HESI
Normal weight
18.5 kg/m2 to 24.9 kg/m2 =
The nurse is preparing to administer a vaccine to an adult client who weighs 200 pounds (90 kg). What equipment is needed for this procedure? Correct
23-to 25- gauge needle. 1-inch needle.
Nonrebreather
6-15 L/min ADVANTAGES Valve closes during expiration, so exhaled air does enter reservoir and mix with inhaled air. Delivers highest possible FiO2 without intubation. Does not dry mucous membranes.
0
Absent pulse
3+
Bounding pulse, may be able to see pulsation
The nurse is assessing the effectiveness of cardiac compressions during cardiopulmonary resuscitation (CPR) for an adult client. Which are the accepted sites for assessing pulse?
Carotid. Femoral.
Zinc
Collagen formation, protein synthesis, cell membrane and host defenses
Vascular Insufficiency
Decreased hair growth on legs and feet • Absent or decreased pulses • Infection of the foot • Poor wound healing • Thickened nails • Shiny appearance of the skin • Blanching of the skin on elevation
Hospitals and other health care organizations receive payment for client services based on which factor?
Diagnosis-related groups.
An adult client has vomiting, diarrhea, dry mucous membranes, skin tenting, and delayed capillary refill. The client's vital signs are: HR 110, sitting BP 104/72 that drops to 84/62 when the client stands up. The client's laboratory results include: BUN 24 mg/dl and urine specific gravity 1.032. Which conditions should the nurse consider in planning care for this client?
Extracellular fluid volume deficit. Postural hypotension. Impaired tissue perfusion.
Protein
Fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function
What are the legal implication of federally initiated healthcare acts on nursing practice?
Ignorance of the health acts is not permissible. Encourages nurses to keep up with current standards. Guides and defines legal boundaries of nursing practice.
2+
Normal pulse, able to palpate with normal pressure
What actions should a nurse take when filling out an incident report?
Record the details in the report and in the client's medical record if the client was involved. Include family members in the report if they are involved in the incident .
Which signs and symptoms are the earliest indicators of shock?
Tachycardia. Restlessness.
When doing an assessment of sensory nerve function, which test should the nurse omit if the pain sensation is normal?
Temperature.
Time limited:
The time frame for each goal and expected outcome indicates when you expect the response to occur. Time frames help you and the patient determine if progress is being made at a reasonable rate. If not, revision of the plan of care is necessary. Time frames also promote accountability in the delivery and management of nursing care.
The nurse is irrigating a client's wound. Which factors could delay wound healing as a result of wound irrigation?
The use of povidone-iodine solution. Hydrogen peroxide poured into wound. Direct force of irrigation solution on wound bed. Irrigation solutions cooler than room temperature.
Singular goal or outcome:
To ensure precise evaluation of care, each goal and outcome addresses only one behavior or response. If an outcome reads, "Patient's lungs are clear to auscultation, and respiratory rate is 22 breaths per minute by 8/22," consider the outcome when you evaluate that the lungs are clear but the respiratory rate is 28 breaths/min. It will be difficult to determine whether the expected outcome has been achieved. By splitting the statement into two parts, "Lungs are clear to auscultation by 8/22" and "Respiratory rate is 22 breaths per minute by 8/22," you determine specifically if the patient achieves each outcome. Singularity allows you to decide if there is a need to modify the plan of care.
Vesicular
Vesicular sounds are soft, breezy, and low pitched. Inspiratory phase is 3 times longer than expiratory phase.
Which has been shown to be the most effective intervention a nurse can perform to prevent most hospital-acquired infections?
Washing hands before and after each client contact.
Review medical records to assess physiological capacity of a patient to transfer and need for special adaptive techniques. Assess the following:
a. Muscle strength b. Joint mobility and contracture formation. c. Paralysis or paresis (spastic or flaccid). d. Bone continuity.
Hypertonic fluid volume deficit, or dehydration,
can be serious if not recognized and treated. As fluid loss continues, the circulating fluid volume decreases, and serum osmolarity increases.The other type of fluid volume deficit occurs when water is lost in excess of sodium.
Bradycardia
can occur in athletes, during sleep, in a state of hypothermia, in association with medications such as beta blockers, during tracheal suctioning, in association with increased intracranial pressure, and in myocardial infarction. Bradycardia accompanied by difficulty breathing and decreased blood pressure should be reported immediately, because this is an indication of imminent cardiopulmonary collapse.
Tachycardia
decreased cardiac output. Factors that lead to tachycardia include a drop in blood pressure; an elevated temperature; conditions such as anemia, which result in poor oxygenation; exercise; prolonged application of heat; pain; strong emotions, such as fear or anxiety; and some medications, including bronchodilators.
