NCLEX-RN
The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care? Place lamb's wool under the lift sheet. Turn the client every 2 to 4 hours. Use an egg crate mattress. Place the client on a pressure redistribution bed.
A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown. Lambs' wool may trap heat and exacerbate skin breakdown. Turning should be at a minimum of every 2 hours. Egg crate has not been proven to be effective to prevent the development of pressure injuries and should not be used.
During the first few weeks after a cholecystectomy, the client should follow a diet that includes: a decreased intake of fruits, vegetables, whole grains, and nuts, to minimize pressure within the small intestine. at least four servings daily of meat, cheese, and peanut butter to increase protein intake that aids incisional healing. a limited intake of fat distributed throughout the day so that there is not an excessive amount in the intestine at any one time. ingestion of pancreatic enzymes with meals to replace the normal enzyme secretion that has been surgically altered.
Bile flows almost continuously into the intestine for the first few weeks after gallbladder removal. Limiting the amount of fat in the intestine at any one time ensures that adequate bile will be available to facilitate digestion. Eating large amounts of meat, cheese, and peanut butter would be undesirable because these foods are often high in fat. There is no need to eliminate high-fiber foods, and doing so would tend to increase pressure within the large intestine, not decrease pressure in the small intestine. Removing the gallbladder does not decrease pancreatic secretions.
Which action should be included in the nursing care for a client with cervical cancer who has an internal radium implant in place? Offer the bedpan every 2 hours. Provide perineal care twice daily. Check the position of the applicator hourly. Offer a low-residue diet.
Bowel movements can be difficult with the radium applicator in place. The purpose of the low-residue diet is to decrease bowel movements. The bowel is cleaned before therapy, and the woman is maintained on a low-residue diet during treatment to prevent bowel distention and defecation. To prevent dislodgment of the applicator, the client is maintained on strict bed rest and allowed only to turn from side to side. Perineal care is omitted during radium implant therapy, although any vaginal discharge should be reported to the health care provider (HCP). It is rare for the applicator to extrude, so this does not need to be checked every hour.
A client is being discharged with nasal packing in place. What should the nurse instruct the client to do? Perform frequent mouth care. Use normal saline nose drops daily. Sneeze and cough with mouth closed. Gargle every 4 hours with salt water.
Frequent mouth care is important to provide comfort and encourage eating. Mouth care promotes moist mucous membranes. Nose drops cannot be used with nasal packing in place. When sneezing and coughing, the client should do so with the mouth open to decrease the chance of dislodging the packing. Gargling should not be attempted with packing in place.
A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief? lithotomy right lateral hands and knees tailor sitting
Placing the client in the hands and knees position pulls the fetal head away from the sacral promontory (relieving pain) and facilitates rotation of the fetus to the anterior position. Lithotomy is the position preferred by some health care providers (HCP) for delivery but does not facilitate rotation. The right lateral position will perpetuate the ROP(right occiput posterior: sunny side-up) position. Tailor sitting facilitates descent in OA positions.
A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement? applying ice applying a breast binder teaching how to express the breasts administering bromocriptine
Teaching the client how to express her breasts will facilitate let-down, and provide temporary relief. Ice can promote comfort by decreasing blood flow, numbing, and discouraging further let-down of milk. It is not recommended because it also causes the rebound reaction of more let-down once the ice is removed. Breast binders are not effective in relieving the discomforts of engorgement. Bromocriptine is no longer recommended for lactation suppression.
A pregnant client late in her first trimester comes to the clinic for a follow-up visit. The woman tells the nurse that she has been having morning sickness, but she "tried using this band on her wrist," and it helped cut down on the number of episodes she was having. The nurse interprets this therapy as an example of acupressure. biofeedback. meditation. aromatherapy.
The band on the wrist described by the client is an example of acupressure. Biofeedback involves connection to electrical sensors provide the person with information about the body so that the person can then focus actions to make small changes in the body to achieve the goal. Meditation involves deep thinking and reflection to focus the mind and body. Aromatherapy involves the use of essential oils to promote well-being
The nurse is preparing to irrigate a client's nasogastric tube and is unable to instill fluid with a syringe into the tube due to meeting resistance. What would the nurse's next action be? Notify the healthcare provider. Use a smaller syringe to increase force of the irrigation. Irrigate the blue air vent on the nasogastric tube with air. Elevate the head of the client's bed and reattempt the procedure.
