid Overdose

PG 269!!

Chart 16-7 Common Examples of Drug Therapy

PG 269!!!

Chart 16-9 Nonpharmacologic Interventions to Reduce Postoperative Pain and Promote Comfort

PG 271!!

The nurse hears in report that an older patient has postherpetic neuralgia. Which sign/symptom is the patient most likely to report?

Pain

Discomfort/Pain Assessment.

Pain after surgery is related to the surgical wound, tissue manipulation, drains, positioning during surgery, presence of an endotracheal tube, and the patient's experience with pain. Assess the patient's discomfort and need for medication by considering the type, extent, and length of the surgical procedure. Assess for physical and emotional signs of acute pain, such as increased pulse and blood pressure, increased respiratory rate, profuse sweating, restlessness, confusion (in the older adult), wincing, moaning, and crying. When possible, ask the patient to rate the pain before and after drugs are given. Plan the patient's activities around the timing of analgesia to improve mobility. Observe for a return of baseline. Pain usually reaches its peak on the second day after surgery, when the patient is more awake and more active and the anesthetic agents and drugs given during surgery have been excreted.

Interventions: Pain

Pain management after surgery includes drug therapy and other methods of management, such as positioning, massage, relaxation techniques, and diversion. Often the patient has better pain relief from a combination of approaches.

Which is the top priority for nurses during the perioperative period? -Patient teaching -Patient diagnostic testing -Patient safety -Patient care of documentation

Patient safety

A patient who is overweight is being evaluated for diabetes. The patient has a blood glucose level of 160 mg/dL and a hemoglobin A1c of 5.8%. The nurse understands that this patient has which condition?

Prediabetes Patients with a hemoglobin A1c between 5.7% and 6.4% are considered to have prediabetes. A level of 6.5% or more indicates diabetes.

A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client?

Presence of protein in the urine

Insufflation:

Procedure of injecting gas or air into the cavity before surgery to separate organs and improve visualization; Important part of M I S for abdominal surgery, pelvic surgery, and other body cavities

The nurse is teaching a patient about treatment of pediculosis pubis. What information does the nurse include?

Proper use of topical sprays or creams such as permethrin (Elimite) Abstinence from sexual intercourse with the infected person Treatment of the patients social contacts Washing clothing and bedding in hot water with detergent

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet should the nurse decrease?

Proteins

The nurse is caring for a client who is in sickle cell crisis. What action does the nurse perform first?

Provide pain medications as needed.

A nurse is preparing to hang a blood transfusion. Which action is most important?

Putting on a pair of gloves To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood.

Types of insulin

Rapid-acting (fastest) Short-acting Intermediate (medium acting) Long (longest)

Benefits of MIS:

Reduced surgery time, smaller incisions, reduce blood loss, faster recovery time, and less pain after surgery

The school nurse discovers a child has tinea capitis. What does the nurse instruct the parents to do?

Refrain from sharing items like combs or hats

A patient who has been taking a sulfonylurea antidiabetic medication will begin taking metformin (Glucophage). The nurse understands that this patient is at increased risk for which condition?

Renal failure

Action Alert: Respiratory Assessment

Respiratory assessment is the most critical assessment to perform after surgery for any patient who has undergone general anesthesia or moderate sedation or has received sedative or opioid drugs.

The nurse assesses multiple clients who are receiving transfusions of blood components. Which assessment indicates the need for the nurse's immediate action?

Respiratory rate of 36 breaths/min in a client receiving red blood cells An increased respiratory rate indicates a possible hemolytic transfusion reaction; the nurse should quickly stop the transfusion and assess the client further.

What should you interpret and how should you RESPOND to a patient who has a wound infection after surgery?

Respond by: • Documenting wound features • Notifying the surgeon or health care provider • Cleansing the wound (obtaining cultures, if within agency policy) • Maintaining or starting IV line • Administering prescribed drug therapy • Monitoring laboratory test results to determine therapy effectiveness • Continuing to assess for changes in the patient's condition, especially indications of infection in any other body area.

What may occur during emergence?

Retching, vomiting, and restlessness (suction equip must be available)

Microvascular Consequences of DM

Retinopathy, Cataracts, Glaucoma, Microalbuminaria, Gross albuminaria, Kidney Failure, Neuropathy (peripheral and autonomic), deterioration of nerve-function (ED)

A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take?

Review the client's liver function study results. Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator

The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification?

Reviews all information with another registered nurse With another registered nurse, verify the client by name and number, check blood compatibility, and note expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses.

___________ ___________ takes M I S to a new level; this system consists of a console, surgical arm cart, and video cart; many gynecologic, urologic, and cardiovascular procedures are being performed this way

Robotic Technology

Anesthesia delivery starts with:

Selecting and giving preoperative drugs

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria?

Serum osmolarity: 375 mOsm/kg

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately?

Serum potassium level of 2.5 mmol/L Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia.

During recovery, ________ ,__________, and _____________ may occur due to temporary change in the body's thermoregulation.

Shivering, rigidity, and slight cyanosis (Nurse provides warm blankets, radiant heat, and oxygen to decrease effects)

After teaching a client with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.

The entire ________ of gown are sterile, from 2 inches above the elbow to the cuff.

Sleeves

What is the most important environmental risk for developing leukemia?

Smoking cigarettes According to the American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is cigarette smoking.

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority?

Sperm banking All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of particular concern if the client is going to have radiation to the lower abdomen or pelvis.

A patient on the unit has herpes zoster. Which staff members would be best to assign to the care of this patient?

Staff members who have had chicken pox

A client who is receiving a blood transfusion suddenly exclaims to the nurse, "I don't feel right!" What does the nurse do next?

Stop the transfusion. The client may be experiencing a transfusion reaction; the nurse should stop the transfusion immediately.

A patient has been prescribed acetretin (Soriatane) for psoriasis. What information does the nurse tell the patient about this drug>

Strict birth control measures are necessary

The nurse will administer parenteral insulin to a patient who will receive a mixture of NPH (Humulin NPH) and regular (Humulin R). The nurse will give this medication via which route?

Subcutaneous

The patient with type 1 diabetes mellitus asks, "Why can't I take a sulfonylurea like my friend who has diabetes?" What is the nurse's best response?

Sulfonylurea increases beta-cell stimulation to secrete insulin, and with your type of diabetes, the beta cells do not contain insulin. This medication will not work for you.

A male patient 24 h post-op tells the nursing student that his nurse "gave him an extra shot of insulin and there must be some mistake." The nursing student verifies the patient received a sliding scale dose of insulin. What information should the nursing student provide to the patient?

Surgery can produce stress, which can produce stress; an additional small amount of insulin helps provide a constant glucose level.

The nurse is assessing a patients skin and notes a 2x2 purplish colored area on the coccyx with skin intact. These finings suggest which stage of a pressure ulcer?

Suspected deep tissue injury

Macrovascular Consequences of DM

TIA, CVA, Cognitive impairment, CAD, MI, Coronary syndrome, CHF, PVD, Ulceration, Gangrene, Amputation

A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important?

Taking a set of vital signs and notifying the surgeon While some bloody drainage on a new surgical dressing is expected, a saturated dressing is not. This client is already at high risk of bleeding due to the ITP. The nurse should assess vital signs for shock and notify the surgeon immediately.

The nurse assesses a client's oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate?

Teach the client about cobalamin therapy. This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. smooth tongue

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How should the nurse respond?

Tell me what it is about the injections that are concerning you

Skin Assessment.

The clean surgical wound regains tissue integrity (heals) at skin level in about 2 weeks in the absence of trauma, connective tissue disease, malnutrition, or the use of some drugs, such as steroids. Smokers and patients who are older, obese, or have diabetes or whose immunity is reduced have delayed wound healing. Complete tissue integrity (healing) of all layers within the surgical wound may take 6 months to 2 years. The physical health and age of the patient, size and location of the wound, and stress on the wound all affect healing time. Head and facial wounds heal more quickly than abdominal and leg wounds because of the better blood flow to the head and neck.

Kidney/Urinary System.

The effects of preoperative drugs (especially atropine), anesthetic agents, or manipulation during surgery can cause urine retention. Assess for urine retention by inspection, palpation, and percussion of the lower abdomen for bladder distention or by the use of a bladder scanner. Urine retention is common early after surgery and requires intervention, such as intermittent (straight) catheterization, to empty the bladder. When the patient has an indwelling urinary (Foley) catheter, assess the urine for color, clarity, and amount. If the patient is voiding, assess the frequency, amount per void, and any manifestations. Report a urine output of less than 30 mL/hr (240 mL per 8-hour nursing shift) to the surgeon. Decreased urine output may indicate hypovolemia or renal complications.

Evaluation: Outcomes

The expected outcomes include that the patient: • Attains and maintains adequate lung expansion and respiratory function • Has complete wound healing without complications • Has acceptable comfort levels after surgery

Discharge

The health care team determines the patient's readiness for discharge from the PACU by the presence of a recovery score rating of 9 to 10 on the recovery scale. Other criteria for discharge (e.g., stable vital signs; normal body temperature; no overt bleeding; return of gag, cough, and swallow reflexes; the ability to take liquids; and adequate urine output). The patient is discharged by the anesthesia provider to the hospital unit or to home.

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

The lower abdomen is the best location because it is closest to the pancreas. The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas.

Planning: Expected Outcomes for Hypoxemia

The patient is expected to attain or maintain optimal lung expansion and breathing patterns after surgery as indicated by: • Partial pressure of arterial oxygen (Pao2) within normal range • Partial pressure of arterial carbon dioxide (Paco2) within normal range • Oxygen saturation values within normal range

Planning: Expected Outcomes for Preventing Wound Infection and Delayed Healing

The patient is expected to have incision healing without wound complications as indicated by: • Wound edges remaining together • No purulent drainage, induration, or redness in, from, or around the incision

Planning: Expected Outcomes for Pain

The postoperative patient is expected to attain or maintain optimal comfort levels. Indicators include: • Reporting that pain is controlled • Absence of physiologic indicators of acute pain (increased heart rate and blood pressure) • Absence of facial grimacing, teeth clenching • Willingness to move and participate in self-care

Postoperative Period

The postoperative period starts with completion of surgery and transfer of the patient to a specialized area for monitoring such as the postanesthesia care unit (PACU) and may continue after discharge from the hospital until all activity restrictions have been lifted. The period of postanesthesia care is divided into three phases that are based on the level of care needed.

Analysis

The priority NANDA-I nursing diagnoses and collaborative problems for patients after surgery include: 1. Potential for hypoxemia related to the effects of anesthesia, pain, opioid analgesics, and immobility 2. Potential for wound infection and delayed healing related to wound location, decreased mobility, drains and drainage, and tubes 3. Acute Pain related to the surgical incision, positioning during surgery, and endotracheal (ET) tube irritation (NANDA-I)

Overview

The purpose of a postanesthesia care unit (PACU) (recovery room) is the ongoing evaluation and stabilization of patients to anticipate, prevent, and manage complications after surgery. After the surgery is completed, the circulating nurse and the anesthesia provider accompany the patient to the PACU. On arrival, the anesthesia provider and the circulating nurse give the PACU nurse a verbal "hand-off" report to communicate the patient's condition and care needs. A hand-off report is at least a two-way verbal interaction between the health care professional giving the report and the nurse receiving it. The language used to give the report is clear, standardized, and cannot be interpreted in more than one way. The nurse receiving the report focuses on the report and is not distracted by the environment or other responsibilities. The receiving nurse takes the time to restate (report back) the information to verify what was said and to make certain he or she has the same understanding as the reporting person. The receiving nurse takes the time to ask questions and the reporting professional must respond.

The nurse is teaching an older adult about how to deal with and prevent dry skin. What information does the nurse include?

Use a humidifier during the winter months or whenever the furnace is in use Avoid clothing that continuously rubs the skin, such as tight belts or pantyhose Throughly rinse soap from the skin

The nurse is irrigating a large pressure ulcer on a patients hip, and notes a small opening in the skin with purulent drainage. Which technique does the nurse use to check for tunneling?

Use a sterile cotton tipped applicator to probe gently for a tunnel

The nurse is caring for a patient in a prolonged coma after a serious head injury. The nurse uses which interventions to prevent the development of pressure ulcers?

Use pillows or padding devices to keep heels pressure free Delegate turning and positioning every 2 hours Obtain an order for pressure relief devices

Which statement is true about the application and use of topical preparations?

Using an oil based ointment in the axillary area could cause folliculitis

Type 1 Characteristics

Usually occurs in childhood or adolescence Onset is abrupt Occurs in 5-10% of all diabetics Caused by an autoimmune process Loss of pancreatic beta cells Insulin levels are absent Insulin replacement is necessary w/ lifestyle modifications Blood glucose levels fluctuate widely DKA is possible

Type 2 Characteristics

Usually occurs over 40 y/o - false! Onset is gradual Family Hx is very common Occurs in 90-95% of diabetics Cause is unknown; family Hx is a risk factor Caused by insulin resistance and inappropriate insulin secretion Insulin levels may be low, normal, or high Blood glucose levels can potentially be more stable than IDDM Hyperglycemic hyperosmolar nonketotic syndrome is possible (HHNS)

The nurse is mentoring a recent graduate RN about administering blood and blood products. What does the nurse include in the data?

Verify with another RN all of the data on blood products. All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities in administering blood and blood products.

Laboratory results for a patient with a large draining abdominal wound show a serum sodium decrease from 138 mEq/L to 131 mEq/L. What is the nurse's first action? Assess the patient's respiratory status. Establish intravenous access. Notify the provider of laboratory results. Assess for orthostatic hypotension

assess the pts resp. status Hyponatremia may present with neuromuscular changes including muscle weakness of the legs, arms, and respiratory muscles. The nurse should assess the respiratory effectiveness of a patient with hyponatremia as a priority. Obtaining assessment data is important when calling the provider in addition to reporting the laboratory result. Establishing IV access and assessing for orthostatic hypotension are important, but are lower-priority interventions.

What might you NOTICE in a patient after surgery who has a surgical wound infection?

• Elevated body temperature • Heart rate elevated above the patient's baseline • Sweating and chills present • Wound edges are red for 1 cm or more on each side of the wound • Incision line is swollen, and skin adjacent to the incision is warmer to the touch than is the skin further away from the incision • Purulent drainage is present • An odor may emanate from the incision • An open area or areas may be present within the incision

Key Points: Safe and Effective Care Environment

• Examine individual patient factors for potential threats to safety, especially risk for surgical site infection, hypoventilation, and venous thromboembolism. Safety • Use aseptic technique during all dressing changes. Safety • Use established criteria to determine when a patient is ready to leave the postanesthesia care unit (PACU) for discharge to home or a medical-surgical nursing unit. • Keep suction equipment, oxygen, and artificial breathing equipment near the patient in the PACU.

Key Points: Psychosocial Integrity

• Keep family members informed of the patient's progress during the time that he or she is in the postanesthesia recovery area. • Reassure patients and family members that taking pain medication when needed, even opioids, does not make them drug abusers.

Management

education exercise health-well balanced diet avoid smoking avoid alcohol Meds: insulin injections, oral (Metformin)

A patient who is unconscious and has a pulse is brought to the emergency department. The patient is wearing a Medic-Alert bracelet indicating type 1 diabetes mellitus. The nurse will anticipate an order to administer

glucagon

A patient who has type 2 diabetes mellitus asks the nurse why the provider has changed the oral antidiabetic agent from tolbutamide (Orinase) to glipizide (Glucotrol). The nurse will explain that glipizide

has a longer duration of action

A patient who has insulin-dependent diabetes mellitus must take a glucocorticoid medication for osteoarthritis. When teaching this patient, the nurse will explain that there may be a need to

increase the insulin dose Glucocorticoids can cause hyperglycemia, so the insulin dose may need to be increased

A patient develops type 2 diabetes mellitus. The nurse will explain that this type of diabetes______

is often related to heredity and obesity.