FiO2,
fraction of inspired oxygen
The Glasgow Coma Scale
is an objective assessment tool used to define a person's level of consciousness by assigning a numeric value to the person's level of arousal. The scale is divided into three areas: eye opening, verbal response, and motor response. Each area is scored separately, and a number is assigned to the person's best response. The three numbers are added, and the total score reflects the patient's level of consciousness. A fully alert, normally responsive patient will have a score of 15. Scores from multiple assessments can be plotted on a graph to provide a visual illustration indicating that the patient is stable, improving, or deteriorating. A score of less than 7 reflects a patient who is comatose. Refer to Table 20-10 for the Glasgow Coma Scale.
Diaphragmatic breathing
is more difficult and requires a patient to relax the intercostal and accessory respiratory muscles while taking deep inspirations. The patient concentrates on expanding the diaphragm during controlled inspiration. Teach the patient to place one hand flat below the breastbone above the waist and the other hand 2 to 3 cm below the first hand. Then ask him or her to inhale while the lower hand moves outward during inspiration. The patient observes for inward movement as the diaphragm ascends. Initially teach these exercises with the patient in the supine position and then practice while the patient sits and stands. The exercise is often used with the pursed-lip breathing technique.
Friction
is the effect of rubbing or the resistance that a moving body meets from the surface on which it moves. As you turn, transfer, or move a patient up in bed, you need to overcome friction. Remember, the greater the surface area of the object you move, the greater the friction generated. A patient who is passive or immobilized produces greater friction to movement. Thus when possible use some of a patient's strength and mobility when lifting, transferring, or moving a patient up in bed. You do this by explaining the procedure and telling the patient when to move. For instance, you decrease friction when patients are able to bend their knees and lift their hips while being moved up in bed. You also reduce friction by safe lifting techniques rather than pushing a patient. Lifting has an upward component and decreases the pressure between a patient and the bed or chair. The use of a drawsheet or transfer board reduces friction because you are able to move the patient more easily along the surface of the bed.
Nociceptive pain
is the most common type of pain. This type of physiologic (physical) pain occurs when nociceptors are stimulated in response to trauma, inflammation, or tissue damage from surgery. Characteristically, nociceptive pain may be sharp, burning, aching, cramping, or stabbing. Nociceptive pain originates in visceral and somatic locations.
Pedal Pulses
lies just behind the medial malleolus of the inner ankle. It can be felt by placing the fingertips around the ankle and gently indenting the soft tissues in the space between the medial malleolus and the Achilles tendon.
Isotonic fluid deficit, or hypovolemia,
occurs when water and sodium are lost at the same rate. In this situation, circulating volume decreases, but serum osmolarity remains unchanged.
Fluid volume deficit
occurs with excessive loss or inadequate intake of fluid
Referred pain
originates in one area but hurts in another area, such as pain from a myocardial infarction (i.e., heart attack) The pain is caused by lack of oxygen to the heart muscle, but the pain may be felt in the jaw or down the left arm
The nurse is reviewing a client's arterial blood gas results. Which results would indicate the client is experiencing respiratory acidosis?
pH 7.30; PaCo2 60; HCO3 24. Correct pH 7.50; PaCo2 30; HCO3 22. pH 7.32; PaCo2 45; HCO3 18. pH 7.48; PaCo2 38; HCO3 20. Rationale The ABG that reflects pH 7.30; PaCo2 60; HCO 3 24, is correct. Respiratory acidosis is indicated by results of a pH<7.35; PaCo2 >45 mmHg and normal HCO3.
A client is experiencing dyspnea, respirations 24 breaths/ minute, O2 saturation of 89% on room air, nasal flaring, and audible expiratory and inspiratory wheezing noted three feet away. Which set of arterial blood gas (ABG) results is consistent with the nurse's assessment of this client?
pH 7.48; PaCO2 40; HCO3 29. pH 7.35; PaCO2 43; HCO3 24. pH 7.28; PaCO2 55; HCO3 24.Correct pH 7.38; PaCO2 38; HCO3 22. Rationale The client is experiencing respiratory acidosis so pH will be below normal, with elevated PaCO2.
cognitive abilities
such as knowledge, decision making, and judgment, ask questions about health status and any chronic or current illnesses. Listening to the patient's description of illness, treatment, and medications enables the nurse to assess language use, patient understanding, and decisions made by the patient concerning health care. On the basis of information shared by the patient during knowledge assessment, the nurse can interpret the need for patient teaching and reinforce needed information at follow-up visits.
determine pain management strategie
the patient's report of pain, the type of pain medication, the medication order, and vital signs
Therapeutic communication
(1) to allow the patient to express thoughts, feelings, behaviors, and life experiences in a meaningful way to promote healthy growth; (2) to understand the significance of the patient's problems and the roles that the patient and the significant people in his or her life play in perpetuating those problems; and (3) to assist with the identification and resolution processes of the patient's health-related behaviors. Therapeutic communication is the nurse's primary tool to help patients attain successful outcomes to the problems that are currently preventing them from achieving optimum health.
