Collaboration / Teamwork & Collaboration PrepU

A nurse is providing care for a client who has had a hip replacement and is going to be discharged in 2 days. The nurse has provided the client instructions for care after discharge. Which instruction would be considered accessing tertiary care?

"Begin physical therapy in 1 week." Starting physical therapy, a type of rehabilitation, is a form of tertiary care. Tertiary care focuses on complex medical and surgical interventions, and specialized services such as cancer care and rehabilitative services. Encouraging the client to see a family health care provider would be promoting primary care. Sending the client for lab studies or instructing them to go to the emergency department would be directing the client to seek secondary care, which includes additional testing and emergency care.

When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the health care provider?

"I really don't like to be in small, enclosed spaces." An MRI scanner is a narrow, tunnel-like machine that will enclose the client during the test. Clients who are claustrophobic (fear enclosed spaces) may need sedation because it is imperative that they lie still and not panic during the test. Therefore, the nurse should notify the health care provider about the client's statement. Typically, the client is NPO for 6 to 8 hours before the test, and he or she must remove any metal objects, credit cards, jewelry, and watch before the test. The machine makes loud repetitive noises while the test is in progress, so earphones may be helpful.

A novice nurse provides aftercare instructions to a client who has just had sutures removed. Which statement by the novice nurse requires the nurse preceptor to clarify?

"If the wound edges are red or raised, you should call your doctor." Wound edges that are slightly red or raised are normal and do not require the client to report these findings to the health care provider. All other statements are true.

Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?

"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers.

The nurse is instructing a nursing student when a new client comes to the eye clinic. The client reports suspecting a corneal abrasion. The nurse should explain what to the student nurse?

"To detect corneal abrasions, a slit lamp is used."

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?

6 to 12 Ursodeoxycholic acid (UDCA [URSO, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Six to 12 months of therapy are required in many clients to dissolve stones, and monitoring of the client for recurrence of symptoms or occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

The nurse administers an injection to a client with AIDS. When finished, the nurse attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse?

Because post exposure protocols can reduce the risk of HIV infection if initiated promptly, nurses must immediately report any needlestick or sharp injury to a supervisor. Obtaining counseling will occur after all other procedures are adhered to. The lab will draw blood from the client if required for documentation and other blood transmitted disorders.

Which is usually the most important consideration in the decision to initiate antiretroviral therapy?

CD4+ counts

A home care nurse is looking at ways that home care nurses can promote holistic care of the client. What action will the nurse implement in order to accomplish this task?

Collaboration with an interdisciplinary team Holistic care in home care occurs with the collaboration of an interdisciplinary team. The other answer choices reflect holistic care as it relates to natural and alternative medicine; however, these are not universal practices in home care and do not best reflect the correct answer choice.

Which diagnostic test is done to determine a suspected pituitary tumor?

Computed tomography

The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the appropriate action by the nurse?

Consult with the prescriber regarding the need for an increased dose of the drug and not to reduce the frequency of administration. The most appropriate action by the nurse would be to consult with the physician regarding the need for an increased dose of the drug and not to reduce its frequency of administration. As a rule of thumb, an ineffective dose should be increased by 25% to 50%. Informing the client that they will not be able to receive more medication is not acting as a client advocate nor acting in the best interest of the client. Suggesting a psychiatrist consultation would not be an appropriate action because the client has a chronic illness that requires medication. Taking a non-narcotic analgesic would not provide the client with the pain relief needed.

An oncologist advises a client with an extensive family history of breast cancer to consider a mastectomy. What type of surgery would the nurse include in teaching?

Also called preventive surgery, prophylactic surgery may be done when there is a family history or genetic predisposition, ability to detect cancer at an early stage, and client acceptance of the postoperative outcome. Local excision is done when an existing tumor is removed along with a small margin of healthy tissue. Palliative surgery relieves symptoms. Cryosurgery uses cold to destroy cancerous cells.

A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority?

Disturbed body image related to loss of fat in the face and arms The client is experiencing lipoatrophy, which results in a localized loss of subcutaneous fat in the face (manifested as sinking of the cheeks, eyes, and temples), arms, legs, and buttocks. These changes as well as his statement about the side effects of the drug being worse than the disease indicate that he is concerned about how he appears to others. Therefore, the nursing diagnosis of disturbed body image would be the priority. Deficient knowledge, risk for infection, and risk for impaired liver function may be applicable; however, they are not concerns at this time.

The nurse is preparing a client for upcoming electrophysiology (EP) studies and possible ablation for treatment of atrial tachycardia. What information will the nurse include in the teaching?

During the procedure, the dysrhythmia will be reproduced under controlled conditions. During EP studies, the patient is awake and may experience symptoms related to the dysrhythmia. The client does not receive general anesthesia. The EP procedure time is not easy to determine. EP studies do not always include ablation of the dysrhythmia.

The nurse and student nurse are observing a cardioversion procedure. The nurse is correct to tell the student that electrical current will be initiated at which time?

During ventricular depolarization The electrical current is initiated at the R wave when ventricular depolarization occurs. The electrical current completely depolarizes the entire myocardium with the goal of restoring the normal pacemaker of the heart.

What intervention is a priority when treating a client with HIV/AIDS?

Fluid and electrolyte deficits are a priority in monitoring clients with HIV/AIDS, and assessment of fluid loss and electrolyte imbalance is essential. Skin integrity should be monitored but is a lower priority. Neurologic and psychological status should also be monitored, but this is not as high a priority as fluid and electrolyte imbalance.