The patient experiences the Somogyi effect. Which statement regarding the Somogyi effect does the nurse identify as being true

it is a response to excessive insulin The Somogyi effect is a response to excessive insulin resulting in a hypoglycemic condition usually occurring in the predawn hours of 2:00 to 4:00 am

Biguanides

metformin (Glucophage) decreases production of glucose by the liver and by making muscle more sensitive to insulin

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client?

pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg When the lungs can no longer offset acidosis, the pH decreases to below normal

A nurse gives a patient NPH insulin at 8:00 am. At 2:00 pm the nurse finds the patient extremely lethargic but conscious. The patient is diaphoretic and slightly combative. The nurse should

provide the patient with 4 ounces of orange juice

Thiazolidinediones

rosiglitazone (Avandia) and pioglitazone (Actos), work in a similar to Glucophage

Type 2 Signs & Symptoms

sedentary lifestyle familial tendency average age of 50 hx of hypertension fatigue decrease energy recurrent infections

Meglitinides

stimulate the release of more insulin from beta cells. Repaglinide (Prandin) and nateglinide (Starlix)are taken before each of three meals.

The nurse is teaching a patient how to administer insulin. The patient is thin with very little body fat. The nurse will suggest injecting insulin

subcutaneously with the needle at a 45- to 60-degree angle.

A patient received regular insulin at 7:30 am. At 9:30 am the patient feels slightly hungry and has a dull headache. The nurse should

test the patient's blood glucose level

The parent of a junior high-school child who has type 1 diabetes asks the nurse if the child can participate in sports. The nurse will tell the parent

to send a snack with the child to eat just prior to exercise Patients generally need less insulin with increased exercise, so the child should consume a snack to prevent hypoglycemia

Key Points: Physiological Integrity

• Begin every assessment of the patient after surgery by checking the airway and breathing effectiveness. Safety • Assess the incision site each shift (on the medical-surgical nursing unit). • Offer alternative therapies for relaxation, pain reduction, and distraction, such as massage, music therapy, and guided imagery. • In the event of wound dehiscence or evisceration, have the patient lie flat (supine) with knees bent to reduce intra-abdominal pressure; apply sterile, nonadherent dressing materials to the wound; and follow the steps outlined in Chart 16-6.

Most sensitive indication of MH:

An unexpected rise in the end-tidal CO2 level with a decrease in oxygen sat and tachycardia.

General anesthesia depresses the CNS, resulting in _________, ________, ________, _________, and ___________.

Analgesia -amnesia -unconsciousness -loss of muscle tone -reflexes

The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education?

"After this therapy, I will not need to have any more." Induction therapy is not a cure for leukemia, it is a treatment; therefore, the client needs more education to understand this

The nurse is teaching a client with newly diagnosed anemia about conserving energy. What does the nurse tell the client? (Select all that apply.)

"Allow others to perform your care during periods of extreme fatigue." "Drink small quantities of protein shakes and nutritional supplements daily." "Provide yourself with four to six small, easy-to-eat meals daily." "Stop activity when shortness of breath or palpitations are present." It is critical to have others help the anemic client who is extremely tired. Although it may be difficult for him or her to ask for help, this practice should be stressed to the client. Drinking small protein or nutritional supplements will help rebuild the client's nutritional status. Having four to six small meals daily is preferred over three large meals; this practice conserves the body's expenditure of energy used in digestion and assimilation of nutrients. Stopping activities when strain on the cardiac or respiratory system is noted is critical.

A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest? (Select all that apply.)

"Ask her how she is feeling." "Ask her if she needs anything." "Talk to her as you normally would when you haven't seen her for a long time."

A hematology unit is staffed by RNs, LPN/LVNs, and unlicensed assistive personnel (UAP). When the nurse manager is reviewing documentation of staff members, which entry indicates that the staff member needs education about his or her appropriate level of responsibility and client care?

"Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" Determination of the need for oxygen and administration of oxygen should be done by licensed nurses who have the education and scope of practice required to administer it.

The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information?

"Do you feel more tired after you get up and go to the bathroom?" Asking about feeling tired after using the bathroom is pertinent to the client's activity and provides a comparison. The specific activity helps the client relate to the question and provide needed answers.

A patient reported painless, raised vesicles that itched. Within a few days, there was bleeding the center and then is sank inwards. Now it looks black and leathery. Which question does the nurse ask in order to elicit more information about this patient's condition?

"Do you work with or around animals"

The nurse is educating a group of young women who have sickle cell disease (SCD). Which comment from a class member requires correction?

"Getting an annual 'flu shot' would be dangerous for me." The client with SCD should receive annual influenza and pneumonia vaccinations; this helps prevent the development of these infections, which could cause a sickle cell crisis.

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best?

"I can see you are upset. I can stay here with you a while if you like."

The nurse is talking to a patient who is planning to have cosmetic plastic surgery. Which patient statement prompts the nurse to report concerns to the surgeon?

"I know this surgery is going to solve my marital problems"

A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition?

"I usually put ice on bumps or bruises." The client should be taught to apply ice to areas of minor trauma.

A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How should the nurse respond?

A single dose of insulin each day would not match your blood insulin levels and your food intake patterns

Which statements best describe the preoperative period? (Select all that apply) -It begins when the patient makes the appointment with the surgeon to discuss the need for surgery -It ends at the time of transfer to the surgical suite -It is a time during which the patients need for surgery is established -It begins when the patient is scheduled for surgery -It is the time during which the patient receives testing and education related to impending surgery

-It ends at the time of transfer to the surgical suite -It begins when the patient is scheduled for surgery -It is the time during which the patient receives testing and education related to impending surgery

A patient with type 1 diabetes mellitus is scheduled for surgery at 0700. Which actions must the nurse perform for this patient before he goes to the operating room?(Select all that apply) -Modify the does of insulin given based on the patient blood glucose -Complete the preoperative checklist before transfer to surgical suite -Teach the patient about foot care and properly fitted shoes -Delegate obtaining vital signs to the unlicensed assistive personnel -Check if the patient has any jewelry on and call security to secure valuables

-Modify the dose of insulin given based on the patient blood glucose -Complete the preoperative checklist before transfer to the surgical suite -Delegate obtaining vital signs to the unlicensed assistive personnel -Check if the patient has any jewelry on and call security to secure valuables

During preoperative screening, the nurse discovers that the patient is allergic to shellfish. What is the nurse's best first action? -Notifies the surgeon -Develops a plan to keep the patient safe -Obtains an order for a shellfish-free diet -Asks the patient if any other family members have the same allergy

-Notifies the surgeon

A colostomy is scheduled to be done on a patient who has severe Crohn's disease. What is the correct classification for this surgery? -Palliative -Minor -Restorative -Curative

-Palliative

The 79 year old patient with type 2 diabetes is scheduled for surgery to remove his left great toe. Which risk factors for complications of the surgery does the nurse assess for in the patient? (Select all that apply) -Presence of chronic illnesses -Problems with healing -Absence of smoking history -Dehydration -Electrolyte imbalance -Daily exercise routine

-Presence of chronic illnesses -Problems with healing -Dehydration -Electrolyte imbalance

Which are the focus areas for the Surgical Care Improvement Project(SCIP)? (Select all that apply) -Prevention of infection -Prevention of respiratory complications -Prevention of serious cardiac events -Prevention of venous thromboembolism -Prevention of acute kidney injury

-Prevention of infection -Prevention of serious cardiac event -Prevention of venous thromboembolism

The nurse is given the ordered preoperative medications to the patient. What actions must the nurse take after administering these drugs? (Select all that apply) -Raise the side rails -Place the call light within the patients reach -Ask th e patient the sign the consent form -Instruct the patient not to get out of bed -Place the bed in the lowest position

-Raise the side rails -Place the call light within the patients reach -Instruct the patient not to get out of bed -Place the bed in the lowest position

Which postoperative interventions will the nurse typically teach a patient to prevent complications following surgery? (Select all that apply) -Range or motion exercises -Massaging of lower extremities -taking of pain medication only when experiencing severe pain -Incision splinting -Deep breathing exercises

-Range of motion exercises -Incision splinting -Deep breathing exercises

A patient who can barely ambulate with a walker at home is having a left total knee replacement. What is the most appropriate category for this surgery? -Urgent -Restorative -Simple -Palliative

-Restorative

Which statement best describes the collaborative roles of the nurse and surgeon when obtaining the informed consent? -The nurse is responsible for having the informed consent form on the chart for the physician to witness -The nurse may serve as a witness that the patient has been informed by the physician before surgery is performed -The nurse may serve as a witness to the patient's signature after the physician has the consent form signed before preoperative sedation is given and before surgery is performed -The nurse has no duties regarding the consent form if the patient has signed the consent form with the physician, even if the patient asks additional questions about surgery

-The nurse may serve as a witness to the patients signature after the physician has the consent form signed before preoperative sedation and before surgery is performed

The nurse has received a patient in the holding area who is scheduled for a left femoral popliteal bypass. What are the priority safety measures for the patient before surgery?(Select all that apply) -The operative limb is marked by the surgeon -The patient is positively identified by checking the name and date of birth -The patient is asked to confirm the marked operative limb -The patient is identified by checking the name and room number -The patient is instructed to verify any family members waiting

-The operative limb is marked by the surgeon -The patient is positively identified by checking the name and date of birth -The patient is asked to confirm the marked operative limb

A 47 year old patient is having surgery to remove kidney stones. What is the correct classification of this surgery? -Restorative -Emergent -Palliative -Urgent

-Urgent

The nurse is preparing the patient for surgery. Which common laboratory test does the nurse anticipate to be ordered? (Select all that apply?) -Total Cholesterol -Urinalysis -Electrolyte levels -Uric Acid -Clotting studies -Serum creatinine

-Urinalysis -Electrolyte levels -Clotting studies -Serum creatinine

Place the physiologic steps of healing of partial thickness wounds in the correct order using numbers 1-5

1. Skin injury results in local inflammation and formation of a fibrin clot. 2. Growth factors stimulate epidermal cell division and new skin cells move into open spaces 3.Fibrin clot acts to frame or scaffold to guide cell movement 4.Regrowth is only one cell layer thick at first, then the cell layer thickens 5. Stratification and keratin form to resemble normal skin

A patient with burns over a large amount of the body surface requires 2g/kg/day of protein for wound healing. The patient weighs 130 pounds. How many grams of protein does the patient need each day?

110g

A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin?

1600 Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours.

How long do you wash your hands?

3-5 min

The primary health care provider prescribes intravenous administration of 100 mL of 20% glucose along with 20 units of insulin in a patient who is receiving furosemide therapy. What is the probable diagnosis of the patient? Hyperkalemia Hyperglycemia Hypernatremia Hypercalcemia

A Hyperkalemia is a condition where serum potassium levels are high. Potassium movement into the cells is enhanced by insulin. Intravenous administration of 100 mL 10% to 20% glucose with 10 to 20 units of regular insulin helps decrease serum potassium levels. Insulin increases the activity of sodium-potassium pumps, which decreases serum potassium levels temporarily by moving potassium from the extracellular fluid to the cells. This therapy is prescribed as an add-on therapy along with diuretics in a hyperkalemic patient. Conditions such as hyperglycemia, hypernatremia, and hypercalcemia cannot be managed with this insulin and glucose therapy.

How is isotonic dehydration defined? Fluids and electrolytes are lost from the body in equal amounts. Fluids are lost from the body in greater quantities than electrolytes. Electrolytes are lost from the body in greater quantities than fluids. Fluids and electrolytes are lost from the body, but only water is used to replace losses.

A Isotonic dehydration is when fluids and electrolytes are lost in equal quantities. Hypertonic dehydration occurs when fluids are lost in greater quantities than electrolytes. Hypotonic dehydration occurs when electrolytes are lost in greater quantities than fluids, or when fluid and electrolyte losses are replaced by water only.

Which total urine output for the previous day would place a patient at risk for accumulating waste products? 500 mL 700 mL 900 mL 1100 mL

A The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. 700 mL, 900 mL, and 1100 mL of total urine output will not place the patient at risk for accumulating waste products.

The RN is assessing a 70-year-old patient admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? Patient behavior that changes from anxious and restless to lethargic and confused Deep furrows on the surface of the tongue Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched Urine output of 950 mL for the past 24 hours

A The patient's change in level of consciousness from anxious and restless to lethargic and confused suggests poor cerebral blood flow, or shrinkage or swelling of brain cells caused by fluid shifts within the brain cells. These changes indicate a need for immediate intervention to prevent further damage to cerebral function. Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.

Which condition would stimulate the renin-angiotensin II to maintain fluid balance within the body? Shock Hypoglycemia Hypercalcemia Water intoxication

A The renin-angiotensin II pathway is highly stimulated whenever the patient is in shock or when the stress response occurs. This is why urine output is used as an indicator of perfusion adequacy after surgery or any time the patient has undergone an invasive procedure and is at risk for hemorrhage. Hypoglycemia, hypercalcemia, and water intoxication are not conditions that stimulate the renin-angiotensin II to maintain fluid balance within the body.

A patient is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect? Hypernatremia Hypomagnesemia Hypercalcemia Hyperphosphatemia

A These symptoms are indicative of hypernatremia. Clinical manifestations of hypomagnesemia are seen in the neuromuscular, central nervous, and intestinal systems. Hypercalcemia manifests with an altered level of consciousness that can range from confusion and lethargy to coma, and severe hypercalcemia depresses electrical conduction, slowing heart rate. Hyperphosphatemia causes few direct problems with body function (although hypocalcemia is usually also present).

Positive Trousseau's and Chvostek's signs are consistent with which electrolyte imbalance? Hypocalcemia Hypokalemia Hypercalcemia Hyperkalemia

A Trousseau's sign (palmar flexion) and Chvostek's sign (facial twitching) are consistent with acute hypocalcemia. These manifestations are caused by overstimulation of the nerves and muscles. Trousseau's and Chvostek's signs are not used to assess for potassium imbalances.

The nurse is caring for a patient with dehydration. Which task can be delegated to unlicensed assistive personnel (UAP)? Offering 2-4 ounces of fluid to the patient every hour. Calculating the IV fluid rate necessary to replace lost fluids. Administering prescribed antidiarrheal medications to stop fluid losses. Assessing the patient every hour for neurologic or cardiovascular changes.

A Unlicensed assistive personnel (UAP) can aid in encouraging patients who are dehydrated to consume the necessary fluids. Calculating IV fluid rates, administering medications, and performing assessments are out of the scope of practice for UAPs.

Which client does the nurse assign as a roommate for the client with aplastic anemia?

A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) Correct Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia should be free from infection or infection risk.

Which client is at greatest risk for having a hemolytic transfusion reaction?

A 34-year-old client with type O blood Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient.

An RN from pediatrics has "floated" to the medical-surgical unit. Which client is assigned to the float nurse?

A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells Because sickle cell disease is commonly diagnosed during childhood, the pediatric nurse will be familiar with the disease and with red blood cell transfusion; therefore, he or she should be assigned to the client with sickle cell disease.

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk?

A 48-year-old American Indian Diabetes is a particular problem among African Americans, Hispanics, and American Indians.