The nurse would use the blue air vent on the nasogastric tube to help relieve pressure in the stomach and potentially dislodge the nasogastric tube from the wall of the stomach as a potential solution to the resistance being met. Using more force with a smaller syringe would be incorrect because it can cause damage to the mucosa of the stomach. The nurse would not notify the healthcare provider at this time because there are other troubleshooting methods that can be used prior to this. Elevating the head of the bed will not have an effect on the tube because it is not dependent on this for irrigation.
A nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. What instructions would the nurse give to this client? Take sleeping pills. Take an afternoon nap. Go to bed earlier at night. Sleep only on the left side.
Fatigue is a common part of pregnancy. It is worst in the first and third trimesters; first-trimester fatigue is often associated with the many physical and psychosocial changes of being pregnant, and third-semester fatigue is caused by sleep disturbances from increased weight and physical discomforts such as heartburn. If physical causes of the fatigue are ruled out, the client should be arranging her life to permit additional rest periods. Naps should be encouraged. It is best to sleep on the left side, but a position of comfort improves sleep. Sleeping pills should be contraindicated during pregnancy. The client should go to bed to sleep on her natural sleep schedule. If one is used to going to bed late at night, then going to bed earlier doesn't mean the client will fall asleep earlier. The client should sleep and rest when her body tells her.
A client with a history of posttraumatic stress is panting and breathing heavily while shouting out some strange words. The nurse reviews the nursing assessment and understands that the client is practicing a form of relaxation called power breathing. The best action for the nurse to take is to: monitor the client for respiratory difficulties. contact the health care provider for a psychiatric consult. allow privacy, but check on the client frequently. arrange for a sitter so the client is not left alone.
The nurse should acknowledge that the client is performing self-care for anxiety symptoms. The most respectful action is to allow privacy but to check on the client frequently. The client is likely chanting or reciting a mantra. There is no indication that the client is experiencing respiratory conflict. The client does not need a sitter or a psychiatric consult.
One day after an appendectomy, a 9-year-old rates pain at 4 out of 5 on the pain scale but is playing video games and laughing with a friend. What should the nurse document on the child's chart? The child is in no apparent distress, and no pain medication is needed at this time. The child rates pain at 4 out of 5. Administered pain medication as ordered. The child does not understand the pain scale. Performed teaching to help child match pain rating to how child appears to be feeling. The child rates pain at 4 out of 5; however, appears to be in no distress. Reassess when the client is visibly showing signs of pain.
Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses passive coping behaviors (such as distraction and cooperative) may rate pain as more intense than children who use active coping behaviors (such as crying and kicking). Nurses frequently make judgments about pain based on behavior, which can result in children being inadequately medicated for pain.
A breastfeeding postpartum client experiencing breast engorgement tells the nurse that she has applied cabbage leaves to decrease her breast discomfort. What is the nurse's best response? "Using cabbage leaves to relieve engorgement is considered a folk remedy." "I'm concerned that the cabbage leaves may harm your nursing baby." "I need to notify your health care provider immediately that you're using cabbage leaves." "Let me know if you get relief using the cabbage leaves."
Holistic nursing honors the client's preference for safe, alternative, and complementary practices. Cabbage leaves tucked into the bra is an alternative practice that may relieve pain and swelling from engorgement in some clients. Saying that using cabbage is a folk remedy does not address the safety or efficacy of the practice. There are no known safety risks to using cabbage as a treatment for engorgement. The nurse should document the client's use of cabbage leaves to treat the engorgement in the medical record, but there is no risk that warrants immediate notification of the health care provider.
The nurse instructs a primigravid client to increase her intake of foods high in magnesium because of its role with which process? prevention of demineralization of the mother's bones synthesis of proteins, nucleic acids, and fats amino acid metabolism synthesis of neural pathways in the fetus
Magnesium aids in the synthesis of protein, nucleic acids, proteins, and fats. It is important for cell growth and neuromuscular function. Magnesium also activates the enzymes for metabolism of protein and energy. Calcium prevents demineralization of the mother's bones. Vitamin B6 is important for amino acid metabolism. Folic acid assists in the development of neural pathways in the fetus.
