Clinical Decision Making / Clinical Judgment PrepU

An older adult client is being evaluated for suspected pyelonephritis and is ordered kidney, ureter, and bladder (KUB) x-ray. The nurse understands the significance of this order is related to which rationale?

Detects calculi, cysts, or tumors Urinary obstruction is the most common cause of pyelonephritis in the older adult. A KUB may reveal obstructions such as calculi, cysts, or tumors. KUB is not indicated for detection of impaired renal function or reveal increased risk for chronic form of the disorder. Urine cultures will reveal causative microorganisms present in the urine.

A client diagnosed with acute kidney injury (AKI) has developed congestive heart failure. The client has received 40 mg of intravenous push (IVP) Lasix and 2 hours later, the nurse notes that there are 50 mL of urine in the Foley catheter bag. The client's vital signs are stable. Which health care order should the nurse anticipate?

Diuretic agents are often used to control fluid volume in clients with acute kidney injury (AKI). The client's urine output indicates an inadequate response to the initial dosage of Lasix and the nurse should anticipate administering Lasix 80 mg IVP. Often in this situation, the initial dosage of Lasix is doubled. The client is experiencing fluid overload, thus, a 500-mL bolus of normal saline bolus would be contraindicated. There is no need to complete a chest x-ray. Mannitol is widely used in the management of cerebral edema and increased intracranial pressure from multiple causes.

The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action?

Ensure atropine is readily available. Atropine should be ready before administration of edrophonium chloride so it is available if needed to control the side effects of the medication. Assessing facial weakness and documenting the results occur after the administration of edrophonium chloride; therefore, they are not the priority interventions.

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?

Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.

Which of the following indicates that a client with HIV has developed AIDS?

Herpes simplex ulcer persisting for 2 months A diagnosis of AIDS cannot be made until the person with HIV meets case criteria established by the Centers for Disease Control and Prevention. The immune system becomes compromised. The CD4 T-cell count drops below 200 cells and develops one of the opportunistic diseases, such as Pneumocystis carinii pneumonia, candidiasis, cytomegalovirus, or herpes simplex.

A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?

Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). An autograft uses the client's own skin, which is transplanted from one part of the body to another.

A client is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The client's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV nitroprusside. Upon assessment, which finding requires immediate intervention by the nurse?

Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The finding of numbness and weakness in left arm may indicate the client is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP; immediate intervention is required. Urine output of 40 mL/h is within normal limits. The other findings are likely caused by the hypertension and require intervention, but they do not require action as urgently as the neurologic changes.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock?

In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?

JVD is noted 4 cm above the sternal angle. JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

A nurse practitioner reviewed the blood work of a male client suspected of having microcytic anemia. The nurse suspected occult bleeding. Which laboratory result would indicate an initial stage of iron deficiency?

Microcytic anemia is characterized by small RBCs due to insufficient hemoglobin. Serum ferritin levels correlate to iron deficiency and decrease as an initial response to anemia before hemoglobin and serum iron levels drop.

Which of the following is a term that refers to individual, family, group, and cultural expressions of grief and associated behaviors?

Mourning refers to individual, family, group, and cultural expressions of grief and associated behaviors. Grief refers to the personal feelings that accompany an anticipated or actual loss. Bereavement refers to the period of time during which mourning takes place. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life.

A nurse is assessing a client and notes a blood pressure (BP) of 205/115. The client has had BP's within normal limits up until this time. The client reports a sudden onset severe headache. The nurse recognizes this as probable malignant hypertension. What would be the nurse's first action?

Notify the health care provider. Malignant hypertension is fatal unless BP is quickly reduced. Even with intensive treatment, the kidneys, brain, and heart may be permanently damaged.

When administering a gamma-globulin infusion, what nursing guideline applies?

Nursing guidelines that apply when administering IV gamma globulin include the IV infusion rate should not exceed 3 mL/min, the client should be weighed prior to treatment, clients with low gamma globulin have more severe reactions, and the nurse should administer pretreatment prophylactic antihistamine 30 minutes prior to beginning infusion.

A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for?

Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.

A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient?

After fracture of long bones or pelvic bones, or crush injuries, fat emboli frequently form. Fat embolism syndrome (FES) occurs when fat emboli cause morbid clinical manifestations. The classic triad of clinical manifestations of FES include hypoxemia, neurologic compromise, and a petechial rash (NAON, 2007), although not all signs and symptoms manifest at the same time (Tzioupis & Giannoudis, 2011). The typical first manifestations are pulmonary and include hypoxia and tachypnea.

A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?

Amsler grid

The nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the client for next?

An elevated ST-segment means an evolving myocardial infarction. A cardiac catheterization would be the logical next step. Telemetry monitoring will only provide dysrhythmia detection. A transesophageal echocardiogram is a diagnostic test to assess cardiac function. The pharmacologic stress test is diagnostic and will determine heart function.

The nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and has developed oral thrush. What type of infection is the nurse aware that has developed due to the immunocompromised state of the client?

