practice
A cleansing enema is prescribed for an adult client. The nurse understands that which is the maximal volume of fluid that can be administered?
1000 ml
ABO
A type of antigen system. The ABO type of the donor should be compatible with the recipient's. Type A matches with types A and O; type B matches with types B and O; type O matches only with type O; and type AB matches with types A, B, and O.
universal RBC recipient
AB pos
A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client are acceptable to eat? Select all that apply.
Baked tuna Baked potatoes Fresh cherries Fruits and vegetables tend to be lower in fat because they do not come from animal sources, although olives, though technically a fruit, are high in fat (as are avocados), and fish is also naturally lower in fat. Meats and dairy products (e.g., cream cheese) are higher in fat, although modifications can be made to these foods to reduce their fat content.
Which clients have a high risk of obesity and diabetes mellitus
Because of their health and dietary practices, Latino Americans, Native Americans, Hispanic Americans, and African Americans have a high risk of obesity and diabetes mellitus. Owing to dietary practices, Asian Americans have a lower risk for obesity and diabetes mellitus.
A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat?
Cherries Potatoes Spaghetti Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables such as lettuce, broccoli, spinach, brussels sprouts, cabbage, and turnip greens. Cherries, potatoes, and spaghetti are foods that are low in vitamin K.
Late signs of blood transfusion reaction
Fever Mild jaundice Decreased hematocrit
An unlicensed assistive personnel (UAP) is providing morning care to a client with a fractured leg who is in skeletal traction. The nurse determines that the UAP needs instruction regarding the guidelines for client bathing if the UAP is implementing which action?
Giving the client a complete bed bath A complete bed bath is for clients who are totally dependent and require total hygiene care. The nurse would promote independence and encourage the client to assist as much as possible in the bath. The nurse would maintain the room's warmth because the client is partially uncovered and may easily be chilled. Privacy is always maintained, and the nurse maintains safety by keeping the side rails up (per agency policy) while away from the client's bedside.
interventions for blood transfusion reactions
If a transfusion reaction occurs, stop the transfusion, change the IV tubing down to the IV site, and keep the IV line open with 0.9% normal saline solution. Notify the health care provider and the blood bank. Remain with the client, observing signs and symptoms and checking vital signs as often as every 5 minutes. Prepare to administer emergency medications (e.g., antihistamines, corticosteroids, vasopressors) and fluids as prescribed. Obtain blood and urine specimens for laboratory studies. (Free hemoglobin in the urine indicates that hemolysis of RBCs has occurred.) Return the blood bag, tubing, attached labels, and tranfusion record to the blood bank.
A client taking a potassium-retaining diuretic has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). The nurse understands that the kidneys will respond to this via which physiological action?
Increase sodium excretion A serum potassium level of 5.8 mEq/L (5.8 mmol/L) is high, indicating potassium retention associated with the use of the potassium-retaining diuretic. When potassium is retained, the kidneys excrete more sodium.
A nurse provides instructions to a client about preventing injury while using crutches. The nurse tells the client to avoid resting the underside of the arm on the crutch pad, mainly because it could result in which problem?
Injury to the nerves When crutches are correctly fitted, the tops are three to four fingerbreadths, or 1 to 2 inches (2.5 to 5 cm), from the axillae. This ensures that the client's axillae are not resting on the crutches or bearing the weight of the crutches, which could result in injury to the nerves of the brachial plexus.
A nurse provides dietary instructions to a client with iron-deficiency anemia. Which foods does the nurse recommend to the client?
Lentils Raisens Kidney beans The client with iron-deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver, and other organ meats, blackstrap molasses, and oysters. Other good sources are kidney beans, soybeans, lentils, whole-wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots.
The health care provider (HCP) prescribes "enemas until clear" for a client. The nurse has administered three enemas to the client, but the client is still passing brown stool and fluid. Which action should the nurse take?
Notify HCP "Enemas until clear" means that the enema is repeated until the client passes fluid that is clear and contains no fecal material. It may be necessary to give as many as three enemas. Excessive enema use seriously depletes fluids and electrolytes. If the fluid fails to return clear after three enemas (check agency policy), the physician should be notified.
universal RBC donor
O neg
A client with diabetes mellitus who has been taught about dietary management of the disease wishes to have 8 oz (240 ml) of nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that which action will be taken after eating the nonfat yogurt?
