QB 4 Flashcards
1
Q
What should the diet with heart failure patients be like ?
A
Sodium restriction, potentially fluid restriction
The client with heart failure should be instructed to reduce sodium intake in order to avoid fluid overload. Processed meats such as salami, cold cuts and bacon are high in sodium and should be avoided. Fresh fruit and vegetables are recommended to manage blood pressure in the client with heart failure. Whole wheat items are high in fiber and low in sodium. Even though some clients with heart failure may be prescribed a fluid restriction, 4 oz of liquid with every meal would not be contraindicated.
Content Refresher
The client requires a therapeutic diet to reduce complications from heart failure. The U.S. Department of Agriculture recommends less than 2300 mg of sodium for all adults and adults with heart failure should consume less than 2000 mg. Smoked, cured, salted, or canned foods should be avoided, while fresh vegetables, lean meats and fish, and unsalted seeds and nuts should be encouraged.
2
Q
The U.S. Department of Agriculture recommends less than _____________ mg of sodium for all adults and adults with heart failure should consume less than _____________mg.
A
2300; 2000
3
Q
What is hypoxia and what are the normal acid base balance indicators ?
A
Hypoxia is a condition in which there is an insufficient level of oxygen in the cells, tissues, and organs to meet their metabolic demands. Adequate oxygen must be available for gas exchange to occur so supplemental oxygen is used. It may be administered using the client’s respiratory ability (via nasal cannula, venturi mask, non-rebreather mask) or, in extreme cases, be delivered mechanically. Normal acid-base balance is indicated by a pH of 7.35 to 7.45, PaCO 2 of 35 to 45 mm Hg (4.7 to 5.9 kPa), PaO 2 of 80 to 100 mm Hg (11 to 13 kPa), oxygen saturation of 95 to 100%, HCO 3 of 22 to 26 mEq/L (22 to 26 mmol/L), and base excess of −2 to +2 mEq/L (−2 to +2 mmol/L).
4
Q
Complications of Immobility
A
Immobility influences the cardiovascular (venous status, orthostatic hypotension), musculoskeletal (osteoporosis, contractures, atrophy of muscles), respiratory (atelectasis), urinary (infection, retention, calculi), metabolic (metabolic rate decreases), gastrointestinal (constipation), and integumentary (breakdown) systems. Immobility also influences the client’s psychological well-being.
5
Q
Physical activity is important to prevent skin breakdown, respiratory tract infections, and to support client mobility.
TRUE OR FALSE
A
ABSOLUTELY TRUE
6
Q
______________tube feedings are indicated for clients who have a functioning gastrointestinal tract, but may have swallowing problems or are at risk for aspiration.
A
Enteral
7
Q
What does the nurse need to do before administering tube feedings?
Think safety
A
Before administering enteral tube feedings, the nurse needs to verify tube placement. Initially, a chest x-ray is the recommended method of determining accurate placement. Prior to instillation of feedings or water, the nurse needs to verify tube placement by aspirating gastric content and determining pH consistent with acidic stomach contents.
In addition, the nurse needs to verify tube length when completing each nursing assessment and prior to feeding.
8
Q
What is the only sure way to verify enteral tube placement ?
A
X ray
9
Q
matter that has been drawn from the body by suction
A
Aspirate
10
Q
What color is gastric aspirate usually ?
Gastric aspirate normal pH
Intestinal gastric pH normal
Respiratory aspirate pH normal
A
gastric aspirate is usually cloudy and green but may also be off-white, tan, bloody or brown
gastric pH - usualyl less than or equal to 4
intestinal aspirate pH - usually greater than 4
respiratory aspirate pH - usually greater than 5.5
11
Q
Which assessment by the nurse indicates that a client’s nasogastric (NG) tube may be malpositioned?
- The nasogastric tube aspirate is cloudy and green.
- The pH of the nasogastric tube aspirate is 3.
- Air injected through tube is auscultated over the epigastrum.
- The external length of the nasogastric tube has increased.
A
1) INCORRECT – Gastric aspirate is commonly cloudy and green, tan, off-white, or brown .
2) INCORRECT – Gastric aspirate pH ranges from 1 to 5.
3) INCORRECT – Injecting air through the NG tube while auscultating the epigastric area to detect air insufflation is an unreliable indicator of NG tube placement and is not evidence-based practice.
4) CORRECT– Increased length of the NG tube may indicate outward migration, and the NG tube tip may be malpositioned in the esophagus instead of the stomach.
The nasogastric tube position should be assessed each and every time prior to administering medications or nutritional support. The nurse should use a simple procedure to check location; when the tube is inserted, a small piece of adhesive tape is placed on the tube as an indication of the location. If this piece of tape is in a different location, or assessment of the tube location is questionable, the tube should not be used until an x-ray verifies placement. The health care provider may need to be notified for tube replacement.
12
Q
_________________-control is essential for the entire body. Blood glucose levels affect cognition, cardiovascular health, nerve function, kidney function, retinal health, immune system function, and wound healing. This client is facing an amputation due to a long history of poor glycemic control, which resulted in severe peripheral vascular disease (PVD), decreased blood supply to the lower extremities, and death of tissue in the leg. Wounds do not heal in the presence of _____________-blood glucose levels
A
Glycemic; uncontrolled
13
Q
Signs of Peripheral Vascular Disease include
A
pale or discolored skin, weak or absent pulses, reduced body hair, poor wound healing, and thick, opaque nails.
14
Q
How does high blood glucose levels damage blood vessels ?
A
Excess blood sugar decreases the elasticity of blood vessels and causes them to narrow, impeding blood flow. This can lead to a reduced supply of blood and oxygen, increasing the risk of high blood pressure and damage to large and small blood vessels.
15
Q
When caring for a client receiving a blood transfusion, the nurse should:
A
Teach client/family about procedure and signs/symptoms to report. Perform hand hygiene, wear gloves. Ensure normal saline IV fluid is running with 14- to 22-gauge catheter; set up infusion equipment with appropriate filter and tubing. Run transfusion slowly, observing client carefully for 15 minutes to observe for any adverse reaction. Monitor vital signs. Increase rate if vital signs are stable and client shows no signs/symptoms of reaction to blood product. Blood transfusion can result in fluid overload, a hemolytic reaction, an allergic reaction, infectious diseases, and a transfusion related acute lung injury.
16
Q
During a blood transfusion, the client develops backpain and headache. What should the nurse do first ?
A
A headache and back pain are indications of a hemolytic transfusion reaction. The nurse knows that the only way to resolve this problem is to stop the transfusion immediately. After the transfusion is stopped, the client’s vital signs should be assessed. The health care provider should be notified and the blood product and tubing preserved in anticipation of returning it to the blood bank for analysis.
17
Q
What to remember about incontinence
Causes and risk factors
A
It is not a normal part of aging
Remember, To urinate, the brain signals the muscular bladder wall to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincters to relax. As the sphincters relax, urine exits the bladder through the urethra.
Incontinence is the unintentional loss of urine and is caused by different factors, including increased abdominal pressure (stress), increased need without control (urge), increased bladder distention (overflow), and cognitive impairments (functional).