Minimally invasive surgery (MIS):

A common practice where one or more small incisions is made in the surgical area and an endoscope is placed through the opening; Preferred for many surgeries, including cholecystectomy, cardiac surgery, splenectomy, spinal surgery, lobectomy, and colectomy

Gastrointestinal System 2

A nasogastric (NG) tube may be inserted during surgery to decompress and drain the stomach, to promote GI rest, and to allow the lower GI tract to heal. Record the color, consistency, and amount of the NG drainage every 8 hours. Normal NG drainage fluid is greenish yellow. Red or pink drainage fluid indicates active bleeding, and brown liquid or drainage with a "coffee-ground" appearance indicates old bleeding. Assess the patient for complications related to NG tube use, such as fluid and electrolyte imbalances, aspiration, and nares discomfort. To prevent aspiration, check the tube placement every 4 to 8 hours and before instilling any liquid, including drugs. Electrolyte imbalances can result from NG drainage and tube irrigation with water instead of saline. Imbalances include fluid volume deficit, hypokalemia and hyponatremia, hypochloremia, and metabolic alkalosis. Constipation may occur after surgery as a result of anesthesia, analgesia (especially opioids), decreased activity, and decreased oral intake. Auscultate before palpation or percussion because these two maneuvers can affect peristalsis. Increased dietary fiber intake, the use of mild laxatives or bulk-forming agents, or the use of enemas may be needed.

General anesthesia:

A reversible loss of consciousness, induced by inhibiting neuronal impulses in several areas of the CNS; this state can be achieved with a single agent or a combination of agents

A 92-year-old woman is admitted from a long-term care facility for treatment of dehydration. The provider has ordered fall precautions. Which interventions does the nurse implement as part of fall precautions? Assess for orthostatic hypotension. Orient the patient frequently. Loosely apply upper-extremity wrist restraints. Maintain a calm, dim room to reduce confusion. Place the bed in the lowest position with brakes locked. Activate the bed alarm.

A, B, E, F Multiple interventions are implemented to prevent falls, especially in older patients with dehydration. Assessing for orthostatic hypotension, orienting the patient frequently, placing the bed in the lowest position with the brakes locked, and activating the bed alarm should all be implemented to reduce the patient's risk of falling. In addition, frequent toileting and assistance to the bathroom may be indicated for this older patient. Restraints are never appropriate. A dimly lit room may increase the risk of falls.

The nurse admits a patient with dehydration. Which electrolyte imbalances does the nurse anticipate based on this diagnosis? Hyperkalemia Hypocalcemia Hypochloremia Hypernatremia Hypermagnesemia

A, D A patient who is admitted with dehydration will have hyperkalemia and hypernatremia. Hypocalcemia, hypochloremia, and hypermagnesemia are not expected electrolyte imbalances for a patient admitted with dehydration.

The nurse is admitting a 78-year-old patient with severe diarrhea in the emergency department. Which assessment findings indicate that the patient may be dehydrated? Dizziness when standing Distended neck veins Bounding radial pulses Newly reported confusion Temperature of 99.4° F

A, D, E Postural hypotension causing dizziness may occur with dehydration. Neck veins are flat, not distended; peripheral pulses are weak, not bounding. Because of decreased perfusion to the brain, confusion is common in older adults. Low-grade fever is a common result of dehydration.

The nurse assesses the client with which hematologic problem first?

An 81-year-old with thrombocytopenia and an increase in abdominal girth An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage; this warrants further assessment immediately.

What is used for the scrub?

An antimicrobial solution

Anesthesia

An induced state of partial or total loss of sensory perception, with or without loss of consciousness; purpose is to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and sometimes to achieve a controlled state of unconsciousness

Management of Evisceration: Preventing Wound Infection and Delayed Healing

An evisceration (a wound opening with protrusion of internal organs) is a surgical emergency. Chart 16-6 lists best practices for emergency care of the patient with surgical wound evisceration. Prepare the patient for surgery to close the wound. Regional or local anesthesia may be used, depending on the location and type of wound. Nausea and vomiting, which stress the already fragile incision, are reduced when regional or local anesthesia is used. To increase the incision's integrity, stay or retention sutures of wire or nylon are used along with standard sutures or staples

Which nursing intervention is appropriate when caring for a client with Alzheimer's disease? A. Provide a large clock and calendar. B. Place the client in a geri-chair to prevent wandering. C. Insert a urinary catheter to prevent incontinence. D. Place the client in the nurse's station.

A. Provide a large clock and calendar. Rationale A. Providing a large clock and calendar may stimulate cognition. The nurse will also be able to use these tools to orient the client to date and time. The clock and calendar should not be abstract, because this may frighten the client. The purpose of cognitive stimulation and memory training is to reinforce or promote desirable cognitive function and facilitate memory. Reference: p. 953, Safe and Effective Care Environment B. Placing the client in a geri-chair is considered a physical restraint and should be avoided. Reference: p. 953, Safe and Effective Care Environment C. The client should be placed on a toileting schedule, but an indwelling catheter is not necessary. Removing the catheter while the balloon remains inflated may increase the client's risk for injury. A foreign object such as a catheter may also increase the client's confusion and agitation. Reference: p. 953, Safe and Effective Care Environment D. The client should not be placed near the nursing station because of the level of noise and activity. In addition to disturbed sleep, other negative effects of high noise levels include decreased nutritional intake, changes in blood pressure and pulse rates, and feelings of increased stress and anxiety. The client with AD is especially susceptible to these changes and must have as much undisturbed sleep at night as possible. Fatigue increases confusion and behavioral manifestations such as agitation and aggressiveness. Reference: p. 953, Safe and Effective Care Environment

Insulins: Action, Use, Interactions

Action Promote use of glucose by body cells, store glucose as glycogen in muscles Use Reduce blood glucose, control diabetes mellitus Interactions Increase glucose with thiazides, glucocorticoids, estrogen, thyroid drugs Decrease glucose with TCAs, MAOIs, aspirin, oral anticoagulants

Sliding scale insulin coverage

Adjusted doses dependent on individual blood glucose Monitor blood glucose. Before meals and at bedtime Involves rapid or short-acting insulin

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?

Administer 1 mg of intramuscular glucagon. blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the client's blood glucose level.

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next?

Administer another half-cup of orange juice

What is the nurse's best action when finding a patient with type 1 diabetes mellitus unresponsive, cold, and clammy?

Administer glucagon

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority?

Administer oxygen. All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process.

Administration of general anesthesia:

Administered by INHALATION and IV INJECTIONS

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take?

Administration of intravenous insulin The rapid, deep respiratory efforts of Kussmaul respirations are the body's attempt to reduce the acids produced by using fat rather than glucose for fuel.

Action Alert: NG intubation

After gastric surgery, do not move or irrigate the NG tube unless prescribed by the surgeon.

When does the surgeon, assistants, and scrub nurse perform a surgical scrub?

After putting on a mask but before putting on sterile gown and gloves

History.

After receiving the report and assessing the patient, review the medical record for information about the patient's history, physical condition, and emotional status.

Health Care Resources.

After returning home, the patient may need supplies or equipment and assistance with dressing changes, ADLs, and meal preparation. Referral to a home care agency is made if needed. The home care nurse provides skilled nursing assessments, dressing supplies, education in self-care, and referrals for services as needed. Such referrals include Meals on Wheels, support groups, and homemaker services (e.g., for housekeeping, food shopping).

Breathing Exercises: Hypoxemia

After the patient regains the gag and cough reflexes and meets the agency's criteria for extubation (if intubated), remove the airway or ET tube. Usual extubation criteria include the ability to raise and hold the head up and evidence of thoracic breathing. Help the patient splint the incision, cough, and deep breathe to promote gas exchange and eliminate anesthetic agents. Urge him or her to cough, use the incentive spirometer, and take deep breaths hourly while awake throughout the postoperative period. The patient who is unable to remove mucus or sputum 267requires oral or nasal suctioning. Perform mouth care after removing secretions.

Action Alert: Patient and Family Education

Always ensure that the patient and family receive written discharge instructions to follow at home. Assess the patient's and family's understanding of the instructions by having them explain the instructions in their own words.

Malignant Hyperthermia (MH):

An inherited muscle disorder, it is an acute, life-threatening complication of certain drugs used for General Anastasia; characterized by poor thermoregulation

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met?

Doing activities of daily living (ADLs) using rest periods Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it.

Oxygen Therapy: Hypoxemia

Apply oxygen by face tent, nasal cannula, or mask to eliminate inhaled anesthetic agents, increase oxygen levels, raise the level of consciousness, and reduce confusion. After the patient is fully reactive and stable, raise the head of the bed to promote respiratory function.

A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.)

Argatroban (Argatroban) Bivalirudin (Angiomax) Lepirudin (Refludan) The standard drugs used to treat HIT are argatroban, bivalirudin, and lepirudin. (LAB)

Dressings and Drains.

Assess all dressings, including casts and elastic (Ace) bandages, for bleeding or other drainage on admission to the PACU and then hourly thereafter. Assess the dressing each time vital signs are taken (at least every 8 hours) in normal unit. During dressing inspection, check for drainage and record its amount, color, consistency, and odor. If drainage is present on a dressing or cast, monitor its progression by outlining it with a pencil and indicating the date and time. Check the area underneath the patient bc of leakage. Ensure that the dressing does not restrict circulation or sensation. A Penrose drain (a single-lumen, soft, open, latex tube) is a gravity-type drain under the dressing. Assess closed-suction drains, such as Hemovac, Vacu-Drain, and Jackson-Pratt drains, for maintenance of suction. Specialty drains, such as a T-tube, may be placed for specific drainage purposes. For example, a T-tube drains bile after a cholecystectomy. Chronic wounds or wounds that heal by delayed primary intention are drained with a negative pressure wound device. Assess all drains for patency when the patient is admitted to the PACU and every time vital signs are taken. Monitor the amount, color, and type of drainage while the patient is in the PACU and at least every 8 hours after he or she is transferred to the medical-surgical nursing unit. Large amounts of sanguineous drainage may indicate poor clotting and possible internal bleeding.

The family of a neutropenic client reports the client "is not acting right." What action by the nurse is the priority?

Assess the client for infection. Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse should assess for infection.

A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.)

Assess vital signs more often. Hold other IV fluids running. The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion.

Physical Assessment/Clinical Manifestations.

Assessment data include level of consciousness, temperature, pulse, respiration, oxygen saturation, and blood pressure. Examine the surgical area for bleeding. Monitor vital signs as often as your facility's policy states, the patient's condition warrants, and the surgeon prescribes. During the postoperative period, all patients remain at risk for pneumonia, shock, cardiac arrest, respiratory arrest, clotting and venous thromboembolism (VTE), and GI bleeding. These serious complications can be prevented or the consequences reduced with collaborative care. Nursing observations and interventions are part of critical rescue management for patient safety and quality care.

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful?

Assist the client to make "sick day" plans for household responsibilities. While all options are reasonable choices, the best option is to help the client make sick day plans, as that is more comprehensive and inclusive than the other options, which focus on a single item.

Movement: Hypoxemia

Assist the patient out of bed and to ambulate as soon as possible to help remove secretions and promote ventilation. The expectation may be to get out of bed the day of or the first day after surgery. If this is not possible, assist him or her to turn at least every 2 hours (side to side) and ensure that breathing exercises and leg exercises are performed. Early ambulation reduces the risk for pulmonary complications. It increases circulation to extremities and reduces the risk for clotting and venous thromboembolism (VTE), especially deep vein thrombosis (DVT). When indicated, offer pain medication 30 to 45 minutes before he or she gets out of bed.

What is the patient at risk for in the OR?

At risk for infection, impaired skin integrity, increased anxiety, poor Thermo regulation in altered body temps, and injury related to positioning

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this client's teaching?

Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents.

Which condition triggers aldosterone secretion to maintain fluid balance within the body? Hypocalcemia Hyponatremia Diabetes mellitus Cardiovascular disease

B Aldosterone is a hormone secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are decreased in order to maintain fluid balance within the body. Hypocalcemia, diabetes mellitus, and cardiovascular disease do not cause the secretion of aldosterone.

Which condition triggers aldosterone secretion to maintain fluid balance within the body? Hypocalcemia Hyponatremia Diabetes mellitus Cardiovascular disease

B Aldosterone is a hormone secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are decreased in order to maintain fluid balance within the body. Hypocalcemia, diabetes mellitus, and cardiovascular disease do not cause the secretion of aldosterone.

What is the function of aldosterone in the body? It causes constriction of renal arterioles. It promotes resorption of water and sodium. It stimulates secretion of renin for the kidneys. It causes constriction of peripheral blood vessels.

B Aldosterone promotes reabsorption of sodium and water into the body, which helps in maintaining blood pressure. Angiotensin II causes constriction of renal arterioles, resulting in low urine output. Factors such as low blood pressure, low blood volume, low oxygen, and low sodium trigger secretion of renin. Angiotensin II causes constriction of peripheral blood vessels and helps in maintaining perfusion to vital organs.

Laboratory results report a patient's serum potassium at 5.6 mEq/L. What does the nurse immediately assess in the patient? Level of consciousness Heart rate Bowel sounds Feet for paresthesias

B Cardiovascular changes, specifically bradycardia; tall, peaked T waves; rhythm changes to complete heart block; asystole; and ventricular fibrillation are life-threatening consequences of elevated potassium. The provider or Rapid Response Team may need to be notified if changes in heart rate and rhythm are assessed. Paresthesias in the arms and feet and increased intestinal motility are lower-priority signs of elevated potassium. Level of consciousness would not be affected.

A patient who is suffering from chronic fluid overload asks the nurse to suggest necessary dietary changes. What dietary changes suggested by the nurse apart from restricting fluid intake would be effective to minimize fluid overload? Intake of 5-6g/day of sodium Intake of 2-4g/day of sodium Intake of 3-5g/day of sodium Intake of 4-6g/day of sodium

B Excessive sodium and fluid intake are the main causes of hypervolemia or fluid overload. Nutrition therapy for the patient with fluid overload may involve restriction of sodium and fluid intake. A patient suffering from chronic fluid overload may be restricted to 2-4g/day of sodium. Intake of 5-6g, 3-5g, or 4-6g of sodium per day may lead to further fluid overload and retention.

How much fluid should a healthy adult consume each day to maintain adequate urine output? 2 L/day 2.3 L/day 2.6 L/day 2.9 L/day

B Most healthy adults take in about 2300 mL of fluid each day, which is equivalent to 2.3 L/day. The other figures do not accurately account for the amount of daily fluid from food and liquids.

The nurse is providing education to a patient diagnosed with hypertension. Which statement by the nurse is most appropriate to help the patient maintain a normal fluid balance? "Increase your intake of water each day to increase urine output." "Limit your intake of sodium to decrease the water you are retaining." "Foods rich in potassium, such as bananas, will increase urine output." "Foods rich in calcium, such as milk, will help to decrease urine output."

B The best way for a patient with hypertension to maintain a normal fluid balance is to limit the intake of dietary salt. The reason for this is that a high sodium intake raises the blood level of sodium, causing more water to be retained in the blood volume and raising blood pressure. The patient may be asked to decrease their fluid intake due to edema. Foods rich in potassium and calcium will not help the patient with hypertension maintain a normal fluid balance.

A hypertensive patient was brought to the emergency department with a heart rate of 115 beats per minute and an abnormal electrocardiogram showing a shortened QT interval. The laboratory findings of the patient show a serum calcium level of 11 mg/dL. What nursing interventions would help stabilize the patient? Administering thiazide diuretics Administering high ceiling or loop diuretics Administering 0.9% normal saline intravenously Administering Ringer's lactate solution intravenously Administering non-steroidal, anti-inflammatory agents

B, C Hypercalcemia clinically manifests as serum calcium levels above 10.5 mg/dL. This condition can be managed by using loop diuretics such as furosemide, which promote the excretion of calcium. One cause of hypercalcemia is dehydration, which can be well managed by administering 0.9% normal saline intravenously. Thiazide diuretics do not promote the excretion of calcium and thus are not suitable treatments for hypercalcemia. Ringer's lactate solution contains calcium; administering this solution does not help decrease the serum calcium levels. Administering non-steroidal, anti-inflammatory agents prevents hypercalcemia by calcium resorption from the bone; however, it does not treat hypercalcemia.