Hematocrit
(normal range is 38% to 47% for women and 40% to 54% for men).
OXYMIZER
1-15l/min ADVANTAGES Higher concentrations without mask. Releases O2 only on inhalation. Conserves O2, increased portability. Does not require humidification.
Nasal cannula
1-6 L/min, ADVANTAGES Safe and simple. Easily tolerated. Delivers low concentrations while allowing the patient to eat, speak, and drink. Does not impede eating or talking. Inexpensive, disposable.
Urine specific gravity
1.010-1.030
Venturi mask
4-12 L/min ADVANTAGES Controls the amount of specified oxygen concentration. Delivers percentage of FiO2 from 24% to 60%. Does not dry mucous membranes. Delivers humidity with oxygen concentration.
Oxygen hood—usually pediatric use
5-12l/min ADVANTAGES Provides warmed humidified oxygen at a specific temperature.
Simple face mask
5-8 L/min AVANTAGES Can assist in providing humidified O2.
Partial nonrebreather—bag should always remain partially inflated. Therefore flow rate must be high enough to prevent collapse of the bag.
6-10L/min Advantages Delivers increased FiO2. It is useful for patients requiring a high concentration of O2 (e.g., asthma, multiple trauma). Easily humidifies O2. Does not dry mucous membranes.
Face tent
8-12l/min ADVANTAGES Alternative to aerosol mask. Provides high humidity with O2.
While assessing an adult client, the nurse identifies generalized edema in the client's arms, legs, and periorbital regions. Which dietary influence could have contributed to this generalized edema?
A diet low in protein.
Pain management
Administering pain medications and using nonpharmacologic pain management techniques enable the patient to feel more comfortable. Pain is managed by a variety of medications, including narcotics, nonopioid medications, and analgesics. Activities such as distraction, relaxation, music, and imagery techniques create comfort and decrease anxiety (see Chapter 36). Heat and cold applications are used as therapies in pain management (see Chapter 29). It is important for the nurse to follow the primary care provider's orders and understand hospital policy to determine which applications are appropriate for the patient.
In an adult client, which pulse should the nurse assess to determine if there is a pulse discrepancy or pulse deficit with the radial pulse?
Apical
Nonrebreathing mask:
Apply as a regular mask. Contains one-way valves with a reservoir; exhaled air does not enter reservoir bag. Can be combined with a nasal cannula to provide higher FiO2. Device of choice for short-term high FiO2 delivery.Valves on mask side ports permit exhalation but close during inhalation to prevent inhaling room air
The nurse is assessing a client's peripheral pulses. What data should the nurse include in the documentation?
Bilateral comparison of peripheral pulses. Comparison of the apical pulse to peripheral pulses. Rate and intensity of the pulses. Description of the rhythm.
Which steps and attitudes should a nurse incorporate when completing a sexual history?
Clarify the vocabulary used by the client to describe sexual health. Allow time for discussion and exploration of the client's concerns. Ensure the client that confidentiality and privacy will be maintained.
Which client behavior indicates to the nurse the client who is most likely proficient in health literacy?
Client questions the healthcare provider about their prescribed plan of care.
Vitamin C (ascorbic acid)
Collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant
Which situations describe palliative care?
Comfort care offered a client with chronic pain from cancer radiation. The care is not related to the life expectancy of the affected person. Care that improves the quality of life from the diagnosis, to include curative measures.
Midline peripheral catheters (7.5-20 cm [3-8 inches])
Continuous and intermittent infusion (1-4 weeks) (INS, 2011b)Solutions or medications with a pH between 5.0 and 9.0 Osmolarity <600
Venturi mask
DISAVANTAGES Hot and confining, increased levels of humidification may irritate skin. A specific flow rate is necessary to deliver a specific FiO2, and the FiO2 can be decreased if the mask does not fit properly. Interferes with eating and talking.
Nonrebreather
DISAVANTAGES Requires tight seal, difficult to maintain and uncomfortable. May irritate skin. Bag should not totally deflate.
nasual cannula
DISAVANTAGES Unable to use with nasal obstruction. Drying to mucous membranes. Can dislodge easily. May cause skin irritation or breakdown. Patient's breathing pattern will affect exact FiO2.
Face tent
Disadvantages Difficult to keep in place, and the FiO2 cannot be controlled.
OXYMIZER
Disadvantages Nasal reservoir may interfere with drinking from cup. May be cosmetically unappealing. Potential reservoir membrane failure. Patient's breathing pattern will affect exact FiO2.
Partial nonrebreather—bag should always remain partially inflated. Therefore flow rate must be high enough to prevent collapse of the bag.
Disadvantages No inspiratory valve, so exhaled air mixes with inspired air. Hot and confining, may irritate skin, tight seal necessary. Interferes with eating and talking. Bag may twist or kink.