Causes of incontinence include weakness of pelvic floor muscles, increased abdominal pressure, infections, over-distention of the bladder, sphincter weakness, and cognitive impairments.
Risk factors include obesity, smoking, gender (females are more likely to experience incontinence due to pregnancies), menopause, and cognitive disorders such as dementia.
Many types of urinary incontinence can be treated successfully with medications, education, bladder retraining, and/or surgery.
18
Q
In a closed head injury, the brain has experienced an injury that can cause bleeding or edema within the cerebral tissue. Because the cranium is within a closed vault, the swelling and bleeding displace the cerebral contents, causing symptoms of_______________- intracranial pressure. The nurse will frequently assess for common symptoms of increasing intracranial pressure, which includes ___________________-
A
increased; nausea and changes in level of consciousness.
19
Q
Esophageal cancer impacts the client’s ability to ______________–. A nursing diagnosis that addresses the risk for _____________is appropriate. Additionally, the client’s ___________status will be compromised due to the problem with swallowing. A nursing diagnosis that addresses weight management is essential. Pain management is an appropriate intervention because of the diagnosis and location of the pathology.
A
swallow; aspiration; nutritional
20
Q
the following are highly suggestive that infection may be present:
A
abrupt onset of fever; high fever, greater than 102°F to 105°F (38.9°C to 40.6°C), without chills; respiratory symptoms; malaise, muscle and joint pains, photophobia, headache; nausea, vomiting, diarrhea; lymph node enlargement; and meningeal signs.
The nurse should consider that an older adult with an infection will have atypical manifestations, such as delirium, falls, and incontinence.
21
Q
Risk factors for Otitis Media
Name at least 5
A
Risk factors for otitis media include respiratory infection, influenza, bottle-fed infants, Down syndrome, children who attend day care, those with cleft palates or poor immune systems, allergies, post-nasal drainage, sinus infections,
cystic fibrosis, asthma, family history of ear infections, and male gender.
22
Q
What to remember about Rhabdomyolosis ?
A
For the client with rhabdomyolysis, administration of crystalloid IV fluid is the primary treatment. Rhabdomyolysis is characterized by the release of massive quantities of myoglobin from damaged muscle cells, as well as the release of intracellular potassium due to cell lysis. Administration of IV fluid is essential to preserving kidney function and promoting excretion of myoglobin and potassium.
Administration of mannitol, an osmotic diuretic, is an appropriate intervention for the client diagnosed with rhabdomyolysis in order to to promote excretion of substances, including myoglobin and potassium.
In rhabdomyolysis, intravenous hydration coupled with diuresis is thought to decrease the risk of myoglobin-associated acute tubular damage and acute kidney injury. Alkalinizing the urine with bicarbonate-containing fluids to a urine pH greater than 6.5 may reduce the aggregation of myoglobin in the kidney.
Content Refresher
When caring a client with rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), intravenous fluids and blood volume expanders are used to improve tissue perfusion. Intravenous calcium chloride, bicarbonate, insulin, and glucose may be needed to reduce serum potassium levels. Symptoms include dark, reddish urine; a decrease in urinary output; weakness; and muscle aches. Osmotic diuretics may be given to reduce fluid overload.
23
Q
A breakdown of muscle tissue that releases a damaging protein into the blood.
This muscle tissue breakdown results in the release of a protein (myoglobin) into the blood. Myoglobin can damage the kidneys.
Symptoms include dark, reddish urine, a decreased amount of urine, weakness, and muscle aches.
Early treatment with aggressive fluid replacement reduces the risk of kidney damage.
What condition is this?
A
Rhabdomyolosis
24
Q
What to remember about Anorexia Nervosa
A
characterized by a BMI of 17.5 or lower, anorexia nervosa is a clinical syndrome in which the client has an irrational fear of weight gain, preoccupation with food, a very restricted diet (e.g., eating 6 peas), refusal to eat, and a disturbed body image. Evaluate laboratory serum and electrolyte levels. Assess nutritional status and weight. Assess vital signs, especially blood pressure. Assess for arrhythmias. Monitor food and fluid intake, daily weights, skin condition, and rest/activity levels. Observe the client before, during, and after meals. Avoid discussion about food, especially while eating, and require consumption of food within a limited amount of time. Insert and provide feedings through a nasogastric tube, if prescribed.
The client with anorexia nervosa should be closely monitored for complications such as electrolyte imbalances, dehydration, cardiac arrhythmia, menstrual problems, and anemia. In cases of severe electrolyte derangement, the client should be attached to a cardiac monitor and replacement electrolytes given intravenously. The nurse should collaborate with an interdisciplinary team to address the client’s psychosocial and mental health issues, if applicable.
25
The client with anorexia nervosa is at risk for fluid and electrolyte imbalance, particularly \_\_\_\_\_\_kalemia, and subsequent \_\_\_\_\_\_\_\_\_\_\_cardiac output and cardiac \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. The serum potassium level should be closely monitored.
hypokalemia; decreased; dysrhythmias
26
signs and symptoms of compartment syndrome (increased pain,
increased pain (especially after pain med administration)
decreased pulses in extremity,
paresthesia,
paralysis,
pale or discolored skin
27
The nurse knows that the goal of checking capillary refill is to assess \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
peripheral circulation
Pressure will compress the blood vessels and restrict blood flow, causing pallor. Release of the pressure will permit return of blood flow and color. The nurse will provide further teaching to the client that the application of pressure should result in skin pallor.
28
Evidence of a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-family includes blaming and using substances or alcohol to cope with stressful life situations.
dysfunctional
29
What is a crisis ?
**A crisis is specific event in which a client is unable to cope.** This may be due to ineffective coping, which leads to increased stress, decreased resources, and inability to prevent the specific event. **During a crisis, there is an initial period of shock, followed by an inability to function, and then a tremendous emotional response.** Complications associated with crisis include inability to carry out activities of daily living, increased anxiety, and impaired personal relationships.
30
Potassium Chloride administration
NEVER GIVEN VIA IV PUSH AS CAN CAUSE CARDIAC ARREST
**Potassium chloride (KCl) is administered slowly via an IV infusion pump. The typical infusion rate of KCl is 10 mEq/hour**. Faster infusion rates are only considered under close supervision in a critical care area and only via a central venous access device. If the client is at risk for fluid volume overload, the nurse consults with the health care provider and pharmacy to increase the medication concentration, such as to 10 mEq/50 mL or 10 mEq/100 mL.
Content Refresher
**Monitor the client’s ECG during potassium chloride (KCl) infusion, as this medication may cause dysrhythmias,** including heart block, as well as cardiac arrest. **Do not administer more than 10 mEq of KCl per hour intravenously**. **Monitor the IV site for signs of phlebitis.**
31
During labor induction, what is the usual contraction pattern?
Contractions that occur every 2-3 minutes, lasting for **90 seconds or less**
**STOP INFUSION IF FETAL DISTRESS OR HYPERTONIC CONTRACTIONS BEGIN**
**(**contractions that last more than 90 seconds or occur more frequently than every 2 minutes)
32
\_\_\_\_\_\_\_\_\_\_\_\_\_\_-is a manifestation of severe hypothyroidism. Manifestations of hypothyroidism are associated with a \_\_\_\_\_\_\_\_\_\_\_-of the metabolism and include lethargy, weight gain, and intolerance to \_\_\_\_\_\_\_\_\_temperatures.
