Hurst 2
A nurse is planning to educate diabetic clients on how to decrease their risk for developing renal failure. What educational points should the nurse include? 1. Avoid daily use of non-steroidal antiinflammatory medications. 2. Aggressive blood pressure management is necessary. 3. Aim to keep Glycosylated Hemoglobin (HgbA1c) less than 7%. 4. Have estimated glomerular filtration rate measured every five years. 5. Increase protein intake to 30% of total calories eaten per day.
1., 2. & 3. Correct: NSAIDs can damage the kidneys with chronic use. Risk factors for diabetic related renal complications include hypertension and hyperglycemia; therefore, management of blood pressure and blood glucose is necessary. The ADA treatment goal for HgbA1c is < 7%. 4. Incorrect: The estimated glomerular filtration rate (eGFR) should be assessed at least yearly if not more frequently. 5. Incorrect: A diabetic client's diet should consist of no more than 15-20% caloric intake of protein because protein makes the kidneys work harder.
A client is transported to the emergency department following a 20-foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately? 1. Apply occlusive dressing to chest. 2. Initiate large gauge I.V. line. 3. Prepare for chest tube placement. 4. Administer high-flow oxygen. 5. Position client on right side.
2, 3 and 4. CORRECT. Based on the assessment data recorded by the nurse, the client most likely has a tension pneumothorax secondary to blunt force trauma from the fall. Immediate actions must focus on preventing tracheal deviation and a fatal outcome. The need for intravenous fluids and medications in any trauma requires at least one large-bore I.V. line or more. This client will need immediate chest tube placement to relieve increasing intrathoracic pressure. While preparing the client for this procedure, high-flow oxygen should be administered via non-rebreather mask because of the client's respiratory distress. 1. INCORRECT. There is no indication in the question of an open chest wound, or that a dressing is needed. The occlusive chest dressing will be placed over the insertion site of the chest tube after placement is completed. 5. INCORRECT. This trauma client will be secured to a back board, most likely with a C-collar in place, until x-rays confirm there has not been a cervical spine injury. Placing the client on the right side is counterproductive and in fact could further impair respiratory efforts.
A client has been trying to implement a low fat diet for prevention of heart disease and enhancement of weight loss. He further reports that his wife shows her love by preparing rich foods and pastries. Which action should the nurse make? 1. Suggest that the client prepare all meals at home. 2. Schedule a meeting with husband and wife to discuss diet and health. 3. Suggest that the client limit intake to one serving of each food at meals. 4. Ask the client to give his wife a cookbook with low fat recipes.
2. Correct: The meeting with the wife and husband together may help to gain the support of the wife. She may not realize that meal preparation is actually serving as a barrier to successful change. Also, the importance of the opinions and behaviors of the wife are important to the client as he tries to engage in long-term behavioral change. 1. Incorrect: This intervention may actually increase barriers to change because the wife's feeling and support are necessary to maintain long-term change.3. Incorrect: While this practice may reduce the intake of fat, the issue of spousal support should be addressed.4. Incorrect: Open discussion with the wife about the need for low-fat meals is essential.
What interventions should the nurse include when teaching a client how to prevent and treat fungal infections of the feet? 1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.
2., 4. 5, & 6. Correct: Athlete's foot is treated with topical antifungal in most cases. Severe cases may require oral drugs. The feet must be washed daily with soap and water and dried thoroughly since the fungus thrives in moist environments.Steps to prevent athlete's foot include wearing shower sandals in public showering areas and wearing shoes that allow the feet to breathe. 1. Incorrect: Clients with fungal skin infections should avoid the use of cornstarch. The carbohydrates in cornstarch may provide nutrition to fungal infections and should be avoided. 3. Incorrect: Allow feet to have exposure to the air. The feet must be kept clean and dry since fungus thrives in moist environments. Keeping the feet covered all the time causes a dark, moist environment for the fungus to thrive.
The nursing supervisor is reviewing several instances in which restraints have been used. The nurse is aware the only acceptable use of restraints is what? 1. An elderly male had a chest restraint applied after crawling over bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV 4. A dementia client with sundowners is placed in Geri-chair with lap belt at nurse's station.
