NURS172: Assessment PrepU Misses
Dyspnea
Difficulty or labored breathing
A client is receiving total parenteral nutrition (TPN) solution. The nurse should assess a client's ability to metabolize the TPN solution adequately by monitoring the client for which sign?
Hyperglycemia Explanation: - During TPN administration, the client should be monitored regularly for hyperglycemia. - The client may require small amounts of insulin to improve glucose metabolism. - The client should also be observed for signs and symptoms of hypoglycemia, which may occur if the body overproduces insulin in response to a high glucose intake or if too much insulin is administered to help improve glucose metabolism. - Tachycardia or hypertension is not indicative of the client's ability to metabolize the solution. An elevated blood urea nitrogen concentration is indicative of renal status and fluid balance
A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should *first?*
Institute droplet precautions. Explanation: The child with meningococcal meningitis requires *droplet precautions for at least the first 24 hours after effective therapy is initiated* to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.
Orthopnea
SOB (dyspnea) when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair
Nuchal rigidity
Stiffness of the neck or inability to bend the neck
A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress? a) The client reported feeling dizzy and weak and perspired profusely. b) The client's pulse and respiratory rate returned to baseline 1 hour after activity. c) The client's head was down, gaze was cast down, and toes were pointed outward. d) The client's pulse and respiratory rates increased moderately during ambulation.
The client's pulse and respiratory rates increased moderately during ambulation. Explanation: - Pulse and respiratory rates normally increase during, and for a short time after, ambulation, especially if it is the first ambulation after 3 days of bed rest. - Vital signs should return to baseline within 5-10 minutes after activity. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. - A client who tolerates ambulation well holds his head erect, gazes straight ahead, and keeps his toes pointed forward. - A client who ambulates with his head down, gaze cast down, and toes pointed outward is exhibiting activity intolerance.
The nurse is caring for a client with a head injury. Which client goal is most appropriate for the acute phase of a neurological injury? a) The client's skin will remain clean, dry and intact. b) The client will return to optimal level of functioning. c) The client will use the adaptive devices to assist with feeding. d) The client's vital signs will stabilize returning to normal range.
The client's vital signs will stabilize returning to normal range. Explanation: - During the acute phase of a neurological injury, the *goal of nursing management is to stabilize the client to prevent further neurological damage.* - A client goal would be to have the vital signs stabilize, indicating an improvement in status, and also returning to normal range. - Using adaptive devices would occur in the recovery or chronic phase of a neurological deficit. - The client's skin and returning to optimal level of functioning is a goal for later in the recovery process
Hypoxemia
Abnormally low concentration of oxygen in the blood
Hemoptysis
Low O2 concentration in blood
Phenotype
Observable physical characteristics of DNA
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed prior to administering anesthesia to the client to avoid wrong-site surgery?
• Verify that the surgeon has marked with a permanent marker the correct knee for the surgical site. • Verbally ask the client to state his or her name, surgical site, and procedure. • Verify the correct client with the correct operative site from medical records and diagnostic reports. • Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision. Explanation: - The root cause of wrong-site surgery involves a breakdown in communication between the client and family and the health care team. - Information retrieved from the client in the preoperative assessment, such as the *client's name, surgical site, and procedure, should be verbally assessed and verified with medical records and radiographic diagnostic reports.* This information should be compiled in a checklist that the intraoperative team can recheck, thus avoiding unnecessary distraction and delay in the operating room. - The nurse in the operating room is *responsible* for calling a "time out" so that every surgical team member can double-check the correct site of surgery, verify the site using the operative consent form, and verify that the surgeon has marked the operative site on the client. - Showing the client an anatomic model will assist the client in understanding the location of the surgery, but it will not prevent anyone from identifying the wrong site on the client.