Myxedema; slowing; cold
33
Symptoms of Myxedema
slowing of the metabolism
lethargy,
weight gain
intolerance to cold temperatures.
Possible goiter from constant thyroid stimulation to get the thyroid gland to produce T3 and T4 MOST COMMON SIGN IN HASHIMOTO’S
Slow heart rate
Thinning and brittle hair
Constipation
Memory loss
Myxedema: swelling of the skin (eyes and face) that gives it a waxy appearance
Dry skin
Depression
Menstrual problems (irregular or heavy periods)
34
The nurse views the cardiac monitors for clients on the unit and notes the presence of elevated T waves. Which client is likely to have this appear on the ECG? (Select all that apply.)
1. A client with Cushing syndrome who has hypertension and a pathologic fracture of the spine.
2. A client with alcoholic liver cirrhosis who has severe ascites and shallow respirations.
3. A client who was in a house fire and suffered extensive burns on the arms, trunk, and face.
4. A client who reports severe vomiting for 3 days and shows symptoms of mild dehydration.
5. A client who has been on prednisone for 6 months.
1) INCORRECT - Elevated T waves indicate hyperkalemia. Cushing disease is caused by an overproduction of corticosteroids. Hypercortisolism is associated with increased blood glucose levels, increased sodium levels, and decreased levels of potassium and calcium. This client will not likely have an elevated T wave.
**2) CORRECT– Clients with liver failure may have an underproduction of bicarbonate, leading to metabolic acidosis. Ascites pushes on the lungs, decreasing lung capacity. Shallow respirations lead to buildup of CO2 and respiratory acidosis. Hyperkalemia is associated with acidosis. This client will likely have an elevated T wave.**
**3) CORRECT – There is a release of intracellular potassium because of cell destruction from the burns, which will increase serum potassium. This client will likely have an elevated T wave.**
4) INCORRECT - A loss of acid from vomiting leads to metabolic alkalosis, which is associated with hypokalemia. This client likely will not likely have an elevated T wave.
5) INCORRECT - Excessive and long-term use of corticosteroids leads to hypokalemia. This client will not likely have an elevated T wave.
35
Cushing disease is caused by an overproduction of corticosteroids. Hypercortisolism is associated with\_\_\_\_\_\_\_\_\_\_\_blood glucose levels,\_\_\_\_\_\_\_\_\_- sodium levels, and \_\_\_\_\_\_\_\_\_\_\_\_\_levels of potassium and calcium
increased; increased; decreased
36
What to remember about MRIs
noninvasive, painless, diagnostic scanning technique in which a client is placed into a magnetic field to obtain clear and differentiated images of the brain, spine, extremities, joints, heart and vasculature, abdomen, and pelvis. The images are used to plan and direct surgical treatment, detect abnormalities, identify tumors, and their response to treatment. Prior to an MRI, the nurse should question the client about implanted metal devices such as orthopedic hardware, implanted pacemakers and defibrillators, heart valves, intrauterine devices, and cochlear implants. Assess the client for understanding of the procedure and its role in the diagnosis or treatment plan, the client’s level of anxiety and anticipated claustrophobia, client’s allergies, body tattoos (especially with red coloring), permanent cosmetics, transdermal patches with foil backing, and implanted metal objects.
**An MRI is contraindicated for clients with actual or suspected metallic foreign body in the eye.** The client who experienced an Motor vehicle crash may have an eye injury that involves metal. A magnetic resonance imaging (MRI) scan is not recommended because the object may be metal and be pulled or moved by the strength of the magnet. This could cause additional damage and possibly jeopardize this client's vision.
37
Postpartum:
During the first 24 hours, temperature can increase to 100.4°F (38°C) as a result of \_\_\_\_\_\_\_\_\_\_\_\_\_\_effects of labor.
dehydrating
After delivery though the body knows that the fetus is no longer in the uterus and begins to change in order to accommodate a non-pregnant state. Excess fluid in the vascular system is eliminated, which can lead to temporary dehydration. Evidence of postpartum dehydration includes a low-grade fever, which can be quickly corrected by the client increasing oral fluid intake.
38
What is stoma prolapse ?
What is a stenosed stoma?
What is a retracted stoma ?
Characteristics of a normal stoma
A prolapsed stoma is protruding and indicates that the bowel is protruding through the stoma.
A stenosed stoma appears narrow and flat.
A retracted stoma appears sunken and inverted.
**A normal stoma is nearly flush with the abdominal skin and is pink to beefy red in color**
39
IV fluid infusions may have serious complications, particularly when used in clients with\_\_\_\_\_\_\_\_\_\_\_\_ and ______________ impairments.
renal and cardiac
40
Characteristics of the Transition Phase of Labor
uterine contractions every 2 to 3 minutes, lasting 60 to 90 seconds, and are strong in intensity. Dilation is 8 to 10 cm with effacement of 80 to 100%. Station is -1 to +2 and bloody show increases. The client may report backache and increasing pain. As fetal descent progresses, the client will have the urge to push and may experience defecation or the urge to urinate. Relaxation is difficult, and the client may be agitated and restless.
Symptoms of the transition stage include increased pressure in pelvis, which causes an intense desire to urinat
41
What to remember about involuntary psychiatric admission clients
An involuntary admission is court-ordered and requires medical certification from a health care provider (usually two) stating the client’s need for involuntary care and treatment in a psychiatric facility. A client who has been involuntarily admitted to a psychiatric facility has the right to legal counsel and can take the case before a judge who may (or may not) order that the client be released from the psychiatric facility.
**Clients are admitted in this way when they are a danger to self or others and are unable to meet basic needs. Only voluntary clients have the right to demand and obtain release.**
These clients are being held against their will until deemed safe. This client may not request and be granted release.
42
What is a T-Tube ?
A tube that may be inserted into the common bile duct during surgery when a common bile duct exploration is part of the surgical procedure. This ensures patency of the duct until the edema produced by the trauma of exploring and probing the duct has subsided. It also allows the excess bile to drain while the small intestine is adjusting to receiving a continuous flow of bile.
43
Normal respiratory rate for a school-age child is ___________ -\_\_\_\_\_\_\_\_\_\_\_ breaths per minute.
14 to 22
44
What is a basal skull fracture ?
**a break of a bone in the base of the skull.** Symptoms may include bruising behind the ears, bruising around the eyes, or blood behind the ear drum. A cerebrospinal fluid (CSF) leak occurs in about 20% of cases and can result in fluid leaking from the nose or ear.
basal skull fracture - there is an interruption in bone integrity at the base of the skull. Internal structures that lie near to this area include the spinal canal and the ear, so the nurse should be alerted by drainage from the client's ear. ***Clear or bloody fluid leaking from the ear on the same side of the injury suggests that there is leakage of cerebrospinal fluid from interruption of the integrity of the skull.*** The risk to the client is the possibility of infection.
