Clinical Judgement
A client receiving total parenteral nutrition (TPN) is ordered to undergo a 24-hour urine test for creatinine clearance. Which actions should the client take to initiate this collection?
Discard the first morning void, then continue the collection for exactly 24 hours. Explanation: Evidence-based practice (EBP) dictates that the nurse should start the test after the first morning void, but this first void should be discarded. The other choices are not correct.
Three weeks after an infant receives a spica cast, the mother calls the nurse because the infant's toes are swollen and cool to the touch. What should the nurse instruct the mother to do?
Call the office to have the infant fitted for a new one. Explanation: Infants grow rapidly and may require application of a larger cast. A cast adequate for an infant after surgery may be outgrown in less than 1 month. The cast becomes too tight, impairing circulation evidenced by toe swelling and coolness to touch.
The nurse is caring for a client who has become unresponsive. The blood pressure is 80/40 mm Hg, and SpO2 is 90% on 50% face mask. What should the nurse do next?
Call the rapid response team. Explanation: The rapid response team should be called immediately to evaluate and treat the client. There is no indication at this time for manual ventilations or chest compressions. If the family is not interfering in client care, it can be reassuring to the family to see that all possible care is being provided.
The nurse is reviewing the physician's order written for a postmenopausal client: "calcitonin salmon nasal spray 200 IU, one spray every day." What is the appropriate action to be taken by the nurse regarding this order?
Clarify with the physician that the spray should be given in only one nostril per day. Explanation: Calcitonin salmon nasal spray should be administered in only one nostril per day. Many preprinted order sheets automatically print "administer in both nostrils" when a nasal spray is ordered. Nurses must be familiar with the directions for each medication they give before administering medications. The other options are incorrect because calcitonin salmon nasal spray is prescribed to postmenopausal clients for the treatment of osteoporosis and requires a physician's order.
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?
elevated 30 degrees Explanation: After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.
During the morning assessment, a nurse notes that a client is awake, alert, and has severe dyspnea; respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3 L of oxygen. The nurse notes that the client's chart includes a living will. When considering best practice, the nurse should
initiate potentially life-prolonging treatment unless the client refuses. Explanation: A living will doesn't go into effect unless the client is unable to make his own decisions. The nurse should give all appropriate care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an appropriate response, but it isn't the best and only action at this time. The family isn't responsible for determining care at this time.
A client receiving a continuous infusion of lidocaine for ventricular dysrhythmias states "I am so tired. Even my vision is blurry." What is the nurse's best action?
Decrease the lidocaine infusion rate. Explanation: Side effects of lidocaine include lightheaded, euphoria, shaking, low blood pressure, drowsiness, confusion, weakness, blurry or double vision, and dizziness. Serious reactions such as seizures, bradycardia, and heart block are possible if lidocaine reaches toxic levels. The nurse should recognize these potential adverse effects and the lidocaine infusion should be decreased while lidocaine blood levels are checked to determine if the cause of the tiredness and blurred vision is a lidocaine toxicity. Knowing when the client's most recent eye examination was completed and allowing the client to rest or administering zolpidem will not address the problem of potential lidocaine toxicity and may lead to the more serious toxic reactions.