3. CORRECT: Restraints are considered a last resort when caring for a client, whether soft cloth or chemical restraints. The most acceptable use is to prevent a client from harming self or others. In this instance, a confused client has previously pulled out a prescribed IV. Therefore, the use of hand mitts is the most appropriate, least-restrictive method to prevent the client from further self-harm. 1. INCORRECT: There are several problems here. The client had side rails up, which are considered a form of restraint and in many facilities are no longer permitted. By applying a chest restraint, the client has been restrained twice. Just because a client is elderly does not mean restraints are needed. This restraint is not acceptable. The nurse should provide regular toileting periods and determine why this client is climbing out of bed. 2. INCORRECT: Closing a client into a room is overly restrictive and unsafe. This Alzheimer's client needs to be observed and closing the room door prevents visual access. Additionally, closing the door may violate fire safety codes in certain facilities. At shift change, when staff is occupied with report, special arrangements should be made so that the client can be observed and not restrained. 4. INCORRECT: Depending on the facility, placing a client upright at night, using a Geri-chair and a lap belt is overly restrictive. A client with dementia is challenging, particularly in the presence of sundowner syndrome. However, keeping a client upright all night, belted into a chair for the purpose of observation, is neither safe nor healthy for the client.
What is the nurse's first priority when treating a client with a chemical burn? 1. Attach client to a cardiac monitor. 2. Apply a sterile bandage. 3. Rinse the area with copious amounts of water. 4. Remove the client's clothing.
3. Correct: The first action in treating a chemical burn is to rinse the affected area with large amounts of cool water. 1. Incorrect: This is necessary with electrical burns. 2. Incorrect: This may come later, not first priority. 4. Incorrect: This can be accomplished while you are rinsing them with water.
The nurse receives the morning lab results of four clients during the change of shift report. Which client should the nurse assess first? 1. Vomiting and diarrhea with a potassium 3.3 mEq/L (3.3 mmol/L). 2. One day post-operative hip replacement with a Hct 30% (0.30) / Hgb 10 g/dL (100 g/L). 3. Pneumonia with a White Blood Cell (WBC) count of 12,000/mm3 (12 x 10^9/L). 4. Diabetes with a Fasting Blood Sugar (FBS) of 40 mg/dL (2.2 mmol/L).
4. Correct: This is a critical value. 1. Incorrect: The potassium level is low but not critical. 2. Incorrect: The hematocrit and hemoglobin are low but not critical. 3. Incorrect: The WBC count is high but not critical.
What would be the best way for the nurse to evaluate the effectiveness of fluid resuscitation during the emergent phase of burn management? 1. Weight increases by 2 pounds in 24 hours 2. Urinary output is greater than fluid intake 3. Blood pressure is 90/60 mmHg 4. Urine output greater than 35mL/hour
4. Correct: Urine output of 30 to 50 mL/hour indicates adequate fluid replacement. 1. Incorrect: May indicate fluid retention. 2. Incorrect: Does not indicate fluid balance. 3. Incorrect: Blood pressure alone does not indicate adequate fluid balance.
The nurse is teaching a group of clients in cardiac rehabilitation how blood flows through the heart. In what order should the nurse present this information? List the order in which blood flows through the heart, starting from deoxygenated blood in the body. Vena Cava Right Atrium Right Ventricle Lungs Left Atrium Left Ventricle Aorta
Deoxygenated blood comes from the body to the heart via the superior and inferior vena cava. From there blood enters the right atrium, then travels to the right ventricle. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle. The left ventricle pumps the blood out through the aorta to the body.
A nurse is reviewing the lab values for a group of clients in a psychiatric emergency department. Rank each lab result from greatest to least concern to the nurse. The client diagnosed with schizoaffective disorder who has a potassium level of 7.0 mEq/L (7 mmol/L The client diagnosed with schizophrenia who is taking clozapine and has a WBC count of < 3000 mm³ (3 x 10^9/L) The client admitted with a blood alcohol level of 0.08% (80 mg/dL) The client diagnosed with bipolar disorder who has a lithium level of 1.3 mEq/L.
First, the client who has a potassium level of 7.0 mEq/L (7 mmol/L) should be of greatest concern to the nurse. The normal reference range for serum potassium is 3.5 mEq/L to 5.0 mEq/L (3.5-5 mmol/L) with a critical value of › 6.5mEq/L (6.5 mmol/L). This client is at high risk for cardiac death. Second,the client who has a WBC count of less than 3,000 mm³ (3 x 109/L) should then be of concern to the nurse. A serious adverse effect of clozapine is agranulocytosis and, if the total white cell and/or neutrophil counts indicate agranulocytosis, clozapine should be immediately discontinued. Third, a client who has a lithium level of 1.3 mEq/L should be documented by the nurse. Therapeutic lithium levels range from 0.8 to 1.2 mEq/L and, since this client's serum lithium level is high, the client is at risk for lithium toxicity. Serum lithium levels greater than 2.0 mEq/L is toxic. Fourth, the client who has a blood alcohol level of 0.08% (80 mg/dL) is intoxicated, but this is not at a dangerous level. A blood alcohol level of 0.30% (300 mg/dL) or greater may cause severe central nervous system depression, unconsciousness, and possible death. Normal is 0-50 mg/dL or 0-0.05%