An opportunistic or superinfection occurs among immunocompromised hosts. Examples would be yeast infections in the mouth, bladder infections, gastroenteritis, and Pneumocystis carinii. An acute infection has a sudden onset with serious and sometimes life-threatening manifestations. A chronic infection is an extended infection that resists treatment. A secondary infection is a complication of some other disease process that occurred first.

A female client with sickle-cell disease is hospitalized for pain management. The client's BUN is 24 mg/dL and creatinine is 1.6 mg/dL. To assist with management of the pain, the nurse

Applies warm soaks to the extremities Warm soaks may help to alleviate pain in the client with sickle-cell disease. Meperidine is not recommended in clients experiencing renal dysfunction. This client's renal studies show some dysfunction. Cold will cause the blood cells to lump even more and constrict blood vessels, increasing pain. Lowering the extremity to a dependent position will encourage blood to pool, particularly in the joints, increasing pain.

A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?

Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen is one of the first tools used to fight pulmonary edema. A mask, rather than nasal cannula, is needed to deliver the maximum percentages of oxygen. Intubation is reserved for when respiratory failure occurs. Mechanical ventilation is applied once respiratory failure occurs.

The nurse is assisting with a bronchoscopy at the bedside in a critical care unit. The client experiences a vasovagal response. What should the nurse do next?

Check blood pressure. During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it in turn may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate, leading to syncope. The nurse will need to assess blood pressure to assure circulation. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.

A client who has extremity right wrist fracture complains of severe burning pain, frequent changes in the skin from hot and dry to cold, and feeling clammy skin that is shiny and growing more hair in the injured extremity. The nurse should anticipate providing care for what complication?

Complex regional pain syndrome The symptoms reported by the client are consistent with complex regional pain syndrome. Avascular necrosis is manifested by pain and limited movement. Pain and decreased function are the prime indicators of reaction to an internal fixation device. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse

Consults with the physician about decreasing the feeding to half-strength The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher osmolality may cause dumping syndrome. The client may report a feeling of fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia. The nurse needs to take steps to prevent dumping syndrome. Increasing the amount of the feeding, administering the feeding at an extreme temperature, or increasing the osmolality of the feedings will continue dumping syndrome. The nurse needs to decrease the osmolality of the feeding as in administering a half-strength solution.

A client has been prescribed alendronate for the prevention of osteoporosis. Which is the highest priority nursing intervention associated with the administration of the medication?

While all interventions are appropriate, the highest priority is having the client sit upright for 60 minutes following administration of the medication. This will prevent irritation and potential ulceration of the esophagus. The client should have adequate intake of vitamin D and obtain yearly dental exams. The concurrent use of corticosteroids and alendronate is link to a complication of osteonecrosis.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important?

Recent pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

The nurse working in the emergency department is caring for a client with signs and symptoms of appendicitis. Which order from the health care provider should the nurse question?

administer an enema An enema is not administered in clients with symptoms associated with appendicitis because it can lead to perforation. Monitoring the complete blood cell count is necessary to identify infection. The client should receive nothing by mouth as surgery is required. Intravenous antibiotics may be ordered to prevent infection.

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called:

conductive hearing loss. Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. The stapes must move freely for sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, preventing sound transmission. In a functional hearing loss, no organic lesion is found. Fluctuating hearing loss is a form of sensorineural hearing loss that varies over time. Sensorineural hearing loss affects the inner ear and involves the cochlea and eighth cranial nerve.

A client has undergone a renal transplant and returns to the health care agency for a follow-up evaluation. Which finding would lead the nurse to suspect that the client is experiencing rejection?

Signs and symptoms of transplant rejection include abdominal pain, hypertension, weight gain, oliguria, edema, fever, increased serum creatinine levels, and swelling or tenderness over the transplanted kidney site.

The nurse is caring for geriatric clients who state that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. The nurse is correct to understand that the aging visual changes relate to which of the following?

The changes that occur in vision during aging, which include difficulty reading and the need for reading glasses, include changes in accommodation. Accommodation occurs when the ciliary muscles contract or relax to focus an image on the retina.

Which is a classic sign of hypovolemic shock?

The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock following insertion of an intravenous catheter. The nurse first

The client may have fainted, which is a sign of transient neurogenic shock. To minimize pooling of blood in the legs and to restore blood flow to the brain, the nurse lays the client flat and elevates his or her feet. Another cause may be hypoglycemia. If the above action does not resolve the client's problem, the nurse should assess the client's blood glucose level. Raising the head of the bed would be done if the client had received spinal or epidural anesthesia. A bolus of IV fluids would be given if the client were dehydrated.

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?

The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The client appears slightly confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult.

Within the heart, several structures and several layers all play a part in protecting the heart muscle and maintaining cardiac function. The inner layer of the heart is composed of a thin, smooth layer of cells, the folds of which form heart valves. What is the name of this layer of cardiac tissue?