Which enzyme aids in the digestion of fats?

Lipase is a pancreatic enzyme that aids in the digestion of fats. Amylase aids in the digestion of carbohydrates. Secretin is responsible for stimulating secretion of pancreatic juice. Trypsin aids in the digestion of protein.

The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. What explanation will the nurse offer to explain the urination?

Nocturia is common in patients with heart failure. Fluid collected in dependent areas during the day is reabsorbed into the circulation at night when the client is recumbent. The kidneys excrete more urine with the increased circulating volume. The client's sleeping position does not cause bladder constriction and increased urination. The client's blood pressure is not causing more urination. The fluid in the client's lungs does not move to the kidneys at night.

A client is diagnosed with an arrhythmia at a rate slower than 60 beats/minute with a regular interval between 0.12 and 0.20 seconds. What type of arrhythmia does the client have?

Sinus bradycardia is an arrhythmia that proceeds normally through the conduction pathway but at a slower than usual (less than 60 beats/minute) rate.

A nurse is planning a health education program for a group of high school students regarding the dangers of texting and driving. Which action by the nurse illustrates the understanding of health education as a primary nursing responsibility?

The nurse gathers evidenced-based information related to texting and driving and coordinates the education with the school. Health education is an independent function of nursing practice and is included in all state nurse practice acts. Teaching, as a function of nursing, is included in all state nurse practice acts. As an independent nursing function a health care provider order or approval is not required. Health education is a primary responsibility of the nursing profession. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness. Prior parental consent is not required for education related to health/safety promotion.

The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. Which action made by the nursing assistant would require instruction?

The nursing assistant places the drainage bag on the client's abdomen for transport. The nurse would instruct the nursing assistant to maintain the drainage bag lower than the genital region to avoid a backflow of urine into the bladder. The nursing assistant is correct to move the catheter and drainage bag with the client to not put tension on the catheter, place the drainage bag on the lower area of the wheelchair, and hold the drainage bag while the client is in the process of moving.

A client has been experiencing a decrease in serum calcium. After diagnostics, the physician believes the calcium level fluctuation is due to altered parathyroid function. What is the role of parathormone?

The parathyroid glands secrete parathormone, which increases the level of calcium in the blood when there is a decrease in the serum level.

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?

The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.

A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as:

The wound appearance for a full-thickness burn would be dry, pale white, leathery, or charred.

When caring for a client with cirrhosis, which symptom(s) should the nurse report immediately?

When caring for a client with cirrhosis, the nurse should report any change in mental status immediately because they indicate secondary complications. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

A client is admitted to the cardiac care unit for an electrophysiology (EP) study. What goal should guide the planning and execution of the client's care?

diagnose the dysrhythmia A client may undergo an EP study in which electrodes are placed inside the heart to obtain an intracardiac ECG. This is used not only to diagnose the dysrhythmia but also to determine the most effective treatment plan. The study does not involve any treatment modalities.

A client is receiving ganciclovir as part of the treatment for cytomegalovirus retinitis. What would the nurse monitor the results of the client's laboratory tests for?

neutropenia A common reaction to ganciclovir is severe neutropenia. Hypocalcemia and hyperphosphatemia are associated with foscarnet. Ganciclovir is not associated with thrombocytopenia.

Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply.

polymerase chain reaction, p24 antigen test It is now possible to measure a person's viral load, the number of viral particles in the blood. The p24 antigen test and polymerase chain reaction test measure viral loads. The ELISA is a screening test for HIV. The Western blot is a diagnostic test for HIV. The T4/T8 ratio determines the status of T lymphocytes.

A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test?

western blot essay A positive EIA test indicates seropositivity. To confirm this, a Western blot assay would be done. The OraSure test uses saliva to perform an EIA test. The p24 antigen test and nucleic acid sequence-based amplification test are used to test viral load and evaluate response to treatment. However, the reverse transcriptase-polymerase chain reaction (RT-PCR) and nucleic acid sequence-based tests have replaced the p24 antigen test. The RT-PCR tests may be used to confirm a positive EIA result.

Which points should be included in the medication teaching plan for a client taking adalimumab?

It is important to monitor for injection site reactions when taking adalimumab. The medication is injected subcutaneously and must be refrigerated. The medication should be withheld if fever occurs.

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 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.

Kaposi sarcoma (KS) is diagnosed through

KS is diagnosed by biopsy of the suspected lesions. Prognosis depends on the extent of the tumor, the presence of other symptoms of HIV infection, and the CD4+ count.

A nurse is preparing to administer an antiretroviral medication to a client who is positive for HIV. The nurse identifies the drug as a nucleoside reverse transcriptase inhibitor (NRTI). What drug will the nurse administer?

Lamivudine (Epivir) is an antiretroviral agent that belongs to the class of NRTIs. Delavirdine (Rescriptor), etravirine (Intelence), and nevirapine (Viramune) are examples of non-nucleoside reverse transcriptase inhibitors (NNRTIs).

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis?

Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in clients with acute pancreatitis.

A nurse cares for an obese client taking phentermine/topiramate-ER. Which laboratory findings will the nurse recognize as most concerning and will report to the health care provider? Select all that apply.

Potassium 3.3 and Bicarbonate 19 The nurse will monitor the client for hypokalemia and signs of metabolic acidosis. The bicarbonate level is low, indicating metabolic acidosis. Although the answer choice for total cholesterol is slightly elevated, this does not pose a priority for the nurse because this medication does not cause increased cholesterol levels. All the other answer choices are within normal limits.