Which assessment findings will indicate the need for continuation of prescribed fluid replacement therapy in a patient diagnosed with dehydration? Hemoglobin of 13.5 g/dL Pulse pressure of 28 mm Hg Urine output of 400 mL per day Respiratory rate of 20 breaths per minute Neck veins distention when the patient is in a supine position

B, C Pulse pressure below 40 mm Hg and urine output below 500 mL are abnormal and require continuation of the fluid replacement therapy. Hemoglobin of 13.5 g/dL is within the normal range. Respiratory rate of 20 breaths per minute is also a normal finding. Neck veins distention is evidence of fluid overload.

What history and assessment findings may be associated with hypocalcemia in a 22-year-old man? Decreased deep tendon reflexes without paresthesia Awakening at night with muscle spasms in the calf Recent blunt trauma to the throat during a football game Absent bowel sounds Tingling around the mouth

B, C, E A history of anterior neck injury may be associated with hypocalcemia. Symptoms of hypocalcemia include "charley horses" in the calf during rest or sleep, and tingling in the lips. Hypocalcemia does not affect bowel sounds. Decreased deep tendon reflexes without paresthesia is a neuromuscular change in hypercalcemia.

A patient reports swelling of the right foot and ankle. Upon assessing the patient, the health care provider confirms it as pitting edema and prescribes diuretic therapy. Which nursing interventions are necessary for this patient? Monitoring the respiratory rate Monitoring the urine output of the patient Assessing the sodium and potassium values Checking the urine for correct specific gravity Monitoring the electrocardiogram patterns (ECG)

B, C, E Patients with fluid overload often have pitting edema, and diuretic therapy focuses on removing the excess fluid. The nursing interventions would be monitoring the patient's response to drug therapy, especially increased urine output and weight loss. Diuretic therapy is associated with electrolyte imbalance; therefore, sodium and potassium levels need to be monitored. Severe electrolyte disturbances may result in arrhythmias. Therefore, changes in the electrocardiogram (ECG) should be monitored. Diuretic therapy does not cause respiratory depression or changes in respiratory rate, so the respiratory rate does not need to be monitored. Checking the urine specific gravity is beneficial in patients to detect the fluid overload. However, it is not useful in patients on diuretic therapy.

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L. What does the nurse include in the patient's medication teaching? Daily weights are a poor indicator of fluid loss or gain. Diuretics can lead to fluid and electrolyte imbalances. Diuretics increase fluid retention. Laxatives can lead to fluid imbalance. It is important to weigh daily at the same time.

B, D, E Diuretics decrease fluid retention and increase loss of fluids, thus can lead to fluid and electrolyte imbalances. Laxatives can also lead to fluid imbalance. Daily weight recording is a good indicator of fluid retention. Patients should be taught to weigh themselves at the same time, in the same clothing, and on the same scale.

Which hormones play a role in the regulation of sodium balance by the kidneys? Cortisol Aldosterone Angiotensin Natriuretic peptide (NP) Antidiuretic hormone (ADH)

B, D, E Serum sodium levels are regulated by the kidneys under the influence of aldosterone, natriuretic peptide (NP), and antidiuretic hormone (ADH). Low serum sodium levels inhibit the secretion of antidiuretic hormone (ADH) and natriuretic peptide (NP) and trigger the secretion of aldosterone. This increases the serum sodium levels by increasing the reabsorption of sodium and enhancing water loss by the kidney. High serum sodium levels inhibit aldosterone secretion and stimulate the secretion of antidiuretic hormone (ADH) and natriuretic peptide (NP). These hormones increase the excretion of sodium and reabsorption of water by the kidney. Cortisol and angiotensin do not regulate the serum sodium levels.

What are the risk factors for the development of leukemia? (Select all that apply.)

Bone marrow hypoplasia Chemical exposure Down syndrome Ionizing radiation educed production of blood cells in the bone marrow is one of the risk factors for developing leukemia. Exposure to chemicals through medical need or by environmental events can also contribute. Certain genetic factors contribute to the development of leukemia; Down syndrome is one such condition. Radiation therapy for cancer or other exposure to radiation, perhaps through the environment, also contributes.

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. What is the major side effect of this therapy?

Bone marrow suppression Intravenous cytosine arabinoside and daunorubicin are a commonly prescribed course of aggressive chemotherapy, and bone marrow suppression is a major side effect.

A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.)

Donor blood type A can donate to recipient blood type AB. Donor blood type O can donate to anyone. Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB.

A client with a history of seizures is placed on seizure precautions. What emergency equipment will the nurse provide at the bedside? Select all that apply. A. Padded tongue blade B. Oxygen setup C. Nasogastric tube D. Suction setup E. Artificial oral airway

B. Oxygen setup D. Suction setup E. Artificial oral airway Rationale Clients placed on seizure precautions should have an oxygen setup, suction equipment, and an artificial oral airway at the bedside. Maintaining a patent airway is the priority for this client's care. Intubation by an anesthesia provider or respiratory therapist may be necessary. Oxygen may need to be administered as indicated by the client's condition. Padded tongue blades do not belong at the bedside and should NEVER be inserted into the client's mouth because the jaw may clench down as soon as the seizure begins. Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk of aspirating tooth fragments than prevent the client from biting the tongue. Furthermore, improper placement of a padded tongue blade can obstruct the airway. There is no physiologic reason to place a nasogastric tube emergently for a client experiencing seizure activity. In fact, convulsions may make it difficult to place the tube and put the client at risk.

Dressings: Preventing Wound Infection and Delayed Healing

Before the first dressing change, reinforce the dressing (add more dressing material to the existing dressing) if it becomes wet from drainage. Document the added material, as well as the color, type, amount, and odor of drainage fluid and time of observation. Assess the surgical site at least every shift, and report any unexpected findings. After removal of the dressing, the surgeon may leave the suture or staple line open to the air, which allows easy assessment of the wound and early detection of poor wound edge adherence, drainage, swelling, or redness. Some surgeons believe that air-drying promotes healing. A draining wound, however, is always covered. An unchanged wet or damp dressing is a source of infection. Change dressings using aseptic technique until the sutures or staples are removed. Common dressings for large incisions consist of gauze or nonadherent pads covered with a larger absorbent pad held in place by tape, a tubular stretchy net, or Montgomery straps. Some incisions may be covered with a transparent plastic surgical dressing (e.g., OpSite) or a spray in the operating room. This type of dressing stays intact for 3 to 6 days, allows direct observation of the wound, prevents contamination, and eliminates the need for dressing changes. Wound or suture line care consists of changing gauze dressings at least once during a nursing shift or daily and may include cleaning the area with sterile saline or some other solution. For large dressing changes or drain removal, offer the patient a prescribed analgesic before the procedure. Always assess the skin for redness, rash, or blisters in areas where tape has been used. Tape can cause a skin reaction. Skin sutures or staples are usually removed 5 to 10 days after surgery, although this varies. After sutures or staples are removed, the incision may then be secured with Steri-Strips. The surgeon or the nurse removes the sutures or staples, depending on the agency's policy. Clean the incision with the prescribed solution before removing sutures or staples. Before removing sutures, examine the condition and healing stage of the wound. First remove every other suture or staple and re-assess the wound for integrity. If wound healing is progressing normally, the rest of the sutures or staples may then be removed.

When are counts of surgical instruments, sharps, and sponges done?

Before, during procedure (when items are added/personelle leave), at closure of first layer of surgical wound, and immediately before complete skin closure

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition?

Bence-Jones protein in urine This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition.

A patient is prescribed metformin. Which is a side effect/adverse effect common to metformin?

Bitter or metallic taste

Complications: Hypoglycemia

Blood glucose less than 60 mg/dL or drops rapidly from an elevated level. Remember the mnemonic: "I'm sweaty, cold, and clammy....give me some candy" Signs and Symptoms: Sweating, clammy, confusion, light headedness, double vision, tremors Treatment: Need simple carbs if they can eat, or if unconscious IV D50 Simple carbs include: hard candies, fruit juice, graham crackers, honey

Diabetes Mellitus

Body is unable to use glucose due to either the absence of insulin or the body's resistance to insulin -Hyperglycemia (glucose remains in blood); body starts to metabolize FATS for energy

Surgeon

Is responsible for surgical procedure and judgments about patient

The nurse manager of the medical-surgical unit assigns which patient to the LPN/LVN? 44-year-old admitted with dehydration who has a heart rate of 126 54-year-old just admitted with hyperkalemia who takes a potassium-sparing diuretic at home 64-year-old admitted yesterday with heart failure who still has dependent pedal edema 74-year-old who has just been admitted with severe nausea, vomiting, and diarrhea

C Because the patient with heart failure is the most stable of the four patients, this patient is most appropriate to assign to the LPN/LVN. Dehydration, tachycardia, potassium overload, and GI signs and symptoms in a patient indicate that he or she is unstable and should be cared for by RN staff members.

What is the reason for relative dehydration? Too much fluid loss Too little fluid intake Fluid shift from plasma to interstitial space Fluid shift from interstitial space to plasma

C Dehydration without actual loss of total body water, such as when the fluid shifts from plasma to the interstitial space, is called relative dehydration. Too much fluid loss is the decrease in the total body water, leading to dehydration. Too little fluid intake also causes an actual decrease in the total water content of the body, which results in dehydration. A fluid shift from the interstitial space to the plasma causes an increase in plasma volume, which is a condition known as hypervolemia.

A patient with a history of hypertension asks the nurse what dietary changes are necessary to make in order to control the blood pressure. What does the nurse include in the instruction? Reduce the intake of iron Reduce the intake of calcium Reduce the intake of sodium Reduced the intake of phosphorous

C High sodium intake raises the serum sodium level, which causes more water to be retained. This in turn increases the blood volume and raises the blood pressure. Hence, patients who have hypertension are often asked to limit their intake of sodium. Intake of iron, phosphorus, or calcium does not cause water retention in the blood, and therefore, does not affect the blood pressure.

When planning care for a patient with hypercalcemia, which intervention does the nurse consider? Assess oxygen saturation levels every 4 hours. Avoid invasive procedures due to increased bleeding tendency. Monitor cardiac rhythm for changes. Limit activities to protect against injury.

C Hypercalcemia increases the risk for cardiac dysrhythmias. It does not impair gas exchange, so oxygen saturation does not need to be routinely monitored. There is a greater tendency to clot, especially with slow venous perfusion, so invasive procedures do not need to be avoided and increased activity (not restriction) is recommended.

Which condition could be evident in laboratory reports of a hypervolemic patient? Hemostasis Homeostasis Hemodilution Hemoconcentration

C Hypervolemia or fluid overload is characterized by decreased hemoglobin, hematocrit, and serum protein levels due to excessive water in the vascular space. This condition is called hemodilution. Hemostasis and homeostasis are not associated with hypervolemia or fluid overload. Hemoconcentration is the condition associated with hypovolemia or dehydration.

The nurse is reviewing the basic metabolic panel for a patient who was admitted to the medical-surgical unit the previous day. Which finding indicates that the patient is suffering from fluid volume overload? Hyperkalemia Hypercalcemia Hyponatremia Hyperchloremia

C Most problems caused by fluid overload are related to excessive fluid in the vascular space or to dilution of specific electrolytes lowering their serum levels. Hyponatremia, or a low level of sodium is often manifested. Hyperkalemia, hypocalcemia, and hypercholoremia is not seen in a patient with fluid volume overload

Which electrolyte imbalance should be anticipated and monitored in a patient with hyperphosphatemia? Hypernatremia Hypokalemia Hypocalcemia Hypermagnesemia

C Phosphorus and calcium have an inverse or reciprocal relationship. When one is increased, the other is usually decreased. Therefore, a patient with hyperphosphatemia should be monitored for hypocalcemia. Hyperphosphatemia does not cause hypernatremia, hypokalemia, or hypermagnesemia.

A patient is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first? Blood pressure Pulse Respirations Temperature

C Respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations. Thus, respiratory status should be assessed first in any patient who might have hypokalemia. Blood pressure and pulse will be altered in this patient, but they are not the priority assessment. Temperature is not a priority assessment for the patient with hypokalemia.

What is the primary assessment in evaluating the effectiveness of diuretic therapy? Blood pressure Respiratory rate Urinary output Skin turgor

C Since the most direct effect of a diuretic is diuresis, urinary output is the most reliable indicator of its effectiveness. Blood pressure, respiratory rate, and skin turgor all reflect volume status, but are not the primary evaluation of diuretic administration.

Which is the most critical fluid to prevent death? Urine Perspiration Blood volume Intracellular fluid

C The most important fluids to keep in balance are the blood volume (plasma volume) and the fluid inside the cells (intracellular fluid). Of these two, the most critical fluid balance to prevent death is maintaining blood volume at a sufficient level for blood pressure to remain high enough to ensure adequate perfusion and gas exchange of all organs and tissues. Urine and perspiration both play a role in fluid balance but are not critical fluids to prevent death.

The nurse is caring for a patient who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? 24-hour urine output Asking the patient about feeling depressed Hourly deep tendon reflexes (DTRs) Monitoring of serum calcium levels

C The patient who is receiving IV magnesium sulfate should be assessed for signs of toxicity every hour by assessment of DTRs. Most patients who have fluid and electrolyte problems will be monitored for intake and output (I&O); this will not immediately generate data about problems with magnesium overdose. Low magnesium levels can cause psychological depression, but assessing this parameter as the levels are restored would not be a method by which to safely assess a safe dose or an overdose. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity

A client with Alzheimer's disease asks the nurse to find her mother, who is deceased. What is the nurse's best response? A. "Your mother died over 20 years ago." B. "I'll find your mother as soon as I finish passing meds." C. "What did your mother look like?" D. "I'll ask your daughter to find your mother."

C. "What did your mother look like?" Rationale A. For the client in the later stages of AD, reality orientation does not work and often increases agitation. Reference: p. 951, Psychosocial Integrity B. Telling the client to wait until medications have been issued or that her daughter will find her mother is not consistent with validation therapy because it reinforces the client's belief that her mother is still alive. Reference: p. 951, Psychosocial Integrity C. The nurse should use validation therapy for the client with moderate or severe Alzheimer's disease (AD). In validation therapy, the staff member recognizes and acknowledges the client's feelings and concerns. This response is not argumentative but also does not reinforce the client's belief that her mother is still living. Reference: p. 951, Psychosocial Integrity D. Telling the client to wait until medications have been issued or that her daughter will find her mother is not consistent with validation therapy because it reinforces the client's belief that her mother is still alive. Reference: p. 951, Psychosocial Integrity

A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority?

Calling the Rapid Response Team With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change.

Complications of general anesthesia:

Can range from sore throat to death

Phase I

Care occurs immediately after surgery, most often in a PACU, although care in an ambulatory care unit or ICU may occur. The length of time the patient remains at a phase I level of observation depends on his or her health status, the surgical procedure, anesthesia type, and rate of progression to complete alertness and hemodynamic stability. It can range from less than 1 hour to days. This level features very close monitoring of the airway, vital signs, and indicators of recovery that varies from every 5 to 15 minutes initially.

Neurologic System.

