QB 13 Flashcards
Clients who are experiencing multiple gestation are at a great risk for premature labor and delivery.
TRUE OR FALSE
True
What to do when providing care for a client who is in labor
When providing care for a client who may be in labor,the nurse should determine if the client is experiencing contractions at regular intervals that increase in intensity and duration. Next, it is important to determine the duration between contractions, if the contractions increase in intensity with activity and/or start in the client’s back and radiate through the abdomen, and if relaxation techniques relieve the contractions. Once this information is determined, the nurse assesses the cervix for dilation and effacement.
The nurse reviews prescriptions for a newly admitted client. Which prescriptions does the nurse clarify with the health care provider? ( Select all that apply.)
- Famotidine 20 mg PO qd.
- Docusate 100 mg PO twice daily.
- Captopril 25.0 mg PO every 8 hours.
- MS ER 30 mg PO twice daily.
- Tetracycline 250 mg PO four times daily.
1) CORRECT — The abbreviation for daily, “qd,” is on the Do Not Use abbreviation list from The Joint Commision. Abbreviations qd (daily) and qod (every other day) are often mistaken for each other.
2) INCORRECT— The docusate prescription is correctly written.
3) CORRECT — The use of a trailing zero is on the Do Not Use abbreviation list from The Joint Commission. If the period is missed, the client receives 10 times the prescribed dosage.
4) CORRECT — The abbreviation for morphine sulfate, “MS,” is on the Do Not Use abbreviation list from The Joint Commission because it could also indicate magnesium sulfate. The abbreviation “ER” is not common and should not be used.
5) INCORRECT— The number of times a medication is prescribed daily should be written out.
Medication safety is a priority in health care. The Joint Commission has published a list of “Do Not Use” abbreviations. This includes Q.D., QD, q.d., qd (daily),Q.O.D., QOD, q.o.d, and qod (every other day). Lack of leading zero (.X mg) or the use of a trailing zero (X.0 mg) is also prohibited due to the risk of overdosing a client. Typically, this list is posted in the medication room or in high traffic areas for nurses and providers. The official “Do Not Use” list applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.
what is agoraphobia
an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. These situations can include open spaces, public transit, shopping centers, or simply being outside their home.
you fear and avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed.
the fear of being helpless in a situation from which escape may be difficult or embarrassing and is often characterized by anxiety, panic, and avoidance of the situation (e.g., public places
To be diagnosed with post-traumatic stress disorder (PTSD), an adult must have all the following for at least 1 month:
at least one re-experiencing symptom; at least one avoidance symptom; at least two arousal and reactivity symptoms; and at least two cognition and mood symptoms.
What can the nurse do to help prevent ARDS
Aspiration is one of the most common causes of ARDS. Prevention of aspiration is a priority action to reduce the risk of ARDS.
To prevent ARDS, the risks for aspiration should be addressed since one of the most common causes of direct pulmonary injury leading to ARDS is aspiration. The nurse should keep the head of the bed for clients at risk at 30 degrees elevation
. Sepsis is the most common indirect cause of lung injury leading to ARDS. Periodic mouth care and oropharyngeal suctioning should be performed as needed.
ARDS leads to an influx of fluid into the alveoli secondary to an increase in the permeability of the alveolar-capillary barrier. The secretion of pro-inflammatory cytokines also contributes to pulmonary edema.
Acute respiratory distress syndrome (ARDS), a sudden and progressive form of acute respiratory failure, is characterized by alveolar-capillary membrane damage. That is, the alveolar-capillary membrane becomes more permeable to intravascular fluid. Common predisposing conditions for ARDS include aspiration of gastric contents or other substances, viral or bacterial pneumonia, sepsis, and severe massive trauma. Signs and symptoms of ARDS include dyspnea, tachypnea, tachycardia, cough, restlessness, diaphoresis, and auscultation of crackles. The chest X-ray impression is often termed “whiteout” or “white lung” because consolidation and infiltrates are widespread throughout the lungs with few recognizable air spaces. Prepare for tracheal intubation.
What is rhogam ?
RhoGAM is a prescription medicine that is used to prevent Rh immunization, a condition in which an individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood. RhoGAM is administered by intramuscular (IM) injection.
If the mother is of one blood type and the baby another, there is a risk that the mother will develop antibodies to the baby’s blood type, which will place the fetus of any future pregnancies at risk.
Clients with Rh negative blood develop antibodies when exposed to the Rh factor. Rho(D) immune globulin is administered to Rh negative women who have delivered an Rh positive newborn or had a miscarriage or abortion of a Rh positive fetus. Rho(D) immune globulin prevents the development of antibodies in the woman, which decreases the incidence of Rh hemolytic disease in future pregnancies.
How to properly suction a laryngectomy tube
Hyperoxygenate client before and after
Suction is applied only as the catheter is withdrawn, not during its insertion.
First, the laryngectomy tube is suctioned and then mouth, in order to prevent introducing bacteria from the mouth into the lungs.
The nurse provides care to a client who is newly diagnosed with gastrointestinal bleeding. The client’s hemoglobin level is 6.8 g/dL (68 g/L). Which intervention does the nurse perform first?