45
What to remember about skull fractures ?
A skull fracture is a break in the continuity of the skull caused by forceful trauma. It may occur with or without damage to the brain. Symptoms depend on the severity and the anatomic location of any underlying brain injury. Signs and symptoms may include changes in level of consciousness, altered mental status, hemorrhage or cerebrospinal drainage from the nose or ears, ecchymosis over the mastoid process (Battle’s sign), hematomas, and signs of increased intracranial pressure. A CT scan is used to diagnose a skull fracture. If a brain injury is suspected, an MRI may also be done. Non-depressed skull fractures generally do not require treatment. Focus of care is recognition of any change in condition and prevention of further injury. Depressed skull fractures usually require surgery.
46
After long periods of immobility, up to 3 months of reconditioning may be needed to return heart rate, stroke volume, and cardiac output to its previous state.
TRUE OR FALSE
TRUE
47
The nurse is aware that prolonged bed rest results in postural hypotension due to changes in \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-Other effects of immobility include hypercoagulability, atelectasis, urinary tract infections and incontinence, muscle atrophy, bone loss, and \_\_\_\_\_\_\_\_\_\_\_\_--in basal metabolic rate.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_- activity is needed to maintain bone mass. After long periods of immobility, up to 3 months of reconditioning may be needed to return heart rate, stroke volume, and cardiac output to its previous state.
cardiac output, venous stasis, and fluid redistribution; decrease; Weight-bearing
48
A complete neurological examination includes the assessment of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
mental status, cranial nerves, and motor and sensory function.
Current level of orientation is usually assessed first. Pupil response to light and accommodation assesses several cranial nerves. Ability to grasp and hold fingers assesses motor function.
49
The manifestations of a cerebrovascular accident (CVA), or stroke, include
change in level of consciousness, behavior, or affect; hypertension; facial droop; dizziness; pronator drift or muscle weakness on one side; gait changes; and visual and speech difficulties. The client may have a carotid bruit or report a severe headache. Assessment will include identifying sensory deficits, paresis, headache, visual changes, incontinence, dizziness, and changes in speech or gait. Nausea and vomiting may be present. Assess the client's level of consciousness using the Glasgow coma scale (GCS).
50
What to remember about urinalysis
A urinalysis is a laboratory test used to identify the components of a urine sample. The urine sample can be obtained by voiding or catheterization. Urinalysis is used to identify conditions such as kidney, bladder, or urinary tract infections, renal disease, fluid and electrolyte imbalance, diabetes, heavy metal or chemical poisoning, septicemia, preeclampsia, hypercortisolism, and misuse or abuse of chemical substances. Before obtaining the urinalysis, the nurse needs to determine the reason for obtaining a urinalysis along with reviewing the client's health history to gather information about medications, diet, fluid intake, exposure to toxins, and use of substances. Also, determine whether the client is pregnant or menstruating. After obtaining the urinalysis, observe sample for appearance, color, odor, and visible blood.
51
After parenteral nutrition is started, the nurse will need to obtain a glucose meter to check the blood glucose every \_\_\_\_\_\_\_\_\_\_hours
6
52
What do we need to monitor for in the client receiving parenteral nutrition ?
When delivering an infusion of parenteral nutrition (PN), the nurse needs to monitor the client for signs and symptoms associated with fluid, electrolyte, mineral, and glucose imbalances. **Closely monitor the client for signs and symptoms of infection.** **Since PN contains a solution of 10% to 50% dextrose, infusion through a central line using an infusion pump is required.** Infusions are started gradually (to prevent hyperglycemia) and increased slowly as the client’s pancreas adjusts to required insulin needs. Infusions are weaned gradually to prevent hypoglycemia when discontinuing. Fat emulsion will also be administered. Strict aseptic technique is essential when maintaining a central line.
53
The client with a fracture is at risk for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
compartment syndrome, deep vein thrombosis, pulmonary embolism, infection, and breakdown of skin. ***With fractures of long bones, the client is also at risk for fat embolism***.
**The primary symptom of compartment syndrome is pain that is unrelieved with medication or position change**. Additional symptoms of compartment syndrome include a change in the peripheral pulse of the effected limb, numbness, and tingling. Compartment syndrome is considered an emergency due to compromised circulatory and neurological functions.
54
With chronic kidney disease, it is essential for the nurse to plan education and referral to a dietitian regarding a \_\_\_\_\_\_\_\_\_\_-protein diet, as well as limiting \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. With hepatitis, the liver is essential in the metabolism of drugs and steroid hormones, synthesis of albumin/clotting factors, and converting ammonia to urea. Therefore, a client with hepatitis should be prescribed a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--diet.
low; sodium, potassium, and phosphorus; low-sodium, low-protein
55
***Certain health problems and disease processes are exacerbated by high levels of protein.***
Clients with kidney failure should be on a \_\_\_\_\_\_\_\_\_\_-restricted diet. An infection that affects renal function, such as glomerulonephritis, will also affect the excretion of the byproducts of protein metabolism, and requires \_\_\_\_\_\_\_\_\_\_\_-restriction. The liver participates in the excretion of protein, and clients with hepatitis should restrict \_\_\_\_\_\_\_\_\_\_\_\_\_-intake. The client with celiac disease should avoid food items that contain \_\_\_\_\_\_\_\_\_\_--The client post-surgery and the client with a pressure injury need protein for adequate healing.
protein; protein; protein; gluten.
56
Proteins are deaminated by the liver and converted to urea for excretion. When the liver does not function properly to convert deaminated protein, \_\_\_\_\_\_\_\_\_\_\_\_\_builds up, which can lead to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-
ammonia; hepatic encephalopathy.
57
A client whose urinalysis is positive for proteinuria and hematuria, but negative for white blood cells and bacteria likely has
This client's labs indicate glomerulonephritis, which can compromise kidney function. A urinalysis that is negative for WBCs and bacteria indicates glomerulonephritis versus infection.
58
Kidney failure impairs the kidney's ability to excrete the nitrogenous byproducts that come from proteins. Therefore, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--are usually restricted.
proteins
59
The symptoms of withdrawal occur from \_\_\_\_\_\_\_\_\_\_\_\_\_hours after the last drink
48 to 72
60
When caring for a client who may be experiencing alcohol withdrawal , the nurse should:
Assess when the client had last consumed an alcoholic drink. Assess how long the client has been drinking and how much alcohol they consume daily. Determine how the alcohol consumption has impacted the client ’s life. Assess blood alcohol levels. Assess serum electrolytes, complete blood count, and coagulation studies. Assess for pain. Assess level of consciousness and orientation.
61
What to remember about seasonal affective disorder ?
For some clients, signs of psychological instability will change with the seasons. One such instability, seasonal affective disorder, is believed to be caused by the reduction in natural sunlight during the winter months in some geographical locations. Individuals with this disorder experience sadness that cannot be attributed to any other cause. One intervention to help reduce the symptoms is for the client to increase exposure to sunlight. There are devices that mimic natural sunlight, which should be used until the amount of natural sunlight increases with the changing season.