Cerebral functioning and the level of consciousness or awareness must be assessed in all patients who have received general anesthesia or any type of sedation. Observe for lethargy, restlessness, or irritability, and test coherence and orientation. Determine awareness by observing responses to calling the patient's name, touching the patient, and giving simple commands such as "Open your eyes" and "Take a deep breath." Eye opening in response to a command indicates wakefulness or arousability but not necessarily awareness. Determine the degree of orientation to person, place, and time by asking the conscious patient to answer questions such as "What is your name?" (person), "Where are you?" (place), and "What day is it?" (time). Compare the patient's baseline neurologic status with the findings after surgery. After the patient is alert + criteria he or she is discharged from the PACU. The medical-surgical nursing unit, assess the level of consciousness every 4 to 8 hours or as indicated. Motor function and sensory function after general anesthesia are altered and must be assessed. Motor and sensory function after spinal and epidural anesthesia are profoundly affected and critical to assess. Assess the level of sensation loss remaining by lightly pricking the patient's skin with a needle or pin and having the patient indicate when the sensation feels sharp rather than dull (just pressure). Evaluate motor function by asking the patient to move each extremity. The patient who had epidural or spinal anesthesia remains in the PACU until sensory function (feeling) and voluntary motor movement of the legs have returned. Also assess the strength of each limb bilaterally. Test for the return of sympathetic nervous system tone by gradually elevating the patient's head and monitoring for hypotension.

A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this client's discharge education?

Change the needle every 3 days

A patient is diagnosed with chronic psoriasis and is prescribed a topical therapy of anthralin (Lasan). What does the nurse teach the patient about proper use of this drug?

Check for local tissue reaction

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia (AML) is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. An infection develops. What knowledge does the nurse use to determine that the appropriate antibiotic has been prescribed for this client?

Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection is the best action to take.

A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.)

Chemical exposure Ionizing radiation exposure Viral infections Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

Who notifies post-anesthesia (PACU) care unit of patients time of arrival and any special needs?

Circulating nurse

The nurse receives the following order for insulin: IV NPH (Humulin NPH) 10 units. The nurse will perform which action?

Clarify the insulin type and route. Only regular insulin can be given intravenously. The nurse should clarify the order. It is not correct to give Humulin NPH insulin IV.

Assessment

Classic 3 P's & SUGAR Slow wound healing blUrry vision Glycosuria (kidneys can't reabsorb extra glucose) Acetone smell of breath Rashes on skin DRY and itchy, repeated yeast infections fasting bld glucose >7.0mmol/L family history, race/ethnicity, age, hypertension, hyperlipidemia, history of gestational DM

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first?

Client who had two bloody diarrhea stools this morning The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first?

Client who reports shortness of breath Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first.

Laboratory Assessment.

Common tests include analysis of electrolytes and a complete blood count. Changes in electrolyte, hematocrit, and hemoglobin levels often occur during the first 24 to 48 hours after surgery because of blood and fluid loss and the body's reaction to the surgical process. Fluid loss with minimal blood loss may cause elevated laboratory values. An indication of infection is an increase in the band cells (immature neutrophils) in the white blood cell differential count, known as a "left-shift" or bandemia. Obtain specimens for culture and sensitivity testing, and monitor the culture reports at 24, 48, and 72 hours. Notify the surgeon of positive culture results. Arterial blood gas (ABG) tests may be needed for patients who have respiratory or cardiac disease, those undergoing mechanical ventilation after surgery, and those who had chest surgery. Notify the surgeon of any acid-base imbalance or hypoxemia that indicates poor gas exchange.

Psychosocial Assessment.

Consider the patient's age and medical history, the surgical procedure, and the impact of surgery on recovery, body image, roles, and lifestyle. Indications of anxiety include restlessness; increased pulse, blood pressure, and respiratory rate; and crying. The patient may be anxious and ask questions about the results or findings of the surgical procedure. Reassure the patient that the surgeon will speak with him or her after he or she is fully awake.

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take?

Consult the provider to test for ketoacidosis The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis.

What is the optimal temp?

Cool room temp between 68-73 degrees F; with low humidity (30-60%)

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory work. Which finding should the nurse report to the provider?

Creatinine: 2.9 mg/dL An elevated creatinine indicates kidney damage, which occurs in SCD.

The nurse is reviewing lab values for a patient recently admitted to the medical-surgical unit. Which lab result is severely abnormal? Potassium, 3.5 mEq/L Sodium, 137 mEq/L Chloride, 107 mEq/L Magnesium, 6.2 mEq/L

D A magnesium level of 6.2 mEq/L is greatly elevated. Patients with severe hypermagnesemia are in grave danger of cardiac arrest. The normal magnesium level is 1.3-2.1 mEq/L. The sodium and potassium results are within normal limits. The chloride level is just slightly elevated, with the normal range being between 98-106 mEq/L.

An older adult admitted with dehydration and a history of stress incontinence expresses embarrassment about the disorder and the need for absorbent undergarments. Which question about nutritional metabolic needs would be best to ask this patient related to the reason for admission? What is your typical urinary elimination pattern and amount? How is your appetite? Have you noticed a change in the tightness of your shoes? What is your typical daily fluid intake and what types of fluids do you drink?

D Asking the patient about the amount and types of fluids will provide additional information as to how the patient deals with incontinence through fluid management and possible causes for the dehydration. Asking the patient about appetite, urinary pattern, and tightness of shoes is not helpful in assessing the patient's current health problem.

A 90-year-old patient with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the patient for admission to which inpatient unit? Dialysis/home care Geriatric/rehabilitation Medical-surgical Telemetry/cardiac stepdown

D Because hypermagnesemia causes changes in the electrocardiogram that may result in cardiac arrest, the patient should be admitted to the telemetry/cardiac stepdown unit. Dialysis/home care units, geriatric/rehabilitation units, and medical-surgical units typically do not have cardiac monitoring capabilities.

A 5-year-old child is brought into the emergency department with persistent vomiting and diarrhea. The child's parents state that the child has lost 4 pounds since the symptoms began. Based on this information, approximately how much fluid has the child lost? 500 milliliters 1 liter 1.5 liters 2 liters

D One pound of body weight is approximately equal to 500 mL of fluid. With a weight change of 4 pounds, the child has lost approximately 2 liters of fluid.

Which assessment finding is consistent with fluid overload? Heart murmurs Decreased pulse rate Decreased respiratory rate Moist crackles in the lungs upon auscultation

D Patients with fluid overload will often have moist crackles in the lungs, an increased respiratory rate, and an increased pulse rate. Heart murmurs are not associated with fluid overload.

A patient presents to the emergency room with confusion, altered level of consciousness, dry mouth, scaly skin, and very loose fitting shoes. Which finding in the patient's history is significant? Unusual increase in body weight Decreased exposure to higher altitudes Decreased sense of thirst in the patient Decreased ingestion of solid foods such as gelatin

D The patient whose shoes are suddenly loose may be dehydrated. Dehydration is manifested as changes in mental status such as confusion and altered levels of consciousness, dry mouth, scaly skin and an elevated serum osmolarity. If the patient stopped eating foods that are liquid at room temperature, such as gelatin, there may be concerns about dehydration. Weight gain that is proportional to fluid loss is not an indication of dehydration. Patients with decreased exposure to higher altitudes are at a lower risk of dehydration. A decreased sense of thirst in patients may not be a sign of dehydration.

Which would be an appropriate task to delegate to unlicensed assistive personnel (UAP) working on a medical-surgical unit?

Obtaining vital signs on a client receiving a blood transfusion

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat?

Dairy products Dairy products such as milk, cheese, and eggs will provide the vitamin B12 that the client needs.

What is the drug of choice for MH?

Dantrolene sodium (a skeletal muscle relaxant)

A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.)

Darbepoetin alfa (Aranesp) Epoetin alfa (Epogen) arbepoetin alfa and epoetin alfa are both red blood cell colony-stimulating factors that will help increase the production of red blood cells.

Which consequence of fluid overload may result in seizures, coma, and death? Decreased hematocrit Decreased hemoglobin Decreased serum proteins Decreased serum sodium and potassium levels

Decreased serum sodium and potassium levels Fluid overload may cause a decrease in serum electrolytes such as sodium and potassium, which can lead to seizures, coma, and death. A decrease in hematocrit due to fluid overload decreases the serum osmolarity, which may cause pulmonary edema or heart failure. A decrease in hemoglobin increases the respiratory rate to meet the oxygen needs of the body. A decrease in serum proteins decreases the serum osmolarity and may cause pulmonary edema or heart failure.

A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.)

Dehydration Extreme stress High altitudes Pregnancy Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

Nursing interventions: Insulin

Determine blood glucose levels and report changes. Monitor the patient's HbA1c to provide feedback of diabetic control. Teach patient to recognize and report hypoglycemia and hyperglycemia. Teach patient how to administer insulin. Advise patient that hypoglycemic reactions are more likely to occur during peak action time

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations?

Diabetes can cause blindness, so I should see the ophthalmologist yearly

Which condition is least likely to cause fluid overload? Heart failure Kidney failure Diabetes insipidus Psychiatric disorders

Diabetes insipidus Diabetes insipidus is manifested as polyuria, which means the passage of frequent and large amounts of urine, leading to dehydration. Heart failure is manifested as peripheral edema, which refers to the retention of fluid in the lower extremities of the body. Kidney failure is manifested as decreasing or no production of urine, which causes retention of fluids in the body, resulting in fluid overload. Psychiatric disorders may lead to polydipsia, which may lead also to fluid overload.

Drug Alert

Do not confuse Toradol with Tramadol (a drug used for central analgesia).

When teaching the patient about the storage of insulin, which statement will the nurse include

Do not place insulin in sunlight or a warm environment

A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this client's teaching to prevent bloodborne infections?

Do not share your monitoring equipment

A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take?

Document the finding in the client's chart. Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period.

Drains: Preventing Wound Infection and Delayed Healing

Drains provide an exit route for air, blood, and bile. Drains also help prevent deep infection and abscess formation during healing. The Penrose drain is placed into the external aspect of the incision and drains directly onto the dressing and skin around the incision. Change a damp or soiled dressing, and carefully clean under and around the Penrose drain. Then place absorbent pads under and around the exposed drain to prevent skin irritation, wound contamination, and infection. As the wound heals, the surgeon or nurse shortens (advances) the drain by pulling it out a short distance and trimming off the excess external portion so that only 2 to 3 inches of drain protrudes through the incision. The drain remains in place until drainage stops. Jackson-Pratt and Hemovac drains are two self-contained drainage systems that drain wounds directly through a tube via gravity and vacuum. Use sterile technique to empty the reservoir. Record the amount and color of drainage during every nursing shift or more often if prescribed. After emptying and compressing the reservoir to restore suction, secure the drain to the patient's gown (never to the sheet or mattress) to prevent pulling and stress on the surgical wound.

A nurse prepares to administer insulin to a client at 1800. The client's medication administration record contains the following information: • Insulin glargine: 12 units daily at 1800 • Regular insulin: 6 units QID at 0600, 1200, 1800, 2400

Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. Insulin glargine must not be diluted or mixed with any other insulin or solution.

The nurse is teaching a patient about home administration of insulin. The patient will receive regular (Humulin R) and NPH (Humulin NPH) insulin at 0700 every day. What is important to teach this patient?

Draw up the regular insulin first. Patients should be instructed to draw up regular insulin first so that NPH is not mixed into the vial of regular insulin

Which technique is most appropriate regarding mixing insulin when the patient must administer 30 units regular insulin and 70 units NPH insulin in the morning?

Draw up the regular insulin into the syringe first, followed by the cloudy NPH insulin.

Normal Wound Healing.

During the first few days of normal wound healing, the incised tissue regains blood supply and begins to bind together. Fibrin and a thin layer of epithelial cells seal the incision. After 1 to 4 days, epithelial cells continue growing in the fibrin and strands of collagen begin to fill in the wound gaps. This process continues for 2 to 3 weeks. At that time, tissue integrity appears regained; however, healing is not complete for up to 2 years, until the scar is strengthened. he surgeon usually removes the original dressing on the first or second day after surgery. Assess the tissue integrity of the incision on a regular basis, at least every 8 hours, for redness, increased warmth, swelling, tenderness or pain, and the type and amount of drainage. Some drainage, changing from sanguineous (bloody) to serosanguineous to serous (serum-like, or yellow), is normal during the first few days. Serosanguineous drainage continuing beyond the fifth day after surgery or increasing in amount instead of decreasing alerts you to the possibility of dehiscence. Crusting on the incision line is normal, as is a pink color to the line itself. Slight swelling under the sutures or staples is also normal. Redness or swelling of or around the incision line, excessive tenderness or pain on palpation, and purulent or odorous drainage indicate wound infection.

What are the typical clinical manifestations of anemia? (Select all that apply.)

Dyspnea on exertion Fatigue Pallor Tachycardia Difficulty breathing—especially with activity—is common with anemia. Lower levels of hemoglobin carry less O2 to the cells of the body. Fatigue is a classic symptom of anemia; lowered O2 levels contribute to a faster pulse (i.e., cardiac rate) and tend to "wear out" a client's energy. Lowered O2 levels deliver less oxygen to all cells, making clients with anemia pale—especially their ears, nail beds, palms, and conjunctivae and around the mouth.

Treatment

Education about glucose regulation Nutrition therapy Pattern management: monitoring meal- related blood glucose values Pharmacological agents Oral hypoglycemic agents Insulin

The speed of _____________ (recovery from anesthesia) depends on the duration of administration, and whether a reversal agent is used

Emergence

Fluid, Electrolyte, and Acid-Base Balance.

Fluid volume deficit or fluid volume overload may occur after surgery. Sodium, potassium, chloride, and calcium imbalances also may result, as may changes in other electrolyte levels. Fluid and electrolyte imbalances occur more often in older or debilitated patients, diabetic, Crohn's, or heart failure. Record any intake or output, including IV fluid intake, vomitus, urine, wound drainage, and nasogastric (NG) tube drainage. You must know the total intake and output from both the OR and the PACU to complete 24-hour I&O. To determine hydration status, inspect the color and moisture of mucous membranes; the turgor, texture, and "tenting" of the skin (test over the sternum or forehead of an older patient); the amount of drainage on dressings; and the presence of axillary sweat. Measure and compare total output (e.g., NG tube drainage, urine output, wound drainage) with total intake. Consider insensible fluid loss, such as sweat, when reviewing total output. IV fluids are closely monitored to promote fluid and electrolyte balance. Isotonic solutions such as lactated Ringer's (LR), 0.9% sodium chloride (normal saline), and 5% dextrose with lactated Ringer's (D5/LR) are used for IV fluid replacement in the PACU. Acid-base balance is affected by the patient's respiratory status; metabolic changes during surgery; and losses of acids or bases in drainage. For example, NG tube drainage or vomitus causes a loss of hydrochloric acid and leads to metabolic alkalosis.

Phase II

Focuses on preparing the patient for care in an extended care environment, such as a medical-surgical unit, step-down unit, skilled nursing facility, or home. This phase can occur in a PACU, on a medical-surgical unit, or in the same-day surgery (SDS) unit (ambulatory care unit) and may last only 15 to 30 minutes, although 1 to 2 hours is more typical. Patients are discharged from this phase when presurgery level of consciousness has returned, oxygen saturation is at baseline, and vital signs are stable.

A client has Crohn's disease. What type of anemia is this client most at risk for developing?

Folic acid deficiency Malabsorption syndromes such as Crohn's disease leave a client prone to folic acid deficiency.

Considerations for Older Adults

For an older adult, a rapid return to his or her level of orientation before surgery may not be realistic. Preoperative drugs and anesthetics may delay the older patient's return of orientation. Reassure family members that most episodes of postoperative confusion or delirium resolve within a day or two.

The nurse is teaching the patient how to administer insulin. What information is essential to include in the plan?

For the most consistent absorption, inject the insulin into the abdomen

The nurse is caring for a client with sickle cell disease. Which action is most effective in reducing the potential for sepsis in this client?

Frequent and thorough handwashing Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best?

Give the client pain medication if it is time for another dose. Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it.