A multigravida prenatal client with a history of postpartum depression tells the nurse that she is taking measures to make sure that she does not suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make? current medications fetal growth liver functions mood status
St. John's wort, an herbal supplement commonly used to treat mild depression, interacts with many medications, making them less effective. If the client is already taking a prescription antidepressant, she can be at risk for serotonin syndrome. St. John's wort is not known to cause fetal growth or liver problems. It would be important to assess the client's mood after determining if the client is at risk for medication interactions.
The nurse is instructing a client who has had an ileostomy about the diet following surgery. The nurse should tell the client: "Limit your fluids to 1,000 mL/day." "Chew your food thoroughly." "There is no need to monitor your diet." "Six small meals a day will prevent abdominal distention."
The client is instructed to chew food well to aid digestion and prevent obstruction.The client should maintain an adequate fluid intake.The client is usually placed on a regular diet but is encouraged to eat high-fiber, high-cellulose foods (e.g., nuts, popcorn, corn, peas, tomatoes) with caution; these foods may swell in the intestine and cause an obstruction.Eating six small meals a day is not necessary.
Lower back pain is a common concern among pregnant clients. Which comfort measure should a nurse include in the teaching plan for a pregnant client? Wear high-heeled shoes. Use an ergonomically correct desk chair. Avoid tilting the pelvis forward. Bend at the waist, not at the knees.
The nurse should instruct the client to use an ergonomically correct desk chair to help alleviate lower back pain. Wearing high heels promotes imbalance and falls. The nurse should not instruct the client to avoid tilting the pelvis forward, because standing with her neck and shoulders straight and pelvis tilted forward alleviates stress caused by excess uterine weight. Bending and lifting at the knees (not at the waist) alleviates strain on lower back muscles.
A client in a hospice program has increasing pain, and the nurse is collaborating with the client to make a pain management plan. Which plan will be most effective for the client? administering doses of analgesic when pain is a "5" on a scale of 1 to 10. providing enough analgesia to keep the client semi-somnolent allowing an analgesia-free period so that the client can carry out daily hygienic activities. administering pain medications over a 24-hour period
The desired outcome for management of pain is that the client's or family's subjective report of pain is acceptable and documented using a pain scale; the goal is that behavioral and physiologic indicators of pain are absent around the clock. The nurse and client/family should develop a systematic approach to pain management using information gathered from history and a hierarchy of pain measurement. Pain should be assessed at frequent intervals. The client should not wait to receive medication until the pain is midpoint on the pain scale, nor should the client receive so much pain medication that he or she is not alert. Continuous pain relief is the goal, not just during particular periods during the day.
An older adult with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is showing the client's family how to place the mattress (see below). What should the nurse instruct the family to do? Turn the mattress over so the air cells face the mattress of the bed, and cover the mattress with a bed sheet. Put a thick pad over the pressure mattress to prevent soiling, and place the bed sheet on top of the pad. Make the bed with the bedsheet on top of the pressure mattress. Place the sheet on the bed, and then remove the pillow to allow full use of the mattress on the neck.
To obtain best results, one sheet should be used to cover the mattress. The air cells should be facing up as shown. Thick pads should not be used; if the client is incontinent, a "breathable" incontinent pad can be added. The client can use a pillow as needed.
One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do? Dim lights in the house and stay inside for one week. Attach sun shields to existing eyeglasses when in direct sunlight. Use sunglasses that wrap around the side of the face when in bright light. Patch the affected eye when in bright light.
To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently, and bright light will come in on the side of the face. It is not necessary to patch the affected eye.
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention would be most appropriate to institute? limiting conversation with the child keeping extraneous noise to a minimum allowing the child to play in the bathtub performing treatments quickly
A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, they should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.
Which is a priority nursing goal for a client with rheumatoid arthritis? The client will: minimize the frequency with which anti-inflammatory drugs are used to control joint discomfort. demonstrate use of adaptive equipment. learn to limit activity so as to avoid joint pain. verbalize that recovery from rheumatoid arthritis will require several years of treatment.
Depending on the degree of joint involvement, clients with rheumatoid arthritis may need to learn to function with adaptive equipment. Such equipment can help the client maintain independence. The consistent use of anti-inflammatory drugs is considered important to minimize joint inflammation and damage. Periods of activity should be alternated with rest periods, but limiting activity to avoid joint pain is not a realistic or desirable outcome. The client needs to understand that rheumatoid arthritis cannot be cured.