Oxygen hood—usually pediatric use
Disadvantages Flow rate of less than 5 L/min may lead to CO2narcosis.
Simple face mask
Disavantages Exact FiO2 level is difficult to estimate. Requires high FiO2 levels to prevent rebreathing of CO2. Patient inhales room air through the side holes in the mask.
The nurse is preparing discharge teaching for a client newly diagnosed with cancer. What should the nurse include in this teaching?
Discussing self-management techniques to enhance wellness. Facilitating strategies to problem-solve anticipated issues. Including client's family members and caregivers into teaching session.
A client with dementia has a diminished gag reflex. The nurse is instructing a caregiver in now to safety assist the client during feeding. What techniques should the nurse include in the teaching plan?
Do not rush the client and offer frequent rest periods. Check the client's open mouth for pocketed food. Verify that the client has swallowed the food between bites.
Vitamin A
Epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation Can reverse steroid effects on skin and delayed healing
The nurse is assessing a client's skin. There is an obvious alteration in skin color over the client's upper arm. The discoloration disappears when pressure is applied. Which term should the nurse use in documenting this finding?
Erythema.
The nurse requests to switch a client assignment with another nurse because the assigned procedure would conflict with the nurse's personal beliefs and values. What is this nurse demonstrating?
Ethical decision making. Moral courage. Professional autonomy.
Oxygen-conserving cannula (Oxymizer):
Fit as for nasal cannula. Reservoir is located under patient's nose or worn as a pendant. Delivers higher flow of oxygen with nasal cannula without changing to a mask, which is claustrophobic for some patients. Delivers a 2 : 1 ratio (e.g., 6-L/min nasal cannula is approximately equivalent to 3.5-L/min with Oxymizer).
Wheezes (sibilant wheeze)
Heard over all lung fieldsHigh-velocity airflow through severely narrowed or obstructed airwayHigh-pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration; usually louder on expiration.
Pleural friction rub
Heard over anterior lateral lung field (if patient is sitting upright)Inflamed pleura; parietal pleura rubbing against visceral pleuraDry, rubbing, or grating quality is heard during inspiration or expiration; does not clear with coughing; heard loudest over lower lateral anterior surface.
Respiratory Alkalosis
Hypoxemia from any cause (e.g., initial part of asthma episode, pneumonia)Acute painAnxiety, psychological distress, sobbingInappropriate mechanical ventilator settingsStimulation of brainstem respiratory control (e.g., meningitis, gram-negative sepsis, head injury, aspirin overdose) Physical examination: Light-headedness, numbness and tingling of fingers, toes, and circumoral region, increased rate and depth of respirations, excitement and confusion possibly followed by decreased level of consciousness, dysrhythmiasLaboratory findings: Arterial blood gas alterations: pH above 7.45, PaCO2 below 35 mm Hg (4.7 kPa), level normal if short lived or uncompensated or below 22 mEq/L (22 mmol/L) if compensated
Respiratory Acidosis
Impaired gas exchange: Type B COPD (chronic bronchitis) or end-stage type A COPD (emphysema) Bacterial pneumonia Airway obstruction Extensive atelectasis (collapsed alveoli) Severe acute asthma episode Impaired Neuromuscular Function: Respiratory muscle weakness or paralysis from hypokalemia or neurological dysfunction Respiratory muscle fatigue, respiratory failure Chest wall injury or surgery causing pain with respiration Dysfunction of Brainstem Respiratory Control: Drug overdose with a respiratory depressant Some types of head injury Physical examination: Headache, light-headedness, decreased level of consciousness (confusion, lethargy, coma), dysrhythmiasLaboratory findings: Arterial blood gas alterations: pH below 7.35, PaCO2 above 45 mm Hg (6 kPa), HCO3 level normal if uncompensated or above 26 mEq/L (26 mmol/L) if compensated
lateral position
In the lateral (or side-lying) position a patient is supported on the right or left side with the opposite arm, thigh, and knee flexed and resting on the bed. Place a pillow under the patient's head to keep the head, neck, and spine in alignment. The upper arm is flexed and supported with a pillow. The upper leg is flexed at the hip and knee and positioned on a small pillow (Pierson and Fairchild, 2013; Sorrentino et al., 2012). Patients who are obese or older are often not able to tolerate this position for any length of time. The 30-degree lateral position is recommended as a position to avoid development of pressure ulcers (WOCN, 2010). The position differs from side-lying in that the dependent hip is brought forward so less pressure is directly on the bony prominence (Figure 27-7). The following trouble points are common in the side-lying position: • Lateral flexion of the neck • Spinal curves out of normal alignment • Shoulder and hip joints internally rotated, adducted, or unsupported • Lack of support for the feet • Lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles • Excessive lateral flexion of the spine if the patient has large hips and a pillow is not placed superior to the hips at the waist