Omitting 8 oz (240 ml) of skim milk from that meal Yogurt is a milk product. Therefore if the client is going to eat 8 oz (240 ml) of yogurt at a meal, the client should eliminate the milk product from the same meal. Ice cream is not recommended for the diabetic diet because it is high in fat and sugar.
picc line
Peripherally Inserted Central Catheter (PICC)
A nurse is developing a bowel-training program for a client after a stroke. Which interventions are appropriate for inclusion in the plan?
Providing privacy and time for defecation Assisting the client into a sitting position Initiating defecation measures every day at the same time Administering a cathartic suppository a half-hour before defecation time A bowel training program can help clients who still have some neuromuscular control after a stroke achieve control of bowel reflexes and have normal defecation. The cornerstone of such a training program is a daily routine. First the client should be encouraged to attempt to defecate at the same time each day after the trigger meal. Other measures include administering a daily stool softener or a cathartic suppository at least a half-hour before defecation time, providing a hot drink or juice that will stimulate peristalsis before defecation time, providing privacy and time for defecation, and assisting the client into a position that will facilitate defecation (e.g., a sitting position). Dietary measures that can help the client achieve bowel-training success include increased fiber intake (with the aim of 25 to 30 g of dietary fiber per day) and adequate dietary fluid intake.
A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's urinary output and laboratory values, anticipating which about the client?
Reduction in urine production A febrile client would be expected to have some degree of dehydration resulting from increased metabolic demands. In response to dehydration, the body attempts to restore fluid balance by reducing urine production. The client who is diaphoretic also loses a large amount of fluid through insensible water loss, which worsens dehydration and further decreases urine production. Urine specific gravity is increased in the presence of dehydration; serum osmolality also increases, indicating hemoconcentration related to dehydration.
The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu selections by the client indicate to the nurse that the client understands what has been taught?
Spaghetti with fresh tomatoes Grilled chicken with turnip greens Foods that are lower in sodium include fruits and vegetables, which do not contain physiologic saline. Fresh poultry and pastas are also low in sodium. Highly processed and refined foods and luncheon meats are high in sodium unless they are specifically labeled "low sodium." Saltwater fish and shellfish are higher in sodium.
A client has been found to have a bladder infection. When planning care, which area of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection?
The ureterovesical junction The ureterovesical junction is the point where the ureters enter the bladder. At this junction, the ureter runs obliquely for 1.5 to 2 cm through the bladder wall before opening into the bladder. This pathway prevents the reflux of urine back into the ureter, in essence acting as a valve to prevent urine from traveling back into the ureter and up to the kidney. The urethra extends from the bladder to the opening of the body where urine is excreted. The nephrons and glomeruli are located in the kidneys.
An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. Which information should the nurse provide to the client?
This is a normal occurrence as a person gets old The total amount of sleep a person needs does not change with increasing age. However, the quality of sleep appears to deteriorate for many older adults, giving rise to complaints of feeling less rested. An older adult awakens more often during the night than a younger person does, and it may take an older adult longer to fall asleep.
A client with liver cancer who is undergoing chemotherapy tells the nurse that some foods on the meal tray taste bitter. Which food does the nurse suggest that the client eliminate from the diet, knowing that it is most likely to taste bitter to the client?
Beef Chemotherapy may distort how certain foods taste to the client. Beef and pork are often reported by people undergoing chemotherapy to taste bitter or metallic. The nurse can promote nutrition by helping the client choose alternative sources of protein.
A nurse is repositioning a client who has returned to the nursing unit after internal fixation of a fractured right hip. The nurse should use which for repositioning?
Pillow to keep the right leg abducted while turning the client After internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The client is then repositioned and proper alignment and abduction are maintained. A trochanter roll or rolled bath blanket is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while the client is being turned.
The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value?
The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.
Air embolism
an air bubble in the bloodstream — is a complication associated with central line placement and tubing changes.
A nurse provides instructions to a client about the use of an electric heating pad. The nurse determines that the client needs further instruction if the client makes which statement?
"I can pin the pad around the affected area." One conventional form of heat therapy is the electric heating pad. The nurse instructs the client to avoid using the pad on the high setting and to never lie on the pad, because these actions can result in burns. The client is also instructed not to insert a safety pin through the pad, which could result in an electric shock. The client must check the skin frequently for redness.