**Seasonal depression can be treated with phototherapy to extend exposure to daylight during the winter months.**
62
The nurse teaches a client about measures to combat seasonal affective disorder. Which statement by the client indicates to the nurse that teaching was effective?
1. “I will make sure to get eyeglasses that have ultraviolet filters.”
2. “I will sit within 3 feet of artificial light for 30 minutes a day.”
3. “I will continue phototherapy until spring.”
4. “I will only use phototherapy during daytime hours.”
1) INCORRECT - The client should avoid wearing eyeglasses or contact lenses that have ultraviolet filters. Stimulation of the light receptors in the eye suppress melatonin. Excessive melatonin is thought to cause seasonal affective disorder. Ultraviolet filters decrease stimulation of the light receptors in the eye, thereby increasing melatonin production.
2) INCORRECT - Phototherapy, a technique used to suppress melatonin by stimulating light receptors in the eyes, should be used 2 to 6 hours a day. During this time, the client should sit within 3 feet of the artificial light.
3) CORRECT—The client with seasonal affective disorder should use phototherapy beginning in October and continue use until spring.
4) INCORRECT - The client should begin phototherapy in the morning soon after awakening and repeat exposure to the light after sundown to simulate extended daylight hours for a cumulative time of 2 to 6 hours a day.
63
a medical condition characterized by abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood.
Azotemia
64
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-uses the peritoneal membrane as a semipermeable membrane to filter out toxins and wastes, manage azotemia, and restore electrolyte balance.
What are complications associated with this ?
Peritoneal dialysis (PD)
The nurse needs to observe the client perform the infusion, dwell, and drain phases while noting the color and amount of dialysate after the dwell time. Explain the importance of monitoring serum glucose as the main ingredient in the dialysate is dextrose. Complications associated with PD include peritonitis, sepsis, hypotension, and fluid deficit.
65
The nurse provides care for a young adult female client undergoing peritoneal dialysis. The nurse notes that the outflow appears red-tinged. Which action does the nurse take first?
1. Contact the health care provider.
2. Determine if the client is menstruating.
3. Obtain the client’s vital signs.
4. Continue with the peritoneal dialysis
1) INCORRECT — The nurse should assess the client first. Blood-tinged effluent is common during the menstrual cycle of premenopausal female clients.
2) CORRECT — Because of the hypertonicity of the dialysate, blood from the uterus can be pulled through the fallopian tubes into the effluent. This is common in premenopausal female clients during menstruation. No intervention is required.
3) INCORRECT — This is an appropriate action if active intraperitoneal bleeding is suspected. However, the nurse should first assess for menstruation, as blood in the effluent of women menstruating requires no intervention.
4) INCORRECT — The nurse should first assess the client.
The nurse evaluates the peritoneal dialysis effluent in the context of the particular client. **This client is a young adult female and may be experiencing menstruation**. The nurse recognizes that an assessment of whether the client is menstruating is needed, as red-tinged effluent would be expected. **The menstrual flow can enter the peritoneal cavity and cause the effluent to be blood-tinged.** Anticipate the likelihood of the health care provider ordering a complete blood count (CBC).
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The nurse must be knowledgeable about diagnostic tests to help adequately prepare a client for the test. **Intravenous dye that is administered for imaging studies commonly causes the client to experience a feeling of** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, **metallic taste, headache, and nausea.**
The client may also feel the need to urinate. It is important to warn the client of these sensations, so the client does not become alarmed. Allergies to IV dye can be life-threatening. If the client knows what to expect during the procedure, the client can quickly alert staff of impending anaphylaxis.
warmth
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What to remember about intravenous pyelograms
what should we know regarding Metformin and IV pyelograms
**Intravenous pyelogram (IVP), an X-ray that provides images of the urinary tract, including the kidneys, bladder, ureters, and urethra, requires administration of contrast dye.**
Kidney function should be assessed before administering the contrast dye. **Determine if the client takes metformin, because this medication should be held for 48 hours before and after the procedure to avoid an interaction with the dye**. Check to see if informed consent is properly signed. Ensure that the client receives nothing by mouth for 12 hours before the procedure. Instruct the client about the procedure. Obtain and record baseline vital signs. Insert an IV catheter. Following the procedure, monitor the intake and output strictly, especially during the first 24 hours.
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What to remember about Chronic Kidney disease
Chronic kidney disease is **the irreversible loss of kidney function with a decrease in glomerular filtration rate to 10 mL/ minute, resulting in pH and electrolyte imbalances and waste product accumulation**.
Medications, **a low-protein diet, limiting sodium, potassium, and phosphorus, and fluid restriction are part of the management of chronic kidney disease** until the disease reaches a point where those interventions are not enough for the client to maintain life.
**Dialysis is a temporary or permanent treatment for chronic kidney disease.**
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What is Sodium Polystyrene Sulfonate ?
Sodium polystyrene sulfonate is **used to treat hyperkalemia** (increased amounts of potassium in the body). Sodium polystyrene sulfonate is in a class of medications called potassium-removing agents. **It works by removing excess potassium from the body.**
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TRUE OR FALSE
Sterile gloves are required when inserting the urinary catheter. However, clean, non-sterile gloves can be worn when removing the catheter.
TRUE
71
Gloves are required if contact is expected with
blood, body fluids, secretions, excretions, contaminated items, mucous membranes, or non-intact skin.
72
What to remember about Lacto-vegetarian diets ?
Lacto-vegetarians consume milk and dairy products along with plant-based food. **They do not eat eggs, meat, fish, and poultry.** The nurse should screen and assess if the client’s diet is lacking in protein. If so, the client should increase the intake of protein from other sources, such as **seeds, tofu, and dark green vegetables, along with beans, legumes, and nuts.**
A lacto-vegetarian diet includes all foods on a vegan diet, along with milk, cheese, yogurt, and other milk products as the only source of animal protein
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What to remember about Meningtitis ?
**Meningitis is the inflammation of the meninges, which are protective coverings of the brain and spinal cord, that may result in infection caused by bacterial, viral, or fungal pathogens.**
Age is a factor that influences the risk of developing meningitis. Infants, older adults, and debilitated persons are most at risk. **People who live in environmentally close settings are also more susceptible**. Persons who have not been immunized for mumps, Haemophilus influenza, and Streptococcus pneumoniae are also at a greater risk
The vaccination for meningitis should be provided to anyone who lives in close quarters with others. This is particularly important for students who live in college dormitories, or other types of living quarters.
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The pneumococcal vaccine is recommended primarily for \_\_\_\_\_\_\_\_\_\_\_\_\_\_-
A booster of the \_\_\_\_\_\_\_\_\_\_\_vaccine is needed 10 years after kindergarten, which is generally around 16 years of age.
older adults.
DTaP
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What to remember about hypoglycemia
risk factors, symptoms, interventions
Hypoglycemia affects level of consciousness and all body functions.
Hypoglycemia occurs when there is too much insulin in the bloodstream relative to the amount of available glucose. **A blood glucose less than 60 mg/dL is diagnostic for hypoglycemia**. Risk factors associated with hypoglycemia include taking too much medication, skipping meals, or engaging in physical activity without additional food intake. Sickness may also increase the risk of hypoglycemia. Signs and symptoms of hypoglycemia include shakiness, irritability, cool skin, difficulty in concentrating, decreased level of consciousness, and slurred speech. **Clients with hypoglycemia need 15 to 20 grams of a rapid acting sugar to correct the condition**.