A patient has administered regular insulin 30 minutes prior but has not received a breakfast tray. The patient is experiencing nervousness and tremors. What is the nurse's first action?

Give the patient orange juice The patient is symptomatic and has hypoglycemia. The nurse should give orange juice

Anesthesia provider

Gives anesthetic drugs to induce and maintain anesthesia and delivers other drugs during surgery; anesthesia provider assesses and monitors: -level of anesthesia -cardiopulmonary function -capnography (monitors ventilation) -vitals -intake and output

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?

Glasgow Coma Scale score is unchanged.

Secretagogues

Glipizide (Glucotrol) and glimepiride (Amaryl). Triggers the release of insulinfrom beta cells

A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.)

Hanging the blood product using normal saline and a filtered tubing set Taking a full set of vital signs prior to starting the blood transfusion Using gloves to start the client's IV if needed and to handle the blood product Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 30 minutes of the transfusion. Two registered nurses must verify the client's identity and blood compatibility.

Complications: Diabetic Ketoacidosis (DKA)

Happens in Type 1 diabetics (rare to happen in type 2) There is no insulin in the body and the body starts to burn fats for energy since it can't get to the glucose Due to this the ketones, which are acids, start to enter into the body and this causes life-threatening situation, such as acid/base imbalances Signs and Symptoms of DKA: N&V, excessive thirst, hyperglycemia, Kussmaul breathing, fruity breath

Drug Therapy 2: Pain

In PCA, the patient adjusts the dosage of the analgesic based on the pain level and response to the drug. This method allows more consistent pain relief and more control by the patient. The maximum dose per hour is "locked in" to the pump so that the patient cannot accidentally overdose. Common drugs used in PCA include morphine and hydromorphone. Epidural analgesia can be given intermittently by the anesthesia provider or by continuous infusion through an epidural catheter left in place after epidural anesthesia. Drugs given by epidural catheter include the opioids fentanyl (Sublimaze), preservative-free morphine (Duramorph), and bupivacaine (Marcaine). Take care not to overmedicate or undermedicate, especially with older patients. In assessing for overmedication, monitor vital signs, especially blood pressure and respiratory rate, and level of consciousness. Complications from the use of opioid analgesics include respiratory depression, hypotension, nausea, vomiting, and constipation. An opioid antagonist, such as naloxone (Narcan), may be needed. Monitor the patient's blood pressure and respirations every 15 to 30 minutes until the full effect of the opioid analgesic has passed. The patient has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed. Assess for undermedication by asking the patient about degree of pain relief and observing for other cues of discomfort (e.g., restlessness, increased confusion, "picking" at bedcovers). Non-opioid analgesics, such as acetaminophen (Tylenol, Atasol image), and NSAIDs, such as ibuprofen (Motrin, Novo-Profen image) and ketorolac (Toradol), are used alone or with an opioid analgesic. Antianxiety drugs may be given with an opioid analgesic to decrease pain-related anxiety, reduce muscle tension, and control nausea.

Drug Therapy: Preventing Wound Infection and Delayed Healing

In accordance with the Surgical Care Improvement Project (SCIP) core measures for prevention of surgical site infection, a patient at risk for wound infection may have received antibiotic therapy with drugs that are effective against organisms common to the specific surgical site both before and during surgery. If manifestations of wound infection are present, they are documented to justify continuation of antibiotic therapy. Wounds that become infected and open are treated with dressing changes and systemic antibiotic therapy. Depending on the surgeon's prescription, irrigate the wound (e.g., with sterile saline, hydrogen peroxide, povidone-iodine, or acetic acid), loosely pack it with solution-soaked gauze (e.g., neomycin, gentamicin, iodoform, povidone-iodine, saline, or acetic acid), and cover the wound with dry, sterile dressings. These wet-to-damp dressing changes, done 1 to 3 times daily, promote healing from within the wound and débridement (removal of the infected or dead tissue) as the wound heals. Negative pressure wound care systems such as Wound VAC may be prescribed to help close the wound.

When is general used most often?

In surgery of the head, neck, upper torso, and abdomen

Positioning: Hypoxemia

In the PACU, immediately position the patient in a semi-Fowler's position unless contraindicated. If the patient cannot have the head of the bed raised, either place him or her in a side-lying position or turn the head to the side to prevent aspiration.

An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition?

Increased rate and depth of respiration

A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan?

Infection The main objective in caring for a newly diagnosed client with leukemia is protection from infection.

Which is the most appropriate action for the nurse who is told that a patient typically takes his glipizide with food?

Inform the patient that it is better to take the medication 30 min before a meal.

The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow?

Infuse the transfusion over a 15- to 30-minute period. The volume of platelets—200 or 300 mL (standard amount)—needs to be infused rapidly over a 15- to 30-minute period.

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take?

Instruct the client to rotate sites for insulin injection.

A patient with type 1 diabetes mellitus is ordered insulin therapy once daily to be administered at bedtime. What is the type of insulin the patient is most likely receiving

Insulin glargine Insulin glargine (Lantus) is long-acting insulin with an onset of 1 hour. It is evenly distributed over a 24-hour duration of action; thus, it is administered once a day, usually at bedtime

A recently admitted client who is in sickle cell crisis requests "something for pain." What does the nurse administer?

Intravenous (IV) hydromorphone (Dilaudid) The client needs IV pain relief, and it should be administered on a routine schedule (i.e., before the client has to request it).

A 60 year old patient requests a Zostavax vaccination. Which health history needs further investigation before Zostavax is administered?

Is being treated for an autoimmune disease

Complementary and Alternative Therapies: Pain

Measures, such as positioning, massage, relaxation, and diversion, reduce anxiety and allow the patient to relax and rest. Assist the patient to a position of comfort. Support the extremities with pillows. Turn or help the patient turn at least every 2 hours while he or she is bedridden to prevent complications of immobility. Urge the patient to increase activity progressively to prevent complications. When he or she is first allowed out of bed, assist the patient to the side of the bed and into a chair. Teach him or her to splint the surgical wound for support and comfort during the transfer. rge the patient to increase activity progressively to prevent complications. When he or she is first allowed out of bed, assist the patient to the side of the bed and into a chair. Teach him or her to splint the surgical wound for support and comfort during the transfer. Relaxation and diversion are also used to control acute episodes of pain during dressing changes and injections. Music and noise reduction may help decrease awareness of discomfort.

A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose?

Metformin (Glucophage)

Monitoring: Hypoxemia

Monitor the patient's oxygen saturation (Spo2) for adequacy of gas exchange with pulse oximetry at least every hour or more often. Patients who normally have a low Pao2, such as those with lung disease or older adults, are at higher risk for hypoxemia. An older adult is often prescribed low-dose oxygen therapy for the first 12 to 24 hours. A patient who received moderate sedation with a benzodiazepine such as midazolam (Versed) or lorazepam (Ativan, Nu-Loraz ) may be overly sedated or have respiratory depression sufficient to need reversal with flumazenil (Romazicon). Hypothermia after surgery causes shivering, which increases oxygen demand and can induce hypoxemia. The highest incidence of hypoxemia after surgery occurs on the second postoperative day.

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching?

Monitor your blood glucose levels at least every 4 hours while sick

What are serious side effects of antiviral agents prescribed for a client with acute myelogenous leukemia? (Select all that apply.)

Nephrotoxicity Ototoxicity Antiviral agents, although helpful in combating severe infection, have serious side effects, especially nephrotoxicity and ototoxicity.

A client has Hodgkin's lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.)

Night sweats Persistent fever Weight loss In this stage, the disease is located in a single lymph node region or a single non-lymph node site. The client displays night sweats, persistent fever, and weight loss. Headache and urinary problems are not related.

The nurse is assessing a newly admitted client with thrombocytopenia. Which factor needs immediate intervention?

Nosebleed The client with thrombocytopenia has a high risk for bleeding. The nosebleed should be attended to immediately

Testing

OGTT: The test is used to determine whether the body has difficulty metabolizing intake of sugar/carbohydrate. Glycated hemoglobin (A1C) test. indicates average blood sugar level for the past two to three months. It measures the percentage of blood sugar attached to hemoglobin. An A1C level of 6.5 percent or higher on two separate tests indicates that you have diabetes. An A1C between 5.7 and 6.4 percent indicates prediabetes. Below 5.7 is considered normal. Fasting blood sugar test. A blood sample will be taken after an overnight fast. Urine test: Ketone levels can be measured in the urine Microalbuminuria: (measures protein in urine)

The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention does the nurse implement first?

Obtain requested cultures. Obtaining cultures to identify the infectious agent correctly is the priority for this client.

Prevention: Preventing Wound Infection and Delayed Healing

Patients also are at risk for developing pressure ulcers from positioning during surgery, from contact with damp surgical linens, and from unpadded surfaces. Examine the patient's skin for areas of redness or open areas. Document and report any abnormalities. Use padding and 269positioning to relieve pressure. Treat any open areas according to facility guidelines and the surgeon's prescription. Ensure that information about the patient's skin condition in the PACU is communicated to the medical-surgical nurse. For patients at high risk, collaborate with a certified Wound, Ostomy, and Continence registered nurse (WOCRN) to plan preventive or interventional skin care.

A 32-year-old client recovering from a sickle cell crisis is to be discharged. The nurse says, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the health care provider will request?

Penicillin V (Pen-V K) Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use.

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best?

Perform a Hemoccult test on the client's stools. This client has laboratory findings indicative of iron deficiency anemia. The most common cause of this disorder is blood loss, often from the GI tract. The nurse should perform a Hemoccult test on the client's stools.

What should you INTERPRET and how should you respond to a patient who has a wound infection after surgery?

Perform and interpret physical assessment, including: • Assessing vital signs with temperature at least every 4 hours • Assessing for increase in pain perception • Assessing cognition • Assessing the wound for pain, size, open areas, and drainage • Assessing the skin immediately surrounding the wound for redness and swelling • Assessing serial white blood cell counts with differential for changes, including elevations above normal, decreases below normal, and presence of a "left shift"

The nurse is caring for a patient with arterial insufficiency in the lower right leg. In order to prevent leg ulcers, what does the nurse do?

Place the leg in a dependent position

A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.)

Placing the client in protective precautions Teaching visitors appropriate hand hygiene Telling visitors not to bring live flowers or plants The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms. Limiting protein is not a healthy option and will not promote engraftment.

Type 1 Signs & Symptoms

Polyuria Polydypsia Polyphagia weight loss fatigue frequency of infections rapid onset insulin dependent early onset

Gastrointestinal System 1

Postoperative nausea and vomiting (PONV) are among the most common reactions after surgery. Patients with a history of motion sickness are more likely to develop nausea and vomiting after surgery. Obese retain anesthetic agents longer. Abdominal surgery and the use of opioid analgesics reduce intestinal peristalsis. rugs often used are a serotonin antagonist such as ondansetron (Zofran), a sedating H1 histamine antagonist such as dimenhydrinate (Dramamine), and an anticholinergic agent such as scopolamine. Often patients have nausea as the head of the bed is raised early after surgery. Help reduce this distressing symptom by having the patient in a side-lying position before raising the head slowly. Intestinal peristalsis may be delayed because of prolonged anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use. Patients who are recovering from abdominal surgery often have decreased or no peristalsis for at least 24 hours. The presence of active bowel sounds usually indicates return of peristalsis; however, the absence of bowel sounds does not confirm a lack of peristalsis. The best indicator of intestinal activity is the passage of flatus or stool. Abdominal cramping along with distention denotes trapped, nonmoving gas—not peristalsis. Assess for the manifestations of paralytic ileus (distended abdomen, abdominal discomfort, vomiting, no passage of flatus or stool).

Self-Management Education.

The teaching plan for the patient and family after surgery includes: • Prevention of infection • Care and assessment of the surgical wound • Management of drains or catheters • Nutrition therapy • Pain management • Drug therapy • Progressive increase in activity If dressing changes and drain or catheter care are needed, instruct the patient and family members on the importance of proper handwashing to prevent infection. Explain and demonstrate wound care to the patient and family, who then perform a return demonstration. Teach about the manifestations of complications such as wound infection. A diet high in protein, calories, and vitamin C promotes wound healing. Supplemental vitamin C, iron, zinc, and other vitamins are often prescribed after surgery to aid in wound healing and red blood cell formation. Encourage the older adult or debilitated patient to continue using dietary supplements, if prescribed, between meals until the wound is completely healed and the energy levels are restored. Teach the patient about drugs for pain, especially about the proper dosage and frequency. Instruct the patient to notify the surgeon if pain is not controlled or if the pain suddenly increases. If antibiotics or other drugs are prescribed, stress the importance of completing the entire prescription. Teach the patient to increase activity level slowly, rest often, and avoid straining the wound or the surrounding area. The surgeon decides when the patient may climb stairs, return to work, drive, and resume other usual activities, such as sexual intercourse. The amount of weight that the patient can lift safely after surgery is specifically defined by the surgeon (i.e., in pounds or kilograms). Instruct the patient in the use of proper body mechanics.

Drug Therapy 1: Pain

The use of opioids or other analgesics for pain management may mask or increase the severity of symptoms of an anesthesia reaction. Therefore give these drugs with caution, especially in the PACU when the patient's condition is not stable. When pain drugs are used in the PACU, they are usually given IV. After receiving any drug for pain, the patient remains in the PACU for a defined period (often 45 to 60 minutes). Assess for hypotension, respiratory depression, and other side effects. Within 5 to 10 minutes after an IV injection, assess the effectiveness of the drug (i.e., on a rating scale) in relieving pain. Opioid analgesics are given during the first 24 to 48 hours after surgery to control acute pain. Around-the-clock scheduling or the use of patient-controlled analgesia (PCA) systems is more effective than "on demand" scheduling because more constant blood levels are achieved. Drugs commonly used include morphine (Statex image), hydromorphone (Dilaudid), ketorolac (Toradol), codeine, butorphanol (Stadol), and oxycodone with aspirin (Percodan) or oxycodone with acetaminophen (Tylox, Percocet). Assess the type, location, and intensity of the pain before and after giving medication. Monitor the patient's vital signs for hypotension and hypoventilation after giving opioid drugs.

Drug Alert

The usual dosage for hydromorphone is much smaller (about one-fifth to one-tenth) that of morphine.

What are the cons of M I S and robotic surgery?

They are very expensive, who are settings, and takes a long time to train the surgeon to be proficient in one surgery

The patient newly diagnosed with type 2 diabetes mellitus has been ordered insulin glargine. What information is essential for the nurse to teach this patient?

This medication has a duration of action of 24 h

What information will the nurse teach the patient who has been prescribed an alpha glucosidase inhibitor

This medication will delay the absorption of carbohydrates from the intestines

Therefore, liver or kidney failure increases risk of ________.

Toxicity

Types of Diabetes

Type 1 Type 2 Gestational (GDM) Other specific conditions resulting in hyperglycemia

A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the client's medication list to determine if the client is taking which drug?

Unfractionated heparin This client has manifestations of heparin-induced thrombocytopenia

Action Alert: Pillow Support

Unless the surgeon prescribes pillow support, place no pillows under the knees, and do not raise the knee gatch, because this position could restrict circulation and increase the risk for venous thromboembolism.

Three zones of surgical area

Unrestricted, semi restricted, and restricted (ensures proper movement of patients and personelle)

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this client's teaching to prevent injury?

Use a bath thermometer to test the water temperature

Cardiovascular System.