If the client has very small veins, a gauge of
24-25 is used
A client with a genitourinary tract infection has been prescribed metronidazole and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed while taking the medication when the client states to eliminate which from the diet?
Alcohol A disulfiram-type reaction may result when someone taking metronidazole ingests alcohol. This syndrome includes flushing, palpitations, shortness of breath, severe headache, and nausea. To help prevent this reaction, the nurse must warn the client not to drink alcohol while taking this medication.
A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal cramping. Which action should the nurse take?
Clamp the enema bag tubing If the client complains of cramping during instillation of the enema solution, the nurse should either reduce the height of the enema bag or clamp the tubing. Temporary cessation of instillation will alleviate the cramping. Raising the enema bag to quickly finish instillation of the solution will worsen cramping. Removing the enema tube and allowing the client to rest and stopping the instillation and allowing the client to expel the solution will each alter the effectiveness of the enema.
The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion?
In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.
A client has been placed in Buck's extension traction. The nurse can provide counter traction to reduce shear and friction by implementing which measure?
Slightly elevating the foot of the bed In Buck's extension traction, the counter traction is typically applied with the use of the client's body and may be augmented through elevation of the foot of the bed. Usually the foot of the bed is elevated on blocks or the bed is put in the Trendelenburg position. For counter traction to be maintained, it is essential that the client not slide down in the bed. Therefore the use of the high Fowler position is discouraged. A footboard is not used for the purpose of counter traction.
A client is receiving intravenous meperidine hydrochloride as prescribed. For which side/adverse effects does the nurse assess the client while the clientis receiving this medication?
Tachycardia Hypotension Mental clouding Side/adverse effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine retention.
Pneumothorax,
an accumulation of air between the lung and chest cavity, is a rare complication of central line placement.
A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need for further instruction?
"My risk for malnourishment is much higher while I'm pregnant." Although pregnancy poses some nutritional risk for the mother, the client is not at risk of becoming malnourished. Calcium intake is critical during the third trimester, but calcium intake must be increased from the start of pregnancy. Adequate nutrition during pregnancy significantly and positively influences fetal growth and development. Intake of dietary iron and vitamins is insufficient for the majority of pregnant women, and the use of iron and vitamin supplements is routinely encouraged.
Check an adults IV line and site every
1-2 hours and children every hour
A therapeutic response to PN is signaled by weight gain, ideally
1-3 pounds per week
The signs of thrombophlebitis include
heat, redness, and tenderness at the IV site; a hard, cordlike vein; and sluggish infusion of the IV solution.
The nurse is caring for a client with breast cancer who has been undergoing chemotherapy. Blood tests indicate a low platelet count. A platelet transfusion is prescribed, and the nurse obtains the platelets from the blood bank. After carrying out the pretransfusion protocol, the nurse should administer the transfusion over what period of time?
15-30 minutes The volume of a unit of platelets may vary from 200 mL for single-donor platelets to 300 mL per unit for pooled platelets. Because the platelet is a fragile cell, platelet transfusions are administered rapidly once they have been brought to the client's room, usually over the course of 15 to 30 minutes. The other options are time frames that are too long for the administration of a platelet transfusion.
A nurse is administering a high cleansing enema. At what level above the client's hips should the nurse place the enema bag?
18 inches (45.5 cm) The health care provider may prescribe a high or a low cleansing enema. In this context, high and low refer to the height of the enema bag and hence the pressure at which the fluid is delivered. High enemas are given to cleanse the entire colon. A low enema cleans only the rectum and sigmoid colon. With a high enema, the bag is raised 12 to 18 inches (30.5 to 45.5 cm) or slightly higher above the hips. With a low enema, the nurse holds the bag 3 inches (7.5 cm) or less above the client's hips.
For lipids (fat emulsion) infusions, a gauge
20-21 is used
A nurse provides information to a client about the importance of consuming fluids every day. If the client has no renal or cardiac disease or any other disorder requiring fluid alterations, how many milliliters of fluid should the nurse recommend that the client consume each day?
2000-2500
In an older client, a small-gauge IV catheter, preferably
21 or smaller
For standard IV fluids and clear-liquid IV medications, a gauge of
22 or 24 is used
Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are acceptable to eat while taking this medication?