- Obtain a type and crossmatch for blood administration.
- Place the client on oxygen 2 L/min by nasal cannula.
- Start an IV with at least a 20-gauge IV catheter.
- Place the client on a cardiac monitor.
View Explanation
1) INCORRECT— The client will likely require a type and crossmatch in anticipation of blood administration. However, supporting the client’s oxygenation is the priority concern.
2) CORRECT— A critically low hemoglobin level leads to decreased delivery of oxygen to cells and tissues. To reduce the risk for ischemia, administration of supplemental oxygen is the highest priority.
3) INCORRECT— Insertion of an IV access device is an appropriate action. However, oxygenation takes priority over inserting an IV access device. In addition, selection of an IV catheter that is larger than 20 gauge may be necessary to allow for blood administration.
4) INCORRECT— Application of a cardiac monitor is appropriate, as decreased availability of oxygen to tissues increases the risk for cardiac dysrhythmias. However, administration of supplemental oxygen is the priority.
Hemoglobin carries oxygen to the tissues. If the hemoglobin level is low, oxygen-carrying capacity is affected and hypoxia can occur. Until the client’s blood volume can be restored, supplemental oxygen should be provided to maximize tissue oxygenation. Continuous cardiac monitoring should be done to determine the effect of hypoxia on cardiac tissue; oxygenation takes priority over circulation.
Neutropenic precautions are_________________________________Neutrophils are a type of WBC made in the bone marrow. They play a significant role in attacking pathogens. When there is a decreased number of neutrophils, the client is at risk for infection. Neutropenia is diagnosed by a WBC count with a differential. A neutrophil count of less than _____________cells/mm3 confirms the diagnosis. If the condition becomes severe, the count could fall to less than ___________cells/mm3. Risk factors for the development of neutropenia include_________________________
infection control procedures that are applied when clients have a high risk of developing an infection due to a low neutrophil count; 1500; 500; infection, hematologic disorders, chronic diseases, and chemotherapy.
What to do when a client is presenting with hypoglycemia
After confirming hypoglycemia by blood glucose testing, Clients with hypoglycemia need 15 to 20 g of a rapid acting sugar to correct the condition. If the client is conscious, give three or four glucose tablets, 4 oz. of fruit juice or regular soda, 8 oz. of milk, five or six pieces of hard candy, or a tablespoon of sugar or honey. If the client is unconscious, administer 1 mg of glucagon, or 25 to 50 mL of 50% dextrose.
This is the first step to determine whether a breast lump is malignant or benign.
Get a mammogram
A mammogram is an x-ray of the breast, which screens for breast cancer
The nurse determines that a client brought to the urgent care center may be in shock. Which action does the nurse implement?
- Placing the client in the Trendelenburg position.
- Elevating the head of the client’s bed to 45 °.
- Placing the client on the left side.
- Elevating the client’s lower extremities.
1) INCORRECT - The Trendelenburg position puts pressure on the thoracic cavity by the abdominal organs, which increases cardiac workload and respiratory effort. Placing the client in this position is not an appropriate nursing action.
2) INCORRECT - This position impairs circulation to the brain and other vital organs and increases cardiac workload. Placing the client in this position is not an appropriate nursing action.
3) INCORRECT - This position is used to prevent aspiration, but not to increase blood flow to vital organs during shock. Placing the client in this position is not an appropriate nursing action.
4) CORRECT— Raising the lower extremities improves circulation to the brain and vital organs without increasing workload or impairing respiratory effort. This, therefore, is an appropriate action by the nurse.
When a client is diagnosed with shock, the nurse needs to place the client in the position that supports and preserves the major organs, primarily the heart, the kidneys, and brain.
By raising the legs, the blood from the lower extremities is routed back into the middle of the body to sustain major organ function. However, the nurse avoids placing the client in Trendenlenburg because the nurse knows this places undue pressure on the lungs and could impair oxygenation.
What is a precipitouse birth ?
also called rapid labor,
labor that is intense and forceful, lasting only 1 to 4 hours from the start of contractions to delivery of the infant. There is a rapid descent of the fetus. Uterine contractions are strong in intensity and there is an abnormally low cervical resistance. The cervix dilates faster than 5 cm/hr in a nulliparous woman or 10 cm/hr in a multiparous woman. Risk factors include small sized infant and history of precipitous delivery.
Complications associated with precipitous birth is the mother’s inability to cope with pain intensity, increased bleeding postpartum, and vaginal or cervical lacerations. To prevent lacerations, delivery of the head and shoulders should be done between contractions.
Complications for the infant include risk for infection if not born in a sterile environment and aspiration of amniotic fluid.
The femoral pulse is located below the inguinal ligament, midway between
the symphysis pubis and the anterosuperior iliac spine.
The nurse needs to assess pulses for rate, rhythm, and quality. The apical pulse should be auscultated if the radial pulse is abnormal, whereas peripheral pulses (femoral, popliteal, posterior tibial, and dorsalis pedis) should be palpated. A dopplar can be used to assess pulses that cannot be palpated.