The inner layer, the endocardium, is composed of a thin, smooth layer of endothelial cells. Folds of endocardium form the heart valves. The middle layer, the myocardium, consists of muscle tissue and is the force behind the heart's pumping action. The pericardium is a saclike structure that surrounds and supports the heart. The outer layer, the epicardium, is composed of fibrous and loose connective tissue.

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician?

The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not need to be reported to the physician.

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?

The nursing assistant is pouring a glass of water to wet the client's mouth. When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?

The patient has developed a stress ulcer that is bleeding. GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus.

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the liklihood of liver problems? Select all that apply.

The skin, mucosa, and sclerae are inspected for jaundice. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. Cyanosis of the lips is indicative of a problem with respiratory or cardiovascular dysfunction. Aphthous stomatitis is a term for mouth ulcers and is a gastrointestinal abnormal finding.

When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching. When urticaria, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?

Type II (cytolytic, cytotoxic) hypersensitivity reaction ABO incompatibility, such as from an incompatible blood transfusion, is a type II hypersensitivity reaction. Transfusions of more than 100 ml of incompatible blood can cause severe and permanent renal damage, circulatory shock, and even death. Drug-induced hemolytic anemia is another example of a type II reaction. A type I hypersensitivity reaction occurs in anaphylaxis, atopic diseases, and skin reactions. A type III hypersensitivity reaction occurs in Arthus reaction, serum sickness, systemic lupus erythematosus, and acute glomerulonephritis. A type IV hypersensitivity reaction occurs in tuberculosis, contact dermatitis, and transplant rejection.

The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation?

Usual pattern of elimination Constipation has many possible reasons and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.

The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess for which conditions? Select all that apply.

sloughing tissue, tissue necrosis, and effectiveness of antidote Extravasation of vesicant chemotherapeutic agents can lead to erythema, sloughing, and necrosis of surrounding tissue, muscle, and tendons. To reduce the likelihood and severity of symptoms due to extravasation of a vesicant, antidotes matched to the vesicant are administered. Nurses caring for a client who experienced extravasation of a vesicant should assess for sloughing tissue, tissue necrosis, erythema, and effectiveness of the antidote.

A client diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering:

sodium polystyrene sulfonate (Kayexalate) The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract. Sorbitol may be administered in combination with Kayexalate to induce a diarrhea-type effect (it induces water loss in the GI tract). If the client is hemodynamically unstable (low blood pressure, changes in mental status, dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be administered to shift potassium back into the cells.

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?

laryngeal cancer Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils.

A client has undergone a liver biopsy. After the procedure, the nurse should place the client in which position?

on the right side Immediately after the biopsy, assist the client to turn on to the right side; place a pillow under the costal margin, and caution the client to remain in this position. In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on the left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but it is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.

Which of the following ventilation-perfusion mismatch would correlate with acute respiratory distress syndrome (ARDS)?

A silent unit (a combination of shunting and dead-space ventilation) occurs when little or no ventilation and perfusion is present, such as in ARDS. A dead space, which is reduced perfusion to a lung unit, occurs in pulmonary embolism. Shunting, reduced ventilation to a lung unit, occurs in pneumonia and atelectasis. Patients with ARDS do not have a normal V/Q [adV]/[adQ]) match.

A nurse knows that a patient exhibiting seizure-like movements localized to one side of the body most likely has what type of tumor?

A tumor in the motor cortex of the frontal lobe produces hemiparesis and partial seizures on the opposite side of the body or generalized seizures. A frontal lobe tumor may also produce changes in emotional state and behavior, as well as an apathetic mental attitude. A cerebellar tumor causes dizziness; an ataxic or staggering gait with a tendency to fall toward the side of the lesion; marked muscle incoordination; and nystagmus (involuntary rhythmic eye movements), usually in the horizontal direction. An occipital lobe tumor produces visual manifestations: contralateral homonymous hemianopsia (visual loss in half of the visual field on the opposite side of the tumor) and visual hallucinations.

A client is receiving adjuvant chemotherapy for breast cancer. Which is most likely her node status and tumor size?

Adjuvant chemotherapy is recommended for clients who have positive lymph nodes or who have invasive tumors greater than 1 cm in size, regardless of nodal status.

The nurse is giving discharge instructions to the client following a bladder ultrasound. Which statement by the client indicates the client understands the instructions?

A bladder ultrasound is a non-invasive procedure. The client can resume usual activities without restriction.

The nurse is caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the arrhythmia?

Atrial fibrillation is treated with elective cardioversion or digitalis if the ventricular rate is not too slow. Defibrillation is used for a ventricular problem. Maze procedures are used for clients who are not candidates for cardiodiversion; these procedures use scar-forming techniques to eliminate rapid firing of ectopic pacemaker sites, thus restoring the normal conduction pathways in the atria. A Maze procedure might be considered for this client only after determining ineligibility for cardiodiversion. Pacemakers are implanted for bradycardia.