Apples Peaches Cranberries Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally high in potassium include dried prunes, avocado, bananas, fresh oranges and mangoes, nectarines, and papayas.
A nurse is preparing to administer a soap suds enema to an adult client. After explaining the procedure and positioning the client, the nurse begins the procedure. The nurse inserts the rectal tube into the client's rectum a maximal distance of of how many inches?
4 inches The nurse inserts the rectal tube slowly, pointing the tip of the tube in the direction of the client's umbilicus. In an adult client the tube is inserted 3 to 4 inches (7.5 to 10 cm), in a child 2 to 3 inches (5 to 7.5 cm), and in an infant 1 to 1½ inches (2.5 to 3.8 cm).
An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. The nurse assists the clientestimating that the client has approximately how many mL inthe bladder if the client is feeling a sensation of fullness?
400 ml With approximately 400 mL of urine in the bladder, the client will feel a sensation of bladder fullness. This amount may be altered by habit and may differ slightly from person to person.
Central venous catheter dressings are changed every
7 days
A nurse has taught a client how to stand on crutches. The nurse determines that the client understands the instructions if the client places the crutches in which position?
8 inches (20 cm) to the front and side of the toes The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed between 6 and 10 inches (15 to 25.5 cm) in front and to the side of the client, depending on the client's body size, providing a wide enough base of support and improving the client's balance.
Circulatory overload
A complication resulting from the infusion of blood at a rate too rapid for the size, cardiac status, or clinical condition of the recipient.
A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement. Which action should the nurse take to protect the knee?
Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting The nurse helps the client get out of bed after putting a knee immobilizer on the affected joint for stability. A compression dressing (a.k.a. elastic wrap or Ace bandage) is usually applied after the surgical procedure is complete. The surgeon prescribes weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in a chair to minimize edema. A CPM machine may be prescribed by some surgeons and is used while the client is in bed.
The nurse instructs a unlicensed assistive personnel (UAP) that a client who is recovering from a myocardial infarction requires a complete bed bath. The nurse would intervene if the nurse observed the UAP doing which?
Asking the client to wash his arms A complete bed bath is for clients who are totally dependent and require total hygiene care. Total care may be necessary for a client recovering from a myocardial infarction as a means of conserving client energy and reduce oxygen requirements. The nurse would intervene if the CNA asked the client to wash his arms.
A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which action?
Aspirating the fluid, advancing the catheter farther, and reinflating the balloon If the balloon is malpositioned in the urethra, inflating the balloon could produce trauma, resulting in pain. If pain occurs, the fluid should be aspirated and the catheter inserted a little farther to provide sufficient space in which to inflate the balloon. The catheter's balloon is behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. There is no need to remove the catheter or call the HCP. Because pain on balloon inflation is not normal, having the client take deep breaths is not an appropriate action.
hypoglycemia signs
Blood glucose level <70 mg/dL (< 3.9 mmol/L) Shakiness Weakness Diaphoresis Anxiety Hunger
Calcitriol is prescribed for a client with hypocalcemia. Which foods does the nurse, knowing that they may interfere with calcium absorption, instruct the client to limit in the diet?
Bran Spinach The client taking a medication to treat hypocalcemia should be instructed to avoid excessive consumption of spinach, rhubarb, bran, and whole-grain cereals, all of which may limit calcium absorption. Good dietary sources of calcium include milk products, dark-green leafy vegetables, clams, oysters, sardines, and orange juice fortified with calcium.
A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods that will promote wound healing does the nurse encourage the client to select from the hospital menu?
Chicken breast, broccoli, strawberries, milk Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatin, jelly, tea, and ginger ale have no nutritional value. Pasta, rice, and bread deliver complex carbohydrates. Spare ribs may contain some protein but are high in fat.
Immediate Signs of blood transfusion reaction
Chills and diaphoresis Muscle aches, back pain, chest pain Rashes, hives, itching, swelling Rapid, thready pulse Dyspnea, cough, wheezing Pallor and cyanosis Apprehension Tingling and numbness Headache Nausea and vomiting, abdominal cramping, diarrhea
The nurse provides instructions to a client who is beginning therapy with oral theophylline. The nurse recognizes that the client understands the instructions when the client states to limit consumption of which items?