Vital signs and heart sounds are assessed on admission to the PACU and then at least every 15 minutes until the patient's condition is stable. Report blood pressure changes that are 25% higher or lower than values obtained before surgery (or a 15- to 20-point difference, systolic or diastolic) to the anesthesia provider or the surgeon. Decreased blood pressure and pulse pressure and abnormal heart sounds indicate possible cardiac depression, fluid volume deficit, shock, hemorrhage, or the effects of drug. Bradycardia could indicate an anesthesia effect or hypothermia. Older patients are at risk for hypothermia. An increased pulse rate could indicate hemorrhage, shock, or pain. Cardiac monitoring is maintained until the patient is discharged from the PACU. A pulse deficit (a difference between the apical and peripheral pulses) could indicate a dysrhythmia. Peripheral vascular assessment needs to be performed because anesthesia and positioning during surgery (e.g., the lithotomy position for genitourinary procedures) may impair the peripheral circulation and contribute to clotting and venous thromboembolism (VTE), especially deep vein thrombosis (DVT). Compare distal pulses on both feet for pulse quality, observe the color and temperature of extremities, evaluate sensation and motion, and determine the speed of capillary refill. Prophylactic measures to prevent DVT: drug therapy with anticoagulants or antiplatelet drugs, sequential compression devices, antiembolic stockings or elastic wraps, early ambulation. Assess the feet and legs for redness, pain, warmth, and swelling, which may occur with DVT.

The nurse is transfusing a unit of whole blood to a client when the health care provider requests the following: "Furosemide (Lasix) 20 mg IV push." What does the nurse do?

Wait until the transfusion has been completed to administer furosemide. Completing the transfusion before administering furosemide is the best course of action in this scenario. Drugs are not to be administered with infusing blood products; they can interact with the blood, causing risks for the client.

A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this client's teaching to decrease the client's insulin needs?

Walk at a moderate pace for 1 mile daily

What do team members where who are scrubbed in and at bedside?

Wear a fluid resistant gown, sterile gloves, and eye protectors/face shield, mask, cap

What do team members who are not scrubbed in (anesthesiologist, circulator) wear?

Wear cover scrub jackets, eyewear, and mask, cap

The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that an infection is present or should be ruled out?

Wheezes or crackles Wheezes or crackles in the neutropenic client may be the first symptom of infection in the lungs.

Critical Rescue: Evisceration

When a surgical wound evisceration occurs, one nurse tends to the patient while another nurse immediately notifies the surgeon.

When does the intraop period begin/end?

When patient enters the surgical suite until time of transfer to post Anastasia recovery area, same day surgery unit, or intensive care unit

Which time frame would be most appropriate for administering sliding-scale lispro insulin?

When the breakfast tray is served and ready to eat

Respiratory System.

When the patient is admitted to the PACU, immediately assess for a patent airway and adequate gas exchange. Although some patients may be awake and able to speak, talking is not a good indicator of adequate gas exchange. An artificial airway may be in place. If the patient is receiving oxygen, document the type of delivery device and the concentration or liter flow of the oxygen. Continuously monitor pulse oximetry for oxygen saturation (Spo2) while the patient is in the PACU. The Spo2 should be above 95% (or at the patient's presurgery baseline). Assess the rate, pattern, and depth of breathing to determine adequacy of gas exchange. A respiratory rate of less than 10 breaths per minute may indicate anesthetic- or opioid analgesic-induced respiratory depression. Rapid, shallow respirations may signal shock, cardiac problems, increased metabolic rate, or pain. Assess breath sounds. Check symmetry of breath sounds and chest wall. Perform ongoing inspection of the chest wall for accessory muscle use, sternal retraction, and diaphragmatic breathing. Listen for snoring and stridor (a high-pitched crowing sound). Snoring and stridor occur with airway obstruction resulting from tracheal or laryngeal spasm or edema, mucus in the airway, or blockage of the airway from edema or tongue relaxation. When neuromuscular blocking agents are retained, the patient has muscle weakness, which could impair gas exchange. Indicators of muscle weakness include the inability to maintain a head lift, weak hand grasps, and an abdominal breathing pattern. Check the lungs at least every 4 hours during the first 24 hours after surgery and then every 8 hours, or more often, as indicated. Older patients, obese, smokers, and patients with a history of lung disease are at greater risk for respiratory complications after surgery and need more frequent assessment.

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately?

White blood cell count: 38,000/mm3 Although individuals with SCD often have elevated white blood cell (WBC) counts, this extreme elevation could indicate leukemia, a complication of taking hydroxyurea. The nurse should report this finding immediately.

Nonsurgical Management: Preventing Wound Infection and Delayed Healing

Wound care includes reinforcing the dressing, changing the dressing, assessing the wound for healing and infection, and caring for drains, including emptying drainage containers/reservoirs, measuring drainage, and documenting drainage features. Emphasize the importance of early deep-breathing exercises to prevent forceful coughing. Urge the patient to bend the hips when in the supine position to reduce tension on a chest or abdominal wound. Remind him or her to always splint the chest or abdominal incision when coughing.

Impaired Wound Healing.

Wound dehiscence is a partial or complete separation of the outer wound layers, sometimes described as a "splitting open of the wound." Evisceration is the total separation of all wound layers and protrusion of internal organs through the open wound. Both of these problems occur most often between the fifth and tenth days after surgery. Wound separation occurs more often in obese patients and those with diabetes, immune deficiency, or malnutrition or who are using steroids. Dehiscence or evisceration may follow forceful coughing, vomiting, or straining and when not splinting the surgical site during movement. The patient may state, "Something popped" or "I feel as if I just split open."

Which data set is most likely to prompt the nurse to call the health care provider to obtain an order for a wound culture?

Wound has moderate exudate that has a foul odor

Which expected outcome is most appropriate for a patient with a 1x1 stage 2 sacral ulcer decubitus ulcer?

Wound will show granulation and decrease in size

A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, "Can I ask my niece to prefill my syringes and then store them for later use when I need them?" How should the nurse respond?

Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up.

The nurse would include which statement when teaching a patient about insulin glargine?

You cannot mix this insulin with any other insulin in the same syringe

Airway Maintenance: Hypoxemia

You may need to insert an oral airway if the patient does not already have one. The oral airway pulls the tongue forward and holds it down to prevent obstruction. If the patient had oral surgery or has clenched teeth, a large tongue, or upper airway obstruction, insert a nasal airway (nasal trumpet) to keep the airway open. Keep the manual resuscitation bag and emergency equipment for intubation or tracheostomy nearby. For patients whose only airway is a tracheostomy or laryngectomy stoma, alert other staff members

The nurse is teaching a patient who has been prescribed repaglinide. Which information will the nurse include in the teaching plan?

You will need to be sure you eat as soon as you take this medication

A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?" How should the nurse respond?

Your brain needs a constant supply of glucose because it cannot store it.

A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How should the nurse respond?

Your risk of diabetes is higher than the general population, but it may not occur

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client?

Zoledronic acid (Zometa) All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid (Zometa), which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well.

Key Points: Health Promotion and Maintenance

• Reinforce to the patient and family after surgery the specific interventions to use to prevent complications (incision splinting, deep-breathing exercises, range-of-motion exercises—as described in Charts 14-5 and 14-6 in Chapter 14). • Encourage early ambulation. • Stress the need for following the activity restrictions prescribed by the surgeon. • Teach the patient and family about any drugs to be continued after discharge from the facility. Patient-Centered Care image • Instruct the patient and family about the clinical manifestations of complications and when to seek assistance

The nurse is performing daily wound care and dressing changes on a patient with a full thickness burn. The patient protests when the nurse attempts to deride the wound. What is the nurses best response?

"Harmful bacteria can grow in the dead tissue and it also interferes with the body's attempt to fill in the wound with new cells and collagen"

A patient diagnosed with bedbug bites says to the nurse, "I am so embarrassed. I shower daily and do not live in an unclean environment". Which response by the nurse is most appropriate?

"Have you been traveling or staying in a hotel".

A patient weighs 110 pounds. The nurse knows that the patient must have an intake of 30-35 calories per kilogram of body weight in order to maintain a positive nitrogen balance. The patient needs ______ total calories per day?

1500-1750

A patient is diagnosed with acting keratoses. Which teaching point would the nurse emphasize?

A follow-up appointment is needed for premalignant condition

Which patients are at risk for pressure ulcers?

A middle aged quadriplegic who is alert and conversant A bedridden patient who is in the late stages of Alzheimer's A very overweight patient who must be assisted to move in the bed A thin patient patient who sits for long periods of time and refuses meals

The spouse of the client with Alzheimer's disease (AD) is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B. "Memantine (Namenda)is indicated for treatment of early symptoms of Alzheimer's disease. C. "Rivastigmine (Excelon) is used to treat depression." D. "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."

A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." Rationale A. Cholinesterase inhibitors (e.g., donepezil) are approved for the symptomatic treatment of Alzheimer's disease. B. Memantine (Namenda) is indicated for advanced Alzheimer's disease. C. Rivastigmine (Excelon) is a cholinesterase inhibitor that is used to treat Alzheimer's symptoms. Selective serotonin reuptake inhibitors (SSRIs) are antidepressants and may be used in Alzheimer's clients who develop depression. D. Some clients with Alzheimer's disease experience depression and may be treated with antidepressants such as sertraline.

The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A. "Have you taken her for a checkup?" B. "She has Alzheimer's disease." C. "That is a normal part of aging." D. "You should look into respite care."

A. "Have you taken her for a checkup?" Rationale A. The mother's symptoms indicate possible Alzheimer's disease or some other physiologic imbalance, and she should be assessed further by a physician. B. The nurse cannot make this diagnosis. The mother should be formally assessed by a physician. C. The mother's behavior is not normal age-related behavior. D. Respite care is for caregivers, not for clients.

The client has been diagnosed with Huntington disease. The nurse is teaching the client and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse's teaching? A. "If she has children, she'll pass the gene on to her kids." B. "She could only have gotten the disease from both of us." C. "Because she got the gene from her father, she'll live longer than other people with the disease." D. "More testing should definitely be done to see if she's really got the gene."

A. "If she has children, she'll pass the gene on to her kids." Rationale A. An autosomal dominant trait with high penetrance, such as Huntington disease, means that a person who inherits just one mutated allele has an almost 100% chance of developing the disease. B. Only one defective gene is needed to inherit Huntington disease. The client could have inherited it from her father or mother. C. If the client inherited the gene from her mother, she would live a longer life than other people with the disease. If she inherited the gene from her father, her life would be shorter. D. Additional testing is not necessary. If the client has Huntington disease, then the client has the gene.

The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A. Absence B. Myoclonic C. Simple partial

A. Absence Rationale A. Absence seizures are more common in children and consist of brief (often just seconds) periods of loss of consciousness and blank staring, as though he or she is daydreaming. B. Myoclonic seizures are characterized by brief jerking or stiffening of the extremities, which may occur singly or in groups. C. Partial seizures are most often seen in adults. D. Tonic seizures are characterized by an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes.

The client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse? A. Administer medications promptly on schedule to maintain therapeutic drug levels. B. Complete activities of daily living for the client. C. Speak loudly for better understanding. D. Provide high-calorie, high-carbohydrate foods to maintain the client's weight.

A. Administer medications promptly on schedule to maintain therapeutic drug levels. Rationale A. This is a correct statement. B. The client should be encouraged to do as much as possible on his own. C. Slow speech rather than loud speech is more effective for the client with Parkinson disease. D. Small, frequent meals are more effective for the client with Parkinson disease.

The client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What will the nurse do next? A. Allow the client to remain undisturbed. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Turn on the lights for a neurologic assessment.

A. Allow the client to remain undisturbed. Rationale A. At the beginning of a migraine attack, the client may be able to alleviate pain with analgesics and by lying down and darkening the room with a cool cloth on his or her forehead. If the client falls asleep, he or she should remain undisturbed until awakening. B. Assessing the client' vital signs will disturb the client unnecessarily. C. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it should be removed. D. This is not appropriate because light can cause the migraine to worsen.

The wife of the client with Alzheimer's disease mentions to the home health nurse that although she loves him, she is exhausted caring for her husband. What does the nurse suggest to alleviate caregiver stress? A. Arranges for respite care B. Provides positive reinforcement and support to the wife C. Restrains the client for a short time each day, to allow the wife to rest D. Teaches the client improved self-care

A. Arranges for respite care Rationale A. Respite care can give the wife some time to re-energize and will provide a social outlet for the client. B. Providing positive reinforcement and support is encouraging but does not help the wife's situation. C. Restraints are almost never appropriate and are used only as an absolute last resort. D. The client with Alzheimer's disease typically is unable to learn improved self-care.

The client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2 to 4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output

A. Assessing neurologic status at least every 2 to 4 hours Rationale A. The most important nursing intervention for clients with meningitis is the accurate monitoring and recording of their neurologic status, vital signs, and vascular assessment. The client's neurologic status and vital signs should be assessed at least every 4 hours, or more often if clinically indicated. The priority for care is to monitor for early neurologic changes that may indicate increased intracranial pressure (ICP), such as decreased level of consciousness (LOC). B. Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. C. Clients with bacterial meningitis report severe headaches requiring pain management, but this is the second-highest priority. D. Assessing fluid balance while preventing overload is not the highest priority.

The client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? A. Assigning a case manager B. Ensuring that all family questions are answered before discharge C. Providing a safe environment D. Referring the family to the Alzheimer's Association

A. Assigning a case manager Rationale A. Whenever possible, the client and family should be assigned a case manager who can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. B. This is necessary for family support but is not relevant for continuity of care. C. This is necessary for safety but is not relevant for continuity of care. D. This is necessary for appropriate resource referral but is not relevant for continuity of care.

The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? A. Bipolar disorder B. Diabetes mellitus C. Glaucoma D. Hypothyroidism

A. Bipolar disorder Rationale A. Cases of suicide have been reported, most often in clients with bipolar disorder. B. Topiramate is not contraindicated in clients with diabetes mellitus. C. Topiramate is not contraindicated in clients with glaucoma. D. Topiramate is not contraindicated in clients with hypothyroidism.

A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse? A. Chest tightness B. Skin flushing C. Tingling feelings D. Warm sensation

A. Chest tightness Rationale A. Triptan drugs are contraindicated in clients with coronary artery disease because they can cause arterial narrowing; the nurse should instruct the client to not take the medication until the nurse can talk with the prescribing health care provider. B. Skin flushing is a common adverse effect with triptan medications and is not an indication to avoid using this group of drugs. C. Tingling feelings is a common adverse effect with triptan medications and is not an indication to avoid using this group of drugs. D. A warm sensation is a common adverse effect with triptan medications and is not an indication to avoid using this group of drugs.

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that the client may have bacterial meningitis? A. Cloudy, turbid CSF B. Decreased white blood cells C. Decreased protein D. Increased glucose

A. Cloudy, turbid CSF Rationale A. Cloudy, turbid cerebrospinal fluid is a sign of bacterial meningitis. Clear fluid is a sign of viral meningitis. B. Increased white blood cells is a sign of bacterial meningitis. C. Increased protein is a sign of bacterial meningitis. D. Decreased glucose is a sign of bacterial meningitis.

The client with Parkinson disease is being discharged home with his wife. To ensure compliance with the management plan, which discharge action is most effective? A. Involving the client and his wife in developing a plan of care B. Setting up visitations by a home health nurse C. Telling his wife what the client needs D. Writing up a detailed plan of care according to standards

A. Involving the client and his wife in developing a plan of care Rationale A. Involving the client and spouse in developing a plan of care is the best way to ensure compliance. B. Home health nurse visitations are generally helpful but may not be needed for this client. C. Instructing the spouse about the client's needs does not reinforce the spouse's involvement and buy-in with the management plan. D. Providing the spouse with a written plan of care does not reinforce the spouse's involvement and buy-in with the management plan.