Metabolic Alkalosis
Increase of Bicarbonate: Excessive administration of sodium bicarbonate Massive blood transfusion (liver converts citrate to ) Mild or moderate ECV deficit (contraction alkalosis) Loss of Metabolic Acid: Excessive vomiting or gastric suctioning Hypokalemia Excess aldosterone Physical examination: Light-headedness, numbness and tingling of fingers, toes, and circumoral region; muscle cramps; possible excitement and confusion followed by decreased level of consciousness, dysrhythmias (may be caused by concurrent hypokalemia)Laboratory findings: Arterial blood gas alterations: pH above 7.45, PaCO2 normal if uncompensated or above 45 mm Hg (6.0 kPa) if compensated, above 26 mEq/L (26 mmol/L)
Metabolic Acidosis
Increase of Metabolic Acids (High Anion Gap): Ketoacidosis (diabetes, starvation, alcoholism) Hypermetabolic state (severe hyperthyroidism, burns, severe infection) Oliguric renal disease (acute kidney injury, end-stage renal disease) Circulatory shock (lactic acidosis) Ingestion of acid or acid precursors (e.g., methanol, ethylene glycol, boric acid, aspirin overdose) Physical examination: Decreased level of consciousness (lethargy, confusion, coma), abdominal pain, dysrhythmias, increased rate and depth of respirations (compensatory hyperventilation)Laboratory findings: Arterial blood gas alterations: pH below 7.35, PaCO2 normal if uncompensated or below 35 mm Hg (4.7 kPa) if compensated, level below 22 mEq/L (22 mmol/L) Loss of Bicarbonate (Normal Anion Gap): Diarrhea Pancreatic fistula or intestinal decompression Renal tubular acidosis COPD, Chronic obstructive pulmonary disease, ECV, extracellular fluid volume.
Which nursing actions are required when performing a transcutaneous electrical nerve stimulation (TENS) procedure with a client?
Instruct the client to adjust the intensity of TENS stimulation for pain relief. Ensure and review there is a healthcare provider's prescription for the TENS. Remove any hair or lotions from the skin where the electrodes are to be placed.
Crackles
Most common in dependent lobes: right and left lung basesRandom, sudden reinflation of groups of alveoli; disruptive passage of air through small airwaysFine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing.Medium crackles are lower, moister sounds heard during middle of inspiration; not cleared with coughing.Coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing.
Short, over-the-needle catheter (7.5 cm [<3 inches])
Most common, continuous infusion, intermittent infusion, short-term duration (rotate site every 72 hours) (INS, 2011b)Solutions or medications with a pH between 5.0 and 9.0 Osmolarity <600 mOsm/L
Peripheral Neuropathy
Muscle wasting of lower extremities • Foot deformities • Soft tissue infection of lower extremities • Abnormal gait • Decreased or absent vibratory, touch, temperature, or painful stimuli
Mutual factors:
Mutually set goals and expected outcomes ensure that the patient and nurse agree on the direction and time limits of care. Mutual goal setting increases a patient's motivation and cooperation. As a patient advocate you apply standards of practice, patient safety, and basic human needs when helping patients set goals.
The nurse is participating on a team writing the policy around sentinel events for the institution. Which topics should be included in the policy?
Near misses are considered sentinel events and should be reported. Changes in nursing practice are implemented to prevent recurrence of the event.
The UAP is assisting a client getting into the shower. The charge nurse answers a call from the cast clinic to immediately send the UAP's other assigned client to the clinic. Which action should the nurse take?
Notify the delegating nurse of the current request from the cast clinic.
The nurse calculates a client's body mass index (BMI). The client's height is 6 feet and 6 inches (198cm) and the BMI is 30. How should the nurse categorize this BMI?
Obesity.
Winged infusion butterfly needle
One-time infusion, IV push administrationSolutions or medications with a pH between 5.0 and 9.0 Osmolarity <600 mOsm/L
Patient-centered:
Outcomes and goals reflect the patient behaviors or responses expected as a result of nursing interventions. Write the goal to reflect this, not to reflect your goals or interventions. A correct goal statement is, "Patient will ambulate independently in 3 days." A correct outcome statement: "Patient ambulates in the hall 3 times a day by 4/22." A common error is to write an outcome as an intervention, "Ambulate patient in the hall 3 times a day."
The nurse is demonstrating to a client how to inject glucagon for emergencies. Which teaching tool is most effective for the client to use to review the sequence of steps in the procedure?
Photos showing how to mix the drug.
Rhonchi (sonorous wheeze)
Primarily heard over trachea and bronchi; if loud enough, able to be heard over most lung fieldsMuscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulenceLoud, low-pitched, rumbling, coarse sounds are heard either during inspiration or expiration; sometimes cleared by coughing.
Pursed-Lip Breathing.
Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, instruct the patient to take a deep breath and exhale slowly through pursed lips as if blowing through a straw. Have him or her blow through a straw into a glass of water to learn the technique. Patients need to gain control of the exhalation phase so it is longer than inhalation. The patient is usually able to perfect this technique by counting the inhalation time and gradually increasing the count during exhalation. In studies using pursed-lip breathing as a method to improve exercise tolerance in patients with COPD, patients were able to demonstrate increases in their exercise tolerance, breathing pattern, and arterial oxygen saturation
The nurse is teaching a group of daycare workers about healthy food choices for children. The nurse stresses that adequate intake of fruit, vegetables and protein is important in preventing which conditions?
Retarded growth. Behavioral problems. Developmental delays.
Pulse Rhythm
Rhythm is the regularity of the heartbeat. An irregular rhythm in the pulse, caused by an early, late, or missed heartbeat, is referred to as a dysrhythmia or an arrhythmia. When an irregular rhythm is detected, the apical pulse is assessed. An electrocardiogram (ECG) is necessary to define the specific dysrhythmia.
What should the nurse do to demonstrate proper body mechanics when assisting a client to a standing position from a sitting position? (Select all that apply.)
Rock their own body weight as they pull the client up towards them. Stand in front of the client, move their own feet apart and bend at the knees. . Assess the client and determine whether or not another care provider is needed to assist.
Which steps indicate that the nurse is following recommended procedure for handwashing?
Rub hands together to create lather for at least 15 seconds. While washing, keep hands and forearms lower than the elbows. Dry hands starting at the fingertips and work upward towards the elbows.
What is the wound closure called that occurs when the healing is prolonged because the skin or wound edges cannot be approximated?
Secondary intention.
Realistic:
Set goals and expected outcomes that the patient is able to reach. Achievable goals give patients a sense of accomplishment. This sense of accomplishment further increases a patient's motivation and cooperation. When establishing realistic goals, be sure to know the resources of the health care facility, family, and patient. For example, do a patient's cultural beliefs affect the goal you set? Does the patient have the necessary resources in the home to successfully meet goals?
As the nurse inflates the balloon of a client's indwelling urinary catheter, the client reports pain and discomfort. What should the nurse do next?
Stop and deflate the balloon of the catheter.
A client was treated three days ago for a puncture wound of the left lower calf. The client returns to the clinic with increased pain, limited range of motion in the left leg, and overall achiness and chills. As the nurse assesses the wound, what indicates possible infection?
Streaking Increased redness. Purulent drainage.
A client has been taking a prescribed dose of 20 mg of oxycodone every 4 hours for the past three weeks for pain relief. The client reports that "The medicine is not working anymore." After notifying the healthcare provider, which action should the nurse anticipate?
The client should be informed that this is an expected outcome and will improve.
Assessing the posterior tibial pulse.
The dorsalis pedis artery (Figure 20-37) is the other pedal pulse assessed. The nurse places the fingertips across the top of the forefoot halfway between the toes and the ankle. The artery lies superficially near the center of the long axis of the foot, between the extensor tendons of the great toe and second toe. In some people, it may be in a slightly different location, necessitating palpation across the dorsum of the foot.
Pulse Volume
The pulse volume, also called amplitude, is the strength of the pulse with each beat. It is described as normal (full and easily palpable), weak (thready and rapid), or strong (bounding). A normal pulse can be felt with moderate pressure of the fingers and obliterated with greater pressure. A forceful volume that is obliterated only with difficulty is a bounding pulse, which may be caused by vasodilation and overhydration. A pulse readily obliterated is described as weak or thready. Causes include vasoconstriction, stiff vessel walls from disease, and shock. A standard pulse-volume scale is used to document findings, with descriptions recorded using a range of 0 to 3+
association
To assess association, ask the patient to relate concepts such as parrot and bird, or guitar and music. Be sure to use simple concepts that are appropriate to the patient's culture and developmental level. If the patient is able to explain idioms and the relationship between associated concepts, higher-level cognitive functions are intact.
Which position is considered the best for a nurse to place a client in who is experiencing respiratory distress?
Tripod posture. Rationale Tripod posture is the correct choice. The tripod posture provides leverage and stability to the client so that the abdominal, intercostal, and accessory muscles of the neck can assist in expiration.
A client is experiencing cancer-related fatigue. What should the nurse advise to help alleviate the symptoms?
Try to eat a well-balanced diet. Participate in routine physical exercise. Develop routine sleeping habits.
1+
Weak and thready pulse, difficult to palpate
Which questions are best for the nurse ask to assess for "disuse syndrome" in clients diagnose with neuromuscular diseases such as muscular dystrophy or multiple sclerosis? (Select all that apply.)
What is included in a typical day for you? How much assistance do you need to move around? On a scale 1-10, how would you rate overall pain level?
How should a nurse instruct a client on the proper use of the incentive spirometer?