Coffee Cola Chocolate Theophylline is a methylxanthine bronchodilator, and the nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, tea, cola, and chocolate.
A client arrives at the emergency department after sustaining an ankle injury, and the health care provider (HCP) prescribes the application of a cold compress to the ankle. The nurse, preparing to apply the compress, assesses the ankle and notes that it is extremely edematous. The nurse should take which action?
Consult with the HCP before applying the cold compress Cold is usually contraindicated if the site of injury is extremely edematous because it further retards circulation to the area and prevents absorption of the interstitial fluid. For this reason, applying the cold compress to the ankle and elevating the ankle and placing a cold compress under and on top of the ankle are both incorrect. The nurse would not place heat on an injury without a prescription to do so. The nurse would consult with the HCP about the prescription for cold application.
Which food should the nurse offer to a client who has been prescribed a full liquid diet?
Cooked custard A full liquid diet consists of liquid foods that are clear or opaque liquid foods, including those that are liquid at room temperature. Cooked custard is allowed on a full liquid diet. Toast and a bagel are allowed on a regular diet (a diet with no restrictions). Scrambled eggs are allowed on a soft diet.
A nurse administers a tap water enema to an adult client who is constipated. The client defecates a scant amount of brown fecal matter, which the nurse interprets as a poor result. The nurse should take which action?
Document the results Tap water is hypotonic, exerting a lower osmotic pressure than fluid in the interstitial space. After infusion into the colon, tap water escapes from the bowel lumen into the interstitial space. The net movement of water is low. The infused volume stimulates defecation before large amounts of water leave the bowel. Tap water enemas should not be repeated, because water toxicity or circulatory overload may occur if a large amount of water is absorbed. Therefore the other options are incorrect. Also, the nurse would not administer an additional enema, a soap suds enema, or a Fleet enema without a specific prescription to do so.
A nurse develops a plan of care for a postoperative client who is receiving intravenous morphine sulfate every 4 hours as needed for pain. Which priority intervention does the nurse include in the plan?
Encouraging coughing and deep breathing Morphine sulfate can depress respiration and suppress the cough reflex, putting the postoperative client at greater risk for atelectasis and subsequent pneumonia. The client should be encouraged to cough and deep-breathe to prevent these postoperative complications. Keeping the client supine is counterproductive and could lead to atelectasis. Adequate fluid intake helps liquefy secretions, making their expulsion easier, but does not prevent atelectasis unless coughing and deep breathing is also performed.
Rh (Rhesus) factor
For A type of antigen system. The presence or absence of Rh antigens on the surfaces of red blood cells determines an Rh-positive or Rh-negative classification. Rh-negative blood can be given to an Rh-negative or Rh-positive recipient without triggering a reaction as long as the ABO type of the donor is compatible with the recipient's ABO type.
A nurse is caring for an older adult client. When planning care, which occurrence does the nurse recognize as part of the normal aging process?
Glomerular filtration rate (GFR) is diminished As part of the normal aging process, the GFR decreases, like all of the other functional capabilities of the kidney. The kidneys' capacity to metabolize medications diminishes. Tubular reabsorption and urine-concentrating capacity also decrease.
The nurse is supervising an unlicensed assistive personnel (UAP)in caring for a client who has just undergone lumbar spinal fusion after herniation of a lumbar disc. Which action by the UAP while repositioning the client would cause the nurse to intervene?
Having the client assist by using the overhead trapeze In the safe care of a client after lumbar spinal fusion, the head of the bed is generally kept flat. The client is log-rolled from side to side as prescribed. As a matter of surgeon preference, pillows may be placed under the entire length of the legs to relieve tension on the lower back. The use of an overhead trapeze is contraindicated during the 48 hours after surgery because its use could result in twisting of the spine.
Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period?
High in Fiber When a client's diverticulitis is asymptomatic, a soft high-fiber diet containing fruits, vegetables, and whole grains is recommended. The client is also instructed to consume a small amount of bran daily and to take bulk-forming laxatives, if prescribed, to increase stool mass and softness. Increasing fluid intake to 2500 to 3000 mL daily (unless contraindicated) is also important. A low-fat diet may be healthy but is not specific to this disorder. A high-carbohydrate diet is not helpful for the client with this condition.
A nurse is inserting an indwelling urinary catheter into a female client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse should take which action?