**If the client is conscious, the nurse can give three to four glucose tablets, 4 oz. of fruit juice or regular soda, 8 oz. of milk, five to six pieces of hard candy, or a tablespoon of sugar or honey.**
**If the client is unconscious, the nurse must give 1 mg of glucagon, or 25 to 50 mL of 50% dextrose.** Complications associated with hypoglycemia include seizures, coma, and possible death.
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The nurse provides care to a client who is admitted to the emergency department (ED) with a serum glucose level of 32 mg/dL (1.8 mmol/L). The client is drowsy and has cold, clammy skin. The nurse anticipates implementation of which priority intervention?
1. Recheck the client’s serum glucose level.
2. Administer glucagon IM.
3. Provide the client with orange juice.
4. Obtain an EKG on the client.
1) INCORRECT – Rechecking the client's serum glucose level is an appropriate action. However, for the hypoglycemic client who demonstrates decreased level of consciousness, the priority intervention is administration of glucagon.
2) CORRECT – **For the hypoglycemic client who demonstrates decreased level of consciousness, the priority intervention is administration of glucagon**. If an IV access device is in place, dextrose 50% (D50) may be administered intravenously instead of glucagon IM. **Administration of oral fluid is contraindicated due to the client's decreased level of consciousness**. Rechecking the client's serum glucose level and obtaining an EKG are appropriate actions. However, administration of glucagon is the priority for this client.
3) INCORRECT – For the hypoglycemic client who demonstrates decreased level of consciousness, the priority intervention is administration of glucagon. Administration of oral fluid is contraindicated due to the client's decreased level of consciousness.
4) INCORRECT – Obtaining an EKG is an appropriate intervention. However, this is not the priority of care. Severe hypoglycemia can cause serious complications, including seizures. For the hypoglycemic client who demonstrates decreased level of consciousness, administration of glucagon is the priority intervention. If an IV access device is in place, dextrose 50% (D50) may be administered intravenously instead of glucagon IM.
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What to remember about Peripheral vascular disease ?
In clients with peripheral vascular disease (PVD) , an important nursing outcome is prevention of injury to the affected leg. **The client should be informed that due to reduced circulation and sensation, the leg is at a higher risk for injury.** The nurse should use the teach-back method to verify the client's knowledge related to foot care. The client is taught to inspect feet and legs daily, wear clean cotton or wool socks and well-fitting shoes, avoid sitting with legs crossed, and avoid prolonged standing.
In peripheral vascular disease, the body cannot adjust to temperature extremes.
Content Refresher
When caring for the client with peripheral vascular disease, the nurse should assess strength of distal pulses (dorsalis pedis, posterior tibial, and popliteal), color, and temperature of extremities. Assess for any non-healing wounds. Ask client about symptoms occurring with walking or activities. Educate client about reducing risk for development/progression of disease. Administer prescribed medications and teach client about side effects. Perform wound care as prescribed for non-healing wounds and assess for infection or complications. The client should be instructed to avoid heat therapy for skin that is cut or injured and avoid cold therapy if the client has circulatory problems.
DON'T SMOKE - Increases vasoconstriction
EXCERCISE - increase collateral circulation - The client should walk until pain begins, rest, and then walk a little farther.
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TRUE OR FALSE
Any spills on a sterile field causes contamination. Should this occur, all items and supplies are to be discarded and a new sterile field is established.
TRUE
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What to remember about Lithium ?
The nurse knows that lithium toxicity poses a high risk to client safety and provides teaching to minimize the risk to the client. **The body recognizes lithium as a salt and may use lithium to replace sodium stores in the body.** Because of this, the client taking lithium must maintain a stable daily intake of sodium. Adequate fluid intake is necessary to ensure adequate excretion of lithium when it is metabolized.
Lithium is a mood stabilizing agent that stimulates neuronal growth and reduces brain atrophy in people with long-standing mood disorders. It is prescribed for clients with bipolar disorder, specifically to help control manic episodes. The nurse needs to monitor dietary intake and sodium levels. **A sodium deficit causes more lithium to be reabsorbed and increases the risk of lithium toxicity.**
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What to remember about reassigning nurses to different units
An assignment to the reassigned nurse should be made based on stable client situations with predictable outcomes
**The reassigned nurse should be assigned to care for stable clients with predictable outcomes. The reassigned nurse can provide basic medical-surgical care, but should not be assigned clients who require specialty knowledge.**
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To assess nutritional status, laboratory testing includes
hemoglobin, serum protein level, albumin, pre-albumin, electrolytes, total lymphocyte count, and serum transferrin level. In addition, urinary creatinine excretion and urea nitrogen may be obtained.
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What kind of diet will a client with extensive burns need?
A client with extensive burns needs **a lot of protein while healing because the body will lose protein through the burn wounds and muscles will break down while trying to produce extra energy for the healing process.** The client’s daily caloric needs can be determined by the dietitian. The additional protein helps rebuild lost muscle. The nurse should find out the client’s food preferences and offer **protein-rich food options.** White poultry meat is an excellent source of lean protein. Seafood is also an excellent high-protein, low-fat option. **Excellent sources of protein, calcium, and vitamin D also may be found in dairy foods (e.g., cheese, milk, yogurt).**
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What to remember about DEEP VEIN THROMBOSIS ?
Every client in the hospital is now screened for deep vein thrombosis (DVT) risks. The nurse is expected to assess the client for these risk factors using standardized tools and review them when there is a change in client's condition. For DVT prophylaxis, the nurse anticipates giving the client heparin or low-molecular weight heparin, applies a sequential compression device to the lower extremities, encourages and assists the client with early mobility, and continues supportive care (e.g. hydration) depending on the client's clinical scenario. The nurse also needs to evaluate the client for thrombocytopenia, if the client is prescribed heparin and its derivatives.
Content Refresher
Deep vein thrombosis (DVT), or blood clots form in the deep leg veins, can travel throughout the body. Risk factors include immobility, recent surgery, obesity, previous history of DVT, **oral contraceptives**, smoking, hormone therapy, pregnancy, prolonged air travel, clotting disorders, and malignancy.
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What is the only IV fluid compatible with blood transfusion ?
Normal saline
85
What to remember about correct blood transfusion adminikstration procedures ?
An 18- or 20-gauge needle is used for a blood transfusion. This size is required to ensure that the cells are not damaged.
**Tubing with a blood filter is to be used when transfusing packed red blood cells.**
Blood products are to be checked by two licensed care providers to ensure that the correct blood product is being provided to the correct client.
Intravenous normal saline is used during a blood transfusion. This solution is to flush the IV line after the transfusion is completed.
**Blood products should be transfused within 2 to 4 hours.**
C**lients receiving a blood product should be monitored for the first 15 minutes and then periodically thereafter.** Since the client is being treated for anemia and may receive several units of red blood cells, there is a risk for fluid volume overload. The client should be monitored frequently.