The client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? A. Potential for injury related to chronic confusion and physical deficits B. Risk for reduced mobility related to progression of disability C. Potential for skin breakdown related to immobility and/or impaired nutritional status D. Lack of social contact related to personality and behavior changes

A. Potential for injury related to chronic confusion and physical deficits Rationale A. The priority for interdisciplinary care is safety. Chronic confusion and physical deficits place the client with Alzheimer's disease at high risk for injury. B. This is not a priority for a short hospital stay. This problem is usually the result of long-term care. C. This is not a priority for a short hospital stay. This problem is usually the result of long-term care. D. This is not a priority for a short hospital stay. This problem is usually the result of long-term care.

The nurse is instructing the UAP in how to perform skin care for a patient who is at risk for pressure ulcers because of immobility and incontinence. Which instructions would the nurse give?

After cleaning, apply a commercial skin barrier to areas exposed to urine or feces

The nurse is on a hiking trip and one of the hikers falls and sustains a laceration to the lower leg. It takes the group more then 36 hours to get to a health care facility. Which description of the drainage would be considered normal and expected within the first 48 hours?

Blood-tinged amber fluid

Which class of medication would exclude a patient from participating in NPWT?

Anticoagulants

When developing a plan of care for a patient who is at high risk for skin breakdown, what does the nurse include in the plant of care?

Apply pressure reduction overlay to the mattress Frequent repositioning of the patient Using positional devices to keep heels pressure free

The nurse is assessing a patients would everyday for signs of healing or infection. Which finding is a positive indication that healing is progressing as expected?

Area appears pale pink, progressing to a spongy texture with a beef red color

The nurse is assessing a wound on a patients abdomen. What is the correct technique?

Assess the wound as a clock face with 12 o'clock toward the patients head and 6 o'clock toward the patients feet

The nurse is directing the home health (UAP) in the care of an older adult patient. The patient reports dry skin and help in applying an emollient cream. What does the the nurse direct the UAP to do?

Assist the patient to soak for 10 minutes in a warm bath and then apply the cream to slightly damp skin within 2-3 minutes after bathing

The HCP recommended over the counter diphenhydramine (Benadryl) to treat the patients hives. What does the nurse suggest to the patient for self care?

Avoid alcohol consumption, which can potentiate the sedative effect of benadryl

The nurse is teaching the client newly diagnosed with migraine about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee."

B. "I must not miss meals." Rationale A. Monosodium glutamate (MSG)-containing foods are a trigger for many people suffering from migraines and should be eliminated until the triggers are identified. B. Missing meals is a trigger for many people suffering from migraines. The client should not skip any meals until the triggers are identified. C. Alcohol is a trigger for many people suffering from migraines and should be eliminated until the triggers are identified. D. Artificial sweeteners are a trigger for many people suffering from migraines and should be eliminated until the triggers are identified.

The female client with newly diagnosed migraine is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A. "Sumatriptan should be taken as a last resort." B. "I must report any chest pain right away." C. "Birth control is not needed while taking sumatriptan." D. "St. John's wort can also be taken to help my symptoms."

B. "I must report any chest pain right away." Rationale A. Sumatriptan must be taken as soon as migraine symptoms appear. B. Chest pain must be reported immediately with the use of sumatriptan. C. Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. D. Triptans should not be taken with selective serotonin reuptake inhibitors (SSRIs) or St. John's wort, an herb used commonly for depression.

The nurse is caring for the client with advanced Alzheimer's disease. Which communication technique is best to use with this client? A. Providing the client with several choices to choose from B. Assuming that the client is not totally confused C. Waiting for the client to express a need D. Writing down instructions for the client

B. Assuming that the client is not totally confused Rationale A. Choices should be limited. Too many choices causes frustration and increased confusion in the client. B. Never assume that the client is totally confused and cannot understand what is being communicated. C. Rather than waiting for the client to express a need, try to anticipate the client's needs and interpret nonverbal communication. D. Rather than writing down instructions, provide the client instructions with pictures, and put them in a highly visible place.

Which is the most effective way for the college student to minimize the risk for bacterial meningitis? A. Avoiding large crowds B. Getting the meningitis polysaccharide vaccine C. Taking a daily vitamin D. Taking prophylactic antibiotics

B. Getting the meningitis polysaccharide vaccine Rationale A. Avoiding large crowds is helpful but is not practical for the college student. B. People who live in highly populated areas, such as a college dorm, should get the meningitis polysaccharide vaccine (Menomune) to prevent infection. C. Taking a daily vitamin is helpful but is not the best way to safeguard against bacterial meningitis. D. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply. A. Alopecia B. Headaches C. Dizziness D. Diplopia E. Increased blood glucose

B. Headaches C. Dizziness D. Diplopia Rationale Carbamazepine does not cause alopecia. Divalproex (Depakote) and valproic acid (Depakene) may cause alopecia.

The client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. A. Bite block at the bedside B. Intravenous access C. Continuous sedation D. Suction equipment at the bedside E. Siderails up

B. Intravenous access D. Suction equipment at the bedside E. Siderails up Rationale Bite blocks or padded tongue blades should not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes Rationale A. This not a medical emergency and does not require immediate attention. B. This client is experiencing status epilepticus, which is a medical emergency and requires immediate intervention. C. This is not a medical emergency and does not require immediate attention. D. A fever of 101.9° F (38.8° C) is not a medical emergency and does not require immediate attention.

Seeing a reddened area on a patients skin, the nurse presses firmly with fingers at the center of the area and sees that the area blanches with pressure. The nurse interprets this finding as changed related to which factor?

Blood vessel dilation

The nurse is teaching a patient about self care for a minor bacterial skin infection. What is the most important aspect the nurse emphasizes?

Bathe daily with an antibacterial soap

A patient receiving negative pressure wound therapy (NPWT) should be monitored closely for which potential complication?

Bleeding

The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil? A. "The reuptake of serotonin is blocked." B. "Donepezil prevents the increase in the protein beta amyloid." C. "It delays the destruction of acetylcholine by acetylcholinesterase." D. "Dopamine levels are increased."

C. "It delays the destruction of acetylcholine by acetylcholinesterase." Rationale A. Donepezil is not a serotonin reuptake inhibitor. B. Donepezil is a cholinesterase inhibitor and does not work on the protein beta amyloid. C. By delaying the destruction of acetylcholine, donepezil improves cholinergic neurotransmission in the central nervous system (CNS), thus delaying the onset of cognitive decline. D. Donepezil does not work on dopamine receptors.

The home health nurse is checking in on the client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A. "Can't you take care of your spouse?" B. "Establishing goals and a daily plan can help." C. "Make sure you take some time off and take care of yourself too." D. "That's not a very nice thing to say."

C. "Make sure you take some time off and take care of yourself too." Rationale A. This response is not supportive and may offend the spouse. B. A better response would be, "Take one day at a time." C. This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted. Of course, further assessment and planning will be necessary. D. This response is judgmental and inappropriate.

The client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What will the nurse do first? A. Administer phenytoin (Dilantin) B. Draw blood C. Assess the need for additional support D. Start an intravenous (IV) line

C. Assess the need for additional support Rationale A. Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already under way. B. Drawing blood is not the priority in this situation. C. Convulsive status epilepticus must be treated promptly and aggressively. After a quick assessment by the nurse, the health care provider must be notified immediately, and intubation by an anesthesiologist, nurse anesthetist, or respiratory therapist may be necessary. D. Starting an IV is not the priority in this situation.

The client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Stroke B. Tension headache C. Classic migraine D. Cluster headache

C. Classic migraine Rationale A. The client's symptoms do not indicate a stroke. B. The client's symptoms do not indicate a tension headache. C. The client's symptoms match those of a classic migraine. D. The client's symptoms do not indicate a cluster headache.

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been requested for treatment of epilepsy. The nurse plans to instruct the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Milk

C. Grapefruit juice Rationale A. Apple juice does not interact with phenytoin. B. Grape juice does not interact with phenytoin. C. Grapefruit juice can interfere with the metabolism of phenytoin. D. Milk does not interact with phenytoin.

The client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? A. Alzheimer's Wandering Association B. National Alzheimer's Group C. Safe Return Program D. Lost Family Members Tracking Association

C. Safe Return Program Rationale A. The Alzheimer's Wandering Association does not exist as an actual organization. B. The National Alzheimer's Group does not exist as an actual organization. C. The family should enroll the client in the Safe Return Program, a national, government-funded program of the Alzheimer's Association that assists in the identification and safe, timely return of those with dementia who wander off and become lost. D. The Lost Family Members Tracking Association does not exist as an actual organization.

Which occurrence is an example of conditions associated with Koebner's phenomenon?

Chronic overexposure to sunlight

A toddler is miserable with itching from chicken pox. Which type of bath is the best to help relieve the toddlers discomfort?

Colloidal oatmeal

A patient had surgery 5 days ago. What is the best way for the nurse to determine the current state of healing or deterioration of the patients surgical wound?

Compare existing wound features to those previously documented

The public health nurse reviewing case files of people who were exposed to and treated for cutaneous anthrax. Which patient who develops the disease warrants further investigation as a possible bioterrorism?

Construction worker

The nurse see in the patient record that the patent has a braden score of 20. Which nursing action in the nurse most likely ago perform in the care of this patient?

Continue routine assessments

The nurse is preparing a teaching plan for a client with migraine headaches who is receiving propranolol (Inderal) for migraine headaches. What health teaching by the nurse is important for the client? A. "Take this drug only when you have symptoms at the beginning of a migraine headache." B. "This drug is low dose, so you don't have to worry about your heart rate or blood pressure." C. "This drug will relieve the pain during the aura phase soon after a headache has started." D. "Take this drug as prescribed every day, even when feeling well, to prevent a migraine."

D. "Take this drug as prescribed every day, even when feeling well, to prevent a migraine." Rationale A. For prevention purposes, this drug should be taken daily, not intermittently. Abruptly stopping a beta-blocker may cause adverse symptoms. Reference: p. 931, Physiological Integrity B. This drug can lower blood pressure and decrease pulse rate. Reference: p. 931, Physiological Integrity C. Inderal is considered a preventive drug; efficacy as an abortive drug has not been substantiated by research. Reference: p. 931, Physiological Integrity D. Propranolol (Inderal) is a beta-blocker and is taken to prevent the development of a migraine headache. Reference: p. 931, Physiological Integrity

The client has Parkinson disease (PD). Which nursing intervention best protects the client from injury? A. Discouraging the client from activity B. Encouraging the client to watch the feet when walking C. Suggesting that the client obtain assistance in performing ADLs D. Monitoring the client's sleep patterns

D. Monitoring the client's sleep patterns Rationale A. Active and passive range-of-motion (ROM) exercises, muscle stretching, and activity are important to keep the client with PD mobile and flexible. B. The client with PD should avoid watching his or her feet when walking to prevent falls. C. The client with PD should be encouraged to participate as much as possible in self-management, including ADLs. Occupational and physical therapists can provide training in ADLs and the use of adaptive devices, as needed, to facilitate independence. D. Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving).

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure B. Forces a tongue blade in the mouth C. Restrains the client D. Positions the client on the side

D. Positions the client on the side Rationale A. Documenting the length and time of seizures is important, but not while the seizure is occurring. B. Forcing a tongue blade in the mouth can cause damage. C. Restraining the client can cause injury. D. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness.

Which chronic health condition is most likely to contribute to delayed would healing or recurrence of a pressure ulcer after healing has occurred?

Diabetes mellitus

The health care provider informs the nurse that the patient is having severe pruritus. Based on this information, the nurse is most likely to observe which assessment finding?

Excoriations from scratching

The nurse is caring for a patient who needs frequent oral hygiene and endotracheal suctioning. In this particular circumstance, the nurse wears gloves to prevent contracting and spreading which organism?

Herpetic whitlow

An older patient who is receiving chemotherapy is diagnosed with toxic epidermal necrolysis. In addition to identifying the causative agent. What does the nurse monitor first?

Fluid and electrolyte imbalance, caloric intake, and hypothermia.

The nurse is assessing a patients skin and observes a superficial infections with a raised, red rash with small pustules. How does the nurse interpret this finding?

Folliculitis

At the hospital, the patient was receiving whirlpool treatments to deride dead tissue. What could the home health nurse suggest as a substitute?

Forceful irrigation of the would with a 35 mL syringe

The nurse is reviewing the results of a pressure mapping on a patient at high risk for pressure ulcers. The map shows a red area over the hips. How does the nurse interpret this evidence?

Greater heat production associated with greater pressure

Which patient is the most likely candidate to be referred for Moh's surgery?

Has squamous cell carcinoma

A thin, malnourished patient requires emergency abdominal surgery. After the operation, in order to promote wound healing, what does the nurse encourage?

High-quality protein diet

The emergency department (ED) nurse is giving discharge instructions to the parents of a child who has been diagnosed with bedbug bites. What instructions does the nurse give to the parents?

Hiring a pest control company with bedbug experience is an option

A mother reports that her child has dry skin with itching that seems to worsen at night. What non-pharmacologic interventions does the nurse teach the mother?

Keep the childs fingernails short and file to reduce skin damage Place mittens or splints on the childs hands at night if the scratching is causing skin tears Read the child a relaxing and familiar story to reduce stress

A patient is prescribed a topical steroid for treatment of contact dermatitis. Which instruction does the nurse provide to the patient about this drug?

Moisten dressing with warm tap water; place over topical steroids for short periods

A patient has stage 3 pressure ulcers over the left trochancter area that has a visible thick exudate. The wound bed is visible and beefy red, and the edges are surrounded with swollen pink tissue. The exudate has an odor. How does the nurse determine which dressing is best for this wound?

Obtains an order to consult certified wound care specialist

The nurse reads in the chart that the patient has palmoplanter pustulosis (PPP). Which area of the patients body will the nurse assess for this condition?

Palms of the hands and soles of the feet

The nurse is caring for an obese patient who has been on bedrest for several days. The nurse observes that the patient is beginning to develop redness on the sacral area. What intervention is used to decrease the shearing force?

Place the patient in a side lying position

A patient is diagnosed with psoriasis vulgarism. Which description of the characteristic lesions of psoriasis would the nurse expect to see in the patients documentation?

Plaques surmounted by silvery-white scales

The nurse is caring for a 25 year old patient who recently had a rhinoplasty as part of reconstruction after cancer treatment. Which complication is cause for the greatest concern?

Postnasal bleeding

The nurse assessing the nutritional status of a patient at risk for skin breakdown who has been refusing to eat hospital food. Which indicator is the most sensitive identifying inadequate nutrition for this patient?

Pre albumin level of 17.5 mg/dL

The school nurse is examining a child and observes linear ridges on the inner aspect of wrists. The child reports intense itching, especially at night. The nurse scrapes the lesion and examines it under a microscope. Which condition does the nurse suspect?

Scabies

The nurse is giving discharge instructions to a patient and family who must continue dressing changes and wound care at home. Which point does the nurse emphasize to help the family prevent infection and minimize cost?

Scrupulous hand washing before and after wound care

The nurse is examining the nevi on a patients back and neck. Because most malignant melanomas arise from moles, which finding is a concern to warrant further investigation?

Sudden report of itching

An adolescent has a painful and unsightly herpes simplex blister on her lip, and would like to have her school photo delayed until after the lesion has resolved. What does the nurse tell the patient about the duration of the outbreak?

Symptoms can last 3-10 days

What does the treatment for psoriasis include?

Ultraviolet light therapy Calcipotriene (Dovonex) topical cream Topical methotrexate (Folex) Corticosteroids

The nurse is caring for several patients who are incontinent of stool and urine. Which task is delegated to the UAP?

Was the skin with a pH-balanced soap to maintain normal acidity

What dose the nurse teach a patient about ultraviolet (UV) therapy used for psoriasis?

Wear dark glasses during and after treatment if psoralen is prescribed