Insert the catheter 2.5 to 5 cm and inflate the balloon The catheter's balloon is behind the opening at the insertion tip. The catheter is inserted 2.5 to 5 cm after urine begins to flow to provide sufficient space in which to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. Inflating the balloon in the urethra could inflict trauma.
A nurse has administered a dose of furosemide to a client with diminished urine output. The nurse expects the urine output to increase once the medication has had time to exert an effect on which structure in the kidney?
Loop of Henle Furosemide works by inducing excretion of sodium, potassium, and chloride in the ascending limb of the loop of Henle.
A client is resuming eating after undergoing partial gastrectomy. What measures should the nurse tell the client to take to minimize the risk of complications?
Lying down after eating Correct Eating high-protein foods Eating six small meals per day The client who has undergone partial gastrectomy is at risk for dumping syndrome. This client should be prescribed a diet that is high in protein, moderate in fat, and low in carbohydrates. The client should lie down after meals and avoid drinking liquids with meals. Frequent small meals are encouraged. The client should also avoid concentrated sweets.
Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium?
Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour.
A nurse is caring for a client whose urine output was 25 mL for 2 consecutive hours. When planning care, which client-related factors does the nurse recognize as increasing blood flow to the kidneys?
Release of dopamine Release of dopamine exerts a vasodilating effect on the renal arteries, improving renal function and increases urine flow.
5% dextrose in water (D5W): isotonic
Replaces deficits of total body water. Not generally used alone to expand extracellular fluid volume because dilution of electrolytes may occur.
A nurse administers an oil retention enema to a client. Afterward, the nurse should provide which instruction to the client?
Retain the enema for several hours Oil retention enemas lubricate the rectum and colon. The feces absorb the oil and become softer and easier to pass. The amount of enema solution is small, and the client usually does not experience cramping. To enhance the action of the oil, the client should retain the enema for several hours, if possible.
A client with a urinary tract infection has been started on nitrofurantoin, a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to eliminate from the diet while taking this medication?
Rhubarb When a client is taking nitrofurantoin, the urinary pH must be maintained in the acid range, and so the client needs to be instructed to consume an acid ash diet. Rhubarb reduces the acidity of the urine and should be avoided when acidic urine is required. Prunes, oranges, and cranberries are acceptable foods.
A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to the nurse that the client needs additional instruction?
Scallops Chicken Liver Organ meats such as liver, as well as certain sea foods, including scallops, sardines, and herring, should be omitted from the diet of the client who with gout because of the high purine content.
A health care provider states that a client's insensible fluid loss is approximately 600 mL/day. The nurse interprets this statement to reflect fluid loss occurring through which routes?
Skin and mechanical ventilator Insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. They occur on a daily basis, without the client's awareness. Sensible losses are those that are measurable; they include wound drainage, gastrointestinal tract losses, and urine output.
tpn
The administration of a nutritionally complete formula through a central or peripheral intravenous catheter; in the clinical setting the term may be used interchangeably with the terms total parenteral nutrition and hyperalimentation Insulin may be added to control the blood glucose level because of the high concentration of glucose in the PN solution. Heparin may be added to reduce buildup of a fibrinous clot at the catheter's tip.
A nurse has taught a client how to ambulate with the use of a cane. The nurse determines that the client needs additional instruction if which is observed?
The client should move the cane and the affected side together. The cane helps support the affected side as it moves forward. It also helps the client maintain balance. The client holds the cane close to the body to keep from leaning. The client holds the cane on the unaffected side to shift the client's weight away from the affected side. The cane's handle should reach the level of the greater trochanter of the client's femur, with 25 to 30 degrees flexion at the client's elbow.
A nurse is providing information to the mother of an 18-month-old about bowel training. The nurse should provide the mother with which information?
The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age Infants and young children are unable to control defecation because of a lack of neuromuscular development. This development usually does not take place until 2 to 3 years of age. A child's letting the parent know when he or she is ready to begin bowel training is not a sign of readiness. There is no difference between neuromuscular development in girls and that in boys.
The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value?
The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.
The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value?
The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report?
The normal values include the following: platelets 150,000-400,000 mm3 (150-400 × 109/L); sodium 135-145 mEq/L (135-145 mmol/L); potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L); segmented neutrophils 60%-70% (0.60-0.70); serum creatinine 0.6-1.3 mg/dL (53-115 mmol/L); and white blood cells 5000-10,000 mm3 (5.0-10.0 × 109/L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low.