When administering a blood transfusion, the nurse teaches the client/family about the procedure and signs/symptoms to report. Perform hand hygiene and wear gloves. Ensure normal saline IV fluid is running through a 14 to 20-gauge catheter (may be acceptable to use a 22-gauge in pediatric client). Set up infusion equipment with appropriate filter and tubing. **Run transfusion slowly, observing client carefully for 15 minutes. Monitor vital signs. Increase IV rate if no reaction occurs**. Discontinue when transfusion is complete and dispose of the equipment properly.
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What to know about Eye medications ?
used for ocular irritation
ocular congestion
glaucoma
anti-infective agent
topical anesthetic
Have client apply light pressure on lacrimal sac for 1 min after instilling drops - we don't want the medication to be absorbed systemically
Monitor BP and pulse
wash hands before and after instillation
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What to remembera about degenerative joint disease
Sometimes called degenerative joint disease or degenerative arthritis, **osteoarthritis (OA) is the most common chronic condition of the joints.** While OA most commonly affects the fingers (small joints), hips, knees, lower back, and neck, it can affect any joint. **The nurse can reinforce good posture and use of effective exercise.** Strengthening the muscles that support the hips is a primary goal of a hip exercise program. The deep stabilizing muscles of the hip can absorb shock and protect the joint from painful and harmful movements. Therefore, exercises that work the buttocks and pelvis can help improve a client’s flexibility, pain, and strength. To improve physical fitness, **the nurse should encourage daily aerobic activities (e.g., bicycling, swimming, walking).** As an added benefit, daily aerobic activities promote a normal body weight, which can prevent OA from developing in the knee joints.
Content Refresher
**Degenerative joint disease is a progressive loss of joint cartilage with increasing synovitis, resulting in joint pain, swelling, stiffness, and limited range of motion.** Determine the client’s ability to carry out activities of daily living. Assess the level of joint pain and current range of motion. Assist the client to plan for regular exercise and a balanced diet to improve strength and decrease risk for impaired mobility. **Advise client to plan for regular rest periods**. Refer to physical or occupational therapy to offer exercise support and assistive devices, as needed. Educate the client about medications prescribed for pain management.
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Clients who sustain burn injuries often exhibit varying degrees of burns, each of which is associated with unique nursing and medical considerations. A full-thickness burn, sometimes referred to as a \_\_\_\_\_\_\_\_\_-degree burn, affects \_\_\_\_\_\_\_\_\_\_\_\_\_\_skin layers and underlying structures, including muscle and nerves. Third-degree burns allow for loss of fluid and hematological components, are more prone to \_\_\_\_\_\_\_\_\_\_\_-, present a more difficult recovery process, and are generally more complex compared to other classifications of burns.
third; multiple; infection
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The organ transplant recipient faces many long-term challenges. Medications are prescribed to help prevent rejection of the transplanted organ by suppressing the body’s immune response. Unfortunately, **use of immunosuppressive medications also increases the client’s risk for \_\_\_\_\_\_\_\_\_\_and may increase the risk for developing certain types of \_\_\_\_\_\_\_\_\_\_\_\_\_** Failure to adhere to the immunosuppressive medication regimen can lead to organ failure.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--- **(GvHD) (**When transplanted cells attack the recipient’s body.) **is not common in kidney transplants, but in the early post-transplant weeks, an acute GvHD may occur.**
Sometimes symptoms are temporary and not harmful. Possible manifestations of mild GvHD include rash, diarrhea, and pruritus.
**infection; cancer;** **Graft-versus-host disease**
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What to remember about HIPPA
Confidentiality refers to protecting and safeguarding a client’s personal, identifiable health information and data. **In 2003, the federal statute known as the Health Insurance Portability and Accountability Act (HIPAA) mandated the protection of client data.**
***Unless officially authorized to do so by the client, nurses do not discuss or share the client’s personal information, including health care data, with family, friends, coworkers, other members of the health care team, insurance providers, or financial aid organizations.***
The nurse should hold self and colleagues accountable when it comes to respecting client confidentiality and privacy.
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The client experiencing pain may exhibit
increased blood pressure, rapid, irregular respirations, increased perspiration, increased neuromuscular activity, nausea, vomiting, and irritability.
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A client stops taking prescribed atenolol 100 mg by mouth every day because of no improvement in health status. Which finding does the nurse expect when assessing this client?
1. Palpitations and diaphoresis.
2. Urinary frequency and dysuria.
3. Increased hunger and thirst.
4. Confusion and tremors.
View Explanation
1) CORRECT— Atenolol is a beta-blocker that decreases excitability of the heart. It reduces cardiac workload and oxygen consumption, decreases release of renin, and lowers blood pressure by blocking the sympathetic nervous system response to stimuli. This medication should not be discontinued abruptly because the client may develop tachycardia, diaphoresis, and malaise. Abrupt discontinuation of atenolol may lead to myocardial ischemia and life-threatening cardiac dysrhythmias
2) INCORRECT - Urinary frequency and dysuria are symptoms of a urinary tract infection. These symptoms are not associated with abruptly stopping atenolol.
3) INCORRECT - Increased hunger and thirst occur when taking central nervous system stimulants. Atenolol blocks the sympathetic nervous system response to stimuli.
4) INCORRECT - Confusion and tremors are symptoms of hypoglycemia. These symptoms are not associated with abruptly stopping atenolol.
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During pregnancy, the nurse is aware that insulin needs will _____________ to support both the client and developing fetus. Once the newborn is delivered, the need for the additional insulin will \_\_\_\_\_\_\_\_\_. The client's blood glucose levels should be **closely monitored immediately after delivery so that the insulin doses can begin to be adjusted.**
increase; decrease
Insulin needs should decline rapidly after the delivery of the placenta and abrupt cessation of placental hormones. Blood glucose levels should be monitored at least four times daily so that the insulin dose can be adjusted to meet individual needs. **Women with type 1 DM usually return to their pre-pregnancy insulin dosages.**
94
Women with type 1 DM usually return to their pre-pregnancy insulin dosages.
TRUE OR FALSE
TRUE
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What to remember about lower Gastrointestinal series
The preparation for the test is a clear liquid or low-residue diet for 2 days, nothing by mouth after midnight before the test, enemas and laxatives to prepare for the test. These preparations can result in dehydration. In addition, the laxatives posttest to remove the barium further increase the risk of dehydration.
**The preparation for the diagnostic testing can be quite extensive**. The client's diet is changed to clear liquids and the client is subjected to laxatives and enemas to clear the large intestines. The absence of regular nutrition and loss of fluids and electrolytes through the bowel when preparing for the test can cause both fluid and electrolyte imbalances. The nurse should plan interventions to address a potential fluid imbalance, including monitoring blood pressure, heart rate, and urine output.
The nurse should include information about the need to **increase fluid intake post-procedure to eliminate the barium used for the test and to reduce the possibility of dehydration.** After the procedure, the nurse should monitor fluid intake and output, assess for signs of dehydration, and provide increased fluids.