Wrap lips around the mouthpiece and inhale through the mouthpiece. Rationale Clients should be instructed to wrap lips around the mouthpiece and inhale through mouthpiece. The nurse should instruct the client to take a slow, deep breath and maintain a constant flow, like pulling through a straw. This technique helps maintain maximal inspiration and reduces risk for progressive collapse of a client's alveoli.
Setting Priorities
You frequently need to set priorities during medication administration, especially when you care for multiple patients at the same time. Assess your patient's clinical condition on an ongoing basis to determine which nursing diagnosis takes the greatest priority and which medications you need to administer first. Medications that are to be administered around the clock (e.g., antibiotics) need to be given in a timely manner to maintain therapeutic serum levels. Frequently medications given for pain or to prevent serious harm to a patient such as antihypertensives, cardiac medications, and antiseizure drugs are of a higher priority than other medications. The priorities for every patient are different. It is your responsibility to know your patients and prioritize their needs appropriately. In addition to administering medications, teaching patients about their medications is another priority. Plan to teach patients about their medications while you administer them. Family members usually reinforce the importance of medication regimens. Therefore collaborate with the patient's family or friends when you provide instruction. When patients are hospitalized, begin teaching when the patient is admitted; do not postpone instruction until the day of discharge. In outpatient or community settings, ensure that patients know where and how to obtain medications and that they are able to read medication labels.
Measurable:
You learn to write goals and expected outcomes that set standards against which to measure a patient's response to nursing care. Examples such as, "Body temperature remains 98.6° F" and "Apical pulse remains between 60 and 100 beats per minute" allow you to objectively measure changes in a patient's status. Do not use vague qualifiers such as "normal," "acceptable," "stable," or "sufficient" in the expected outcome statement. Vague terms make it difficult to determine a patient's response to care. Terms describing quality, quantity, frequency, length, or weight allow you to accurately evaluate if outcomes are met.
Observable
You must be able to observe if change takes place in a patient's status. Observable changes occur in physiological findings and the patient's knowledge, perceptions, and behaviors. For example, you observe the goal, "Patient will achieve improved activity tolerance" through the outcome of, "Patient's heart rate remains within 10% of baseline following exercise." The outcome statement, "Patient appears less short of breath" is not a correct statement because there is no specific observable behavior for "appears less short of breath."
Abstract thinking and association
are higher-level cognitive functions. To determine a patient's ability to interpret abstract concepts, ask the patient to explain a common idiom, such as "penny wise and pound foolish." If patients are able to interpret idioms, it is more likely that they will be able to comprehend and apply medication and treatment instructions. Keep in mind that a person whose primary language is different from that of the examiner may be unable to interpret idioms regardless of having intact higher-level cognitive functions.
Bronchial
are loud and high pitched with hollow quality. Expiration lasts longer than inspiration (3 : 2 ratio).
short-term memory
assess by having the patient recall three words or numbers chosen by the nurse. Later in the interview, ask the patient to repeat the same three words or numbers used earlier in the assessment. The patient should be able to accurately recite the list. Another way to test patient short-term memory is to ask what occurred earlier in the same day.
Radiating pain
extends from the source to an adjacent area of the body. For example, in gastroesophageal reflux, pain in the stomach radiates up the esophagus.
Pursed-lip breathing
involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. Instruct the patient to sit up and then take a deep breath and exhale slowly through pursed lips. Patients need to gain control of the exhalation phase so exhalation is longer than inhalation. The patient is usually able to perfect this technique by counting inhalation time and gradually increasing the count during exhalation.
Incentive spirometry
is a method of encouraging voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It is an effective method for promoting deep breathing to prevent or treat atelectasis in the postoperative patient. Incentive spirometry encourages patients to breathe to their normal inspiratory capacities. A postoperative inspiratory capacity one half to three fourths of the preoperative volume is acceptable because of postoperative pain. Administration of pain medications before incentive spirometry helps a patient achieve deep breathing by reducing pain and splinting. There is no clinical benefit to using incentive spirometry in place of early ambulation. Encourage your postoperative patients to ambulate as soon as possible. Flow-oriented incentive spirometers consist of one or more plastic chambers that contain freely moving colored balls. The patient inhales slowly with an even flow to elevate the balls and keep them floating as long as possible. This allows a maximally sustained inhalation. Volume-oriented incentive spirometry devices have a bellows that rises to a predetermined volume by an inhaled breath. An achievement light or counter is used to provide feedback. Some devices do not turn the light on unless the bellows is at a minimum desired volume for a specified period of time.
Yankauer or tonsillar
is a rigid plastic catheter with one large and several small eyelets through which mucus is removed. The catheter is angled to facilitate removal of secretions from the mouth. Use the Yankauer suction catheter when oral secretions are thick and plentiful. Do not use it in the nares because of its size.