The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment?
There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.
A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which instruction?
To increase the intake of legumes Dietary instructions to the client with a uric acid type stone include increasing consumption of legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine. The client should also be instructed to decrease intake of purine sources such as organ meats, gravies, red wines, goose, venison, and seafood.
5% dextrose in 0.225% saline (5% D and 1/4 NS): isotonic 5% dextrose in 0.45% saline (5% D and 1/2 NS): hypertonic
Used as initial fluid for hydration because it provides more water than sodium. Commonly used as maintenance fluid.
Ringer's lactate solution: isotonic 5% dextrose in Ringer's lactate solution: hypertonic
Used to remedy extracellular fluid deficits (e.g., fluid loss from burns, bleeding, or dehydration resulting from loss of bile or diarrhea).
5% dextrose in 0.9% saline (5% D/NS): hypertonic
Used to remedy extracellular fluid deficits in clients with low serum levels of sodium or chloride and metabolic acid-base imbalances.
0.9% saline (normal saline, NS): isotonic
Used to remedy extracellular fluid deficits in the client with a low serum level of sodium or chloride and metabolic acid-base imbalances. Used before or after the infusion of blood products.
The nurse is preparing to administer lipids (fat emulsion) intravenously which has been sent up from the pharmacy in a glass bottle. Which items should the nurse obtain to help administer this solution? Select all that apply.
When administering lipids, the nurse will need the lipid solution, vented IV tubing, and an alcohol swab. Vented IV tubing is used because the lipid solution is supplied in a glass container for administration. The alcohol swab is needed to clean the IV port (on the primary IV tubing) at the site of insertion (piggyback) of the lipid tubing. An IV filter is not used to administer a lipid-emulsion only solution because particles in the lipid solution are too large to pass through filters. If the fat emulsion is to be added to the PN solution, then a filter gauge of 1.2 µm or larger is needed to allow it to pass through. A thermometer and blood pressure cuff are not necessary to help administer the solution; however, these items are needed to monitor the vital signs during the infusion.
A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which foods listed on the client's shopping list indicate to the nurse that the client has understood the information?
Yogurt Parsley Cranberry juice Deodorizing foods for the client with an ostomy include beet greens, parsley, buttermilk, cranberry juice, and yogurt. Eggs, broccoli, and cucumbers are gas-forming foods.
For the administration of blood products and anesthetics and the rapid administration of emergency fluids
a large gauge is used (e.g., 14, 16, 18, or 19).
blood salvage
inoperative collections "salvaged" blood collected during surgery, washed on-site and returned to patient during procedure
Examine the lipid preparation for separation of emulsion into layers or fat globules and for the accumulation of froth; if such separation is noted
do not use return to pharmacy
The nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. Which menu selection, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction?
eggs One large egg provides 66 mg of potassium. A half-cup (114 gm) of raisins contains 700 mg of potassium. Four ounces (113 gm) of beef contains 420 mg of potassium, and 4 oz of pork (113 gm) contains 525 mg. eggs lowest in K
The nurse suspects hyperglycemia in the client who is receiving parenteral nutrition (PN) if which signs/symptoms are noted?
excessive thirst increase in urine output kussmauls breathing
A large volume of refrigerated blood infused rapidly through a central catheter into the heart can cause
cardiac dysrthmias
crossmatching
method of matching a donor's blood to the recipient by mixing a sample in a test tube to determine compatibility
Never warm blood products in a
microwave or in hot water
No fluid other than normal saline solution should be added to blood components
nor should medications be added to a blood transfusion.
lipids
or fat emulsion, are administered to prevent or correct fatty acid deficiency.
autologous donation
patients own blood donation collected for use at a later time
If an air embolism is suspected
place the client in a left side-lying position with the head lower than the feet (to trap air in right side of the heart), administer oxygen as prescribed, and notify the health care provider.
three ds of hyperglycemia
polydipsia, polyuria, and polyphagia.
once removed from the blood bank, if the blood is not administered within 30 minutes
return back to the blood bank refrigerator
The lower the gauge number
the larger the outside diameter of the cannula
Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the nurse monitor while the client is taking this medication?
volume of urine output frequency of bowel movements Because urine retention may occur with the use of opioid analgesics, the nurse would monitor the volume of the client's urine output. Because the client is also at risk for constipation, the nurse would monitor the frequency of bowel movements. Other side/adverse effects include hypotension and slowed respiration.
Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application?
An older client Older clients have diminished sensitivity to pain and are therefore at great risk for injury from heat or cold applications. Other clients at risk for injury are the very young; those with open wounds; those with spinal cord injuries or peripheral vascular disorders, such as the client with diabetes mellitus; and those who are confused or unconscious.
A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed while the disease is in remission. Which menu selection by the client indicates to the nurse that the client best understands the instructions?
Boiled Potatoes During remission, the client must avoid intestinal stimulants such as alcohol, caffeinated beverages, high-fat foods, gas-forming foods, milk products, and foods such as raw fruits and some vegetables, that are very high in fiber. Vitamins and iron supplements may be prescribed.
A nurse is providing dietary instructions to a client with tuberculosis. Which foods would the nurse specifically instruct the client to include more of in the daily diet?
Meat and citrus fruit The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Liver and other meats, from which 10% to 30% of available iron is absorbed, are good choices. Less than 10% of iron is absorbed from eggs and less than 5% from grains and vegetables.
A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse determines that the client needs further teaching if the client is observed doing what?
Moves the cane when the right leg is moved The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches (15 cm) lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side moves forward.
A nurse is caring for a client with cirrhosis. As part of the teaching regarding dietary means of minimizing the effects of the disorder, the nurse educates the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase the intake of which foods?
Peanuts Asparagus Whole grain cereals Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin, but other good sources are peanuts, asparagus, legumes, and whole-grain and enriched cereals. Milk is high in vitamins A and D, calcium, and magnesium. Chicken is high in protein. Broccoli is high in calcium and folic acid.
A client who experienced a stroke (brain attack) is experiencing residual dysphagia. Which foods should the nurse remove from the client's meal tray?
Peas In general, flavorful, warm, or well-chilled foods with texture stimulate the swallow reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw vegetables, chunky vegetables such as diced beets, stringy vegetables, and those with skin, such as corn and peas are foods commonly excluded from the diet of a client with dysphagia.
The nurse teaches a client who has begun taking phenelzine, a monoamine oxidase inhibitor (MAOI), about the medication. Which foods are allowed in the diet of the client taking phenelzine?
Peas Broccoli Potatoes Because phenelzine is an MAOI, the client should avoid foods that are high in tyramine, which could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, red wines, beer, and certain fruits, including avocados, raisins, and figs. Vegetables, with the exception of broad-bean pods, are generally acceptable.
A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does the nurse tell the client are most likely to acidify the urine?
Plums Prunes Cranberries Meats, eggs, whole-grain breads, cranberries, plums, and prunes increase urine acidity. These foods are metabolized into acid end-products that eventually enter the urine.
A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown?
Right Heel Certain areas are under pressure and at risk for breakdown in the client who is in skeletal traction. These areas include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg, which is used as a brace when the client pushes up from the bed). Other such pressure points include the ischial tuberosity, popliteal space, and Achilles tendon.
A nurse is providing information to a mother of a 1-year-old who has asked about bladder-training her child. The nurse should provide which information to the mother?
That a child cannot begin to control urination until approximately the age of 24 months A child cannot control micturition voluntarily until he or she is approximately 24 months old. A child must be able to recognize the feeling of bladder fullness, to hold urine for 1 to 2 hours, and to communicate the sense of urgency to an adult. Telling the mother that her child is too young and to not be worrying about bladder training is a nontherapeutic response because it provides false reassurance and places the mother's issue on hold. Bowel control develops before bladder control; however, 1 year of age is too early for the mother to begin elimination training.
Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)
client who has undergone colectomy A client with acute pancreatitis A client who has undergone gastrectomy A PCA pump contains a cartridge or syringe that holds the prescribed pain medication. The client pushes a button to administer a dose of the medication within limitations prescribed by the health care provider. The client must be able to understand the use of the equipment and be physically able to locate and press the button to deliver the dose. Clients who are confused and unresponsive, those with neurological disease, and those with impaired renal or pulmonary functions are not candidates for PCA.