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What to remember about Buck's traction
Also known as skin traction, Buck traction is a non-invasive method to stabilize a fracture of the hip. **The purpose of this type of traction is to maintain bone alignment and to immobilize the bone, which promotes comfort by reducing muscle spasms**. A boot or wrap/straps are applied to the lower extremity and the pulley with weights are applied to this, resulting in the needed traction.
**The nurse knows that care of a client in Buck traction focuses on maintaining skin integrity, protecting the affected extremity, and frequently assessing sensorimotor status of the affected limb.** The nurse also understands that Buck traction is generally used for short-term treatment (48 to 72 hours) until surgery is possible.
**When providing care for a client in Buck traction, the nurse assesses the affected extremity for pulses, color, numbness/tingling, pain, and paralysis every 1 to 2 hours.** Maintain traction and administer prescribed prophylactic anticoagulation. Assess for pain and administer analgesics and/or nonsteroidal anti-inflammatory drugs (NSAIDs) as prescribed. **Reposition the client every 2 hours and inspect the skin around boot and/or wrap/straps for breakdown every 4 to 6 hours.**
Elevating the foot of the bed provides countertraction for the client.
It is appropriate that if client has a fracture, to turn to the unaffected side and support the upper leg with pillows.
Back care should be provided every 2 hours to prevent pressure sores and discomfort.
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Bottom line: The nurse cannot promise to keep secret any information about sexual abuse and should be honest with the child. Child abuse is to be reported. There might be a need to share the information with the child's parents.
TRUE OR FALSE
TRUE
Sexual abuse is sexual assault or sexual exploitation of others. Documentation and reporting of the sexual abuse case should be performed. If a child is involved, referral to Child Protective Services is needed along with a referral to a Sexual Assault Nurse Examiner (SANE). Additional referrals for counseling or family therapy depending on the circumstances of the abuse should be done. Crisis intervention may be needed, depending on the situation.
98
What to remember about negative nitrogen balance
The nurse is aware that negative nitrogen balance is a condition in which **protein catabolism (breakdown) exceeds protein anabolism (synthesis), resulting in tissues losing protein faster than it can be replaced.** The nurse anticipates treating the reversible causes, collaborating with the dietitian to suggest an appropriate diet, and to treat underlying conditions. The nurse is expected to monitor the client’s albumin and protein levels as needed. The nurse might receive a prescription to conduct a caloric count for the client.
Content Refresher
**Negative nitrogen balance is a result of more nitrogen (by-product of protein metabolism) being excreted than ingested.**
**Negative nitrogen balance is a complication of such conditions as burns, serious tissue injuries, starvation, and immobility.**
**Negative nitrogen balance can lead to anorexia, debilitation, and weight loss.** Provide the client with small, frequent feedings that are high in protein. Protein foods with high biologic value include milk, eggs, cheese (especially cottage cheese), meat, poultry, and fish.
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the amount of nitrogen excreted from the body is greater than the amount of nitrogen ingested.
Negative Nitrogen Balance
Nitrogen Balance = Nitrogen intake - Nitrogen loss Sources of nitrogen intake include meat, dairy, eggs, nuts and legumes, and grains and cereals. Examples of nitrogen losses include urine, feces, sweat, hair, and skin
100
Complete proteins contain all \_\_\_\_\_\_\_\_\_-essential amino acids, whereas incomplete proteins are \_\_\_\_\_\_\_\_\_\_\_\_\_
9; missing one or more
101
. A negative nitrogen balance indicates tissue destruction.
TRUE OR FALSE
TRUE
102
The nurse provides care to a client diagnosed with a negative nitrogen balance. Which dietary selection is most appropriate for the nurse to recommend to the client?
1. Rice cereal.
2. Celery.
3. Green peas.
4. Salmon.
1) INCORRECT– Cereal is an incomplete protein, meaning it is missing one or more of the nine indispensable amino acids.
2) INCORRECT– Vegetables, including celery, are incomplete proteins, meaning they are missing one or more of the nine indispensable amino acids.
3) INCORRECT– Legumes, including green peas, are incomplete proteins, meaning they are missing one or more of the nine indispensable amino acids.
4) CORRECT – Fish, including salmon, is a complete protein, also called a high-quality protein. Fish contains all of the essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. A negative nitrogen balance indicates tissue destruction.
103
Because levothyroxine stimulates the metabolism, it may cause insomnia if taken at night. It should be taken\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
first thing in the morning.
104
What to remember about hypothyroidism
Hypothyroidism is a condition in which the thyroid gland is not producing enough thyroid hormones (T 3 and T 4).
Clinical manifestations include **fatigue, dry skin, feeling cold all the time, constipation, depression, myxedema (**Puffiness of the skin, facial and periorbital edema, and a masklike effect.Most commonly associated with hypothyroidism) **, and confusion**.
A serum thyroid stimulating hormone (TSH) concentration is used to diagnose hypothyroidism (normal range is 0.45 to 4.5 mU/L). Levothyroxine (thyroxine, T 4) is the drug of choice to treat hypothyroidism.
105
What to remember about mastectomy
Mastectomy is the removal of the whole breast. There are five different types of mastectomy: radical mastectomy, total mastectomy, modified radical mastectomy, partial mastectomy, and subcutaneous mastectomy. Mastectomy may be elected for those at high risk of breast cancer. It is also recommended in cases where tumors are large or widespread, or when prior treatment was not effective. Complications following mastectomy include bleeding, pain, infection, andlymphedema. **Elevation of the affected side of the body and the involved arm can reduce the development of lymphedema.** The client is closely monitored for manifestations of the other possible complications.
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The nurse provides care to a client who just underwent left modified radical mastectomy. When assisting the client with positioning, the nurse implements which action?
1. Extend the client's left arm flat along the affected side.
2. Elevate the client's left arm on a pillow.
3. Rest the client's left arm across her chest.
4. Place the client's left arm below the level of her torso.
1) INCORRECT - Extending the arm flat along the affected side may limit circulation and impede lymphatic drainage, resulting in lymphedema. Following modified radical mastectomy, elevation of the affected arm on a pillow is recommended.
2) CORRECT– Following modified radical mastectomy, the client should be placed in semi-Fowler position. To promote lymphatic drainage without compromising circulation, the arm on the affected side should be elevated on a pillow. Elbow flexion or dependent positioning of the arm may impede lymphatic drainage and compromise circulation.
3) INCORRECT - Resting the arm across the chest requires significant flexion of the elbow, which may impede lymphatic drainage and circulation, and ultimately lead to the development of lymphedema.
4) INCORRECT - Dependent positioning of the arm to below the level of the torso may impede lymphatic drainage and circulation, and promote the development of lymphedema.
The nurse needs to mentally ask, "What is a likely manifestation for a client following a mastectomy?" Reviewing the surgical procedure for a modified radical mastectomy, the nurse recalls it is likely that many, if not all, of the lymph nodes and glands surrounding the breast tissue were removed. **The nurse can now conclude the removal of lymph tissue increases the client's risk of developing lymphedema in the extremity that is on the same side of the surgery.** Lymphedema can increase pain and complicate healing. **To reduce the risk of lymphedema, the nurse should make sure that the limb on the same side of the surgery is elevated on a pillow.**