Diaphragmatic Breathing.
is useful for patients with pulmonary disease, postoperative patients, and women in labor to promote relaxation and provide pain control. The exercise improves efficiency of breathing by decreasing air trapping and reducing the WOB. Diaphragmatic breathing is more difficult than other breathing methods because it requires a patient to relax intercostal and accessory respiratory muscles while taking deep inspirations, which takes practice. The patient places one hand flat below the breastbone (upper hand) and the other hand (lower hand) flat on the abdomen. Ask him or her to inhale slowly, making the abdomen push out (as the diaphragm flattens, the abdomen should extend out) and moving the lower hand outward. When the patient exhales, the abdomen goes in (the diaphragm ascends and pushes on lungs to help expel trapped air). The patient practices these exercises initially in the supine position and then while sitting and standing. The exercise is often used with the pursed-lip breathing technique.
Bilevel positive airway pressure (BiPAP)
provides continuous bilevel positive airway pressure. It uses two pressures: a higher pressure during inhalation and a lower pressure during exhalation.
Continuous positive airway pressure (CPAP)
provides continuous positive airway pressure; that is, it provides the same pressure during both inhalation and exhalation.
Somatic pain
results from injury to skin, muscles, bones, and joints. Somatic pain occurs in conditions such as sunburn, lacerations, fractures, sprains, arthritis, and bone cancer.
Bronchovesicular
sounds are blowing sounds that are medium pitched and of medium intensity. Inspiratory phase is equal to expiratory phase.
apical pulse
the heart rate measured at the apex of the heart on the anterior chest wall. It is best heard between the left fifth and sixth intercostal spaces, over the midclavicular line (see Skill 19-2 to review apical pulse landmarks). Assessing the apical rate requires auscultation with a stethoscope. The apical site is used if the patient has weak heart contractions, has an irregular rhythm, is taking medications that affect cardiac function, or needs a more accurate assessment. A pulse deficit results when the apical pulse rate exceeds the radial pulse rate. A deficit occurs when the cardiac ejection of a volume of blood is too small to initiate a peripheral pulse wave. To measure this deficit, two people count both pulses simultaneously.
long-term memory
to assess long-term memory, ask the patient to recall a date or name from the past that can be verified with a family member.
oropharyngeal or nasopharyngeal suctioning
to help a patient who is able to cough effectively but is unable to clear secretions by expectorating or swallowing.
Visual Analog Dyspnea Scale (VADS),
which is a straight line with verbal anchors at the beginning and end of a 100-mm line (Fig. 30-9). Ask the patient to place a mark on the line to indicate his or her perceived breathing difficulty. Document the response, and use this scale to determine the therapy effectiveness and pace the patient's activities.
= Overweight
• 25.0 kg/m2 to 29.9 kg/m2
Obese (class 1)
• 30.0 kg/m2 to 34.9 kg/m2 =
= Obese (class 2)
• 35.0 kg/m2 to 39.9 kg/m2
Severity of dehydration is classified by percentage of total body weight:
• A 2% loss is mild dehydration. • A 5% loss is moderate dehydration. • An 8% loss is severe dehydration. • A 15% loss is life-threatening, usually fatal.
Factors Affecting Blood Pressure
• Age: With age, elasticity in arteries decreases; this increases peripheral resistance, leading to higher blood pressure. • Gender: Blood pressure usually is lower in women than in men until menopause. • Race: Hypertension is more prevalent in African American men and women. • Medications: Oral contraceptives cause an increase in blood pressure in some women. • Weight: Blood pressure usually is higher in people who are obese. • Circadian rhythm: Blood pressure usually is lower in the morning and slightly higher by late afternoon. • Head injury: Increased intracranial pressure from head injury causes increased blood pressure. • Increased blood volume: Increased fluid in the cardiovascular system increases blood pressure. • Food intake: Blood pressure increases after eating. • Emotions: Anger, fear, and excitement cause blood pressure to rise until the emotion passes. • Pain: Pain increases blood pressure.
Determine if it is appropriate to measure patient's orthostatic blood pressure. Orthostatic vital signs are not indicated in patients who
• Have supine hypotension. • Have a sitting blood pressure ≤90/60 mm Hg. • Have acute deep vein thrombosis. • Exhibit the clinical syndrome of shock. • Have severely altered mental status. • Have possible spinal injuries. • Have lower extremity or pelvic fractures. • Are not mobile enough to get out of bed.
Inadequate pain management may lead to detrimental outcomes such as:
• Impaired recovery and progression to chronic pain • Compromised ability to carry out ADLs • Inability to get adequate rest and sleep, leading to a diminished quality of life • Significant suffering, with increasing anxiety, depression, fear, and anger • Work absenteeism and potential underemployment or loss of employment • Increased health care costs • Difficulty accessing disability compensation
Underweight
• Less than 18.5 kg/m2 =
= Extreme obesity (class 3)
• More than 39.9 kg/m2
