QB 6 Flashcards
What is augmentation of labor ?
Augmentation of labor is the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labour.
What to remember about fetal decelerations …
late decelerations indicate a reduction in heart rate, usually after a uterine contraction. Once deceleration starts, it takes about 20 to 30 seconds to reach its lowest point. When the timing of deceleration is delayed, it means that the lowest point is occurring past the peak of your uterine contraction.
late decelerations could be considered dangerous. They’re a sign of hampered blood flow to your placenta, which might trigger imminent fetal hypoxia (or a lack of oxygen for fetal tissues).
When persistent late decelerations are noted, further assessment is not needed prior to taking action. Interventions include re-positioning the client to the left side or to the knee-chest position to increase uterine blood flow, administering oxygen and fluid to increase oxygenation and cardiac output, and correcting the stimulus of the late decelerations. Late decelerations may stem from excessive contractions or maternal hypotension. Late decelerations are caused by decreases in fetal oxygenation and subsequent fetal hypertension. If allowed to continue, fetal hypoxia results in sustained fetal bradycardia.
Nurse Empowerment
Characterized by innovating in solving problems, resulting in a sense of accomplishment and feeling of worth
Feeling empowered is critical in nursing practice. The lack of empowerment will lead the staff to rely heavily on rigid bureaucratic structures rather than their own professional power to guide, practice, or create a solution.
How to help a clinet in a situational crisis ?
When caring for a client in a situational crisis, the nurse should: Evaluate current and prior coping strategies, and provide support and encouragement. It is most important for the nurse to assess for signs the client is a risk to self or others; the nurse needs to initiate safeguards for client or others in crisis as needed. Therapeutic communication techniques will assist in identification of coping mechanisms and assist client to decide on a course of action. The nurse should also help identify available support systems and community resources.
Remember signs of lithium toxicity
EARLY SIGNS - diarrhea, muscle weakness,
LATE SIGNS - Coarse hand tremors, ataxia,
Diarrhea is a sign of lithium toxicity, along with oversedation, ataxia, tinnitus, slurred speech, and muscle weakness/twitching.
muscle weakness, diarrhea, oversedation, ataxia, tinnitus, slurred speech, tremors, fever, mental confusion, seizures, coma, and death.
What to remember about bronchiolitis and RSV?
What do we need to remember about care for infants with RSV?
Bronchiolitis is an infection of the lower respiratory tract causing inflammation and obstruction of the bronchioles.
It may be of viral or bacterial origin and the most frequent causative organism is the respiratory syncytial virus (RSV). Treatment includes respiratory assessments to monitor changes in the infant/child’s condition, maintaining elevation of the head of bed, and suctioning to facilitate breathing. Administer oxygen and medications as prescribed to dilate bronchioles and improve gas exchange at the alveolar level. Address hydration and provide fluids via oral and intravenous routes as prescribed.
Infants with these infections can have nasopharyngeal secretions that block airway passages so a bulb syringe is required for airway management. An infant is unable to clear the airway and would need to have secretions removed through the use of a bulb syringe.Young infants are obligatory nose breathers. Parents should be instructed on how to use the syringe before feedings and as necessary.
When are arterial blood gases drawn ?
Arterial blood gases (ABGs)are drawn whenever a client is at risk for respiratory failure. They are also used to detect a metabolic disorder. Trends in respiratory status can be assessed using pulse oximetry and periodic ABG analysis. Arterial blood gases are used to detect impaired gas exchange (SaO 2 <92% to 95%; PaO 2 <80 mm Hg) or a metabolic problem (HCO 3 <22 or >26 mEq/L).
Altered level of consciousness, visual disturbances, headache, and slurred speech are associated with conditions including
hypoglycemia, transient ischemic attack (TIA), or stroke (cerebrovascular accident [CVA]). A bedside blood glucose assessment is quick, simple, and noninvasive and is one of the nurse ’s initial actions. While ruling out hypoglycemia or TIA, the nurse continues to anticipate treatment of the client for the most serious of the suspected diagnoses, which is stroke.
Stroke is an interruption of blood flow in the brain as a result of hemorrhage or thrombus. Strokes are classified as hemorrhagic or ischemic. The phrase “time is brain ” has been used to demonstrate the importance of stroke recognition and seeking medical treatment quickly. Prepare the client for emergent CT scan of the brain to assess for hemorrhage, carotid Doppler to assess blood flow, magnetic resonance angiography (MRA) to visualize blood flow, magnetic resonance imaging (MRI) to assess damage if an ischemic stroke is diagnosed, and ECG if atrial fibrillation is present. Laboratory blood work includes a complete blood count, blood chemistry, and coagulation studies.
What to remember about UTI’s and pregnancy ?
Pregnancy is a risk factor for urinary tract infection (UTI) partly because hormonal changes make the tissues of the urinary tract vulnerable to infection. To prevent and manage UTI, the client should drink at least eight glasses of water a day. Common antibiotics such as amoxicillin, erythromycin, and penicillin, are considered safe for pregnant women. The nurse should teach the client that the majority of urinary symptoms are due to pregnancy-related changes in the urinary system. Past history of UTI, sexual activity, lower socioeconomic group, and multi-parity are significant risk factors for UTI.
Content Refresher
During pregnancy, a mother will experience physiological changes in all systems of the body. Distention and dilation of the renal pelvis due to the increased progesterone level may lead to urinary stasis and development of a urinary tract infection . The nurse should review methods to reduce urinary tract infections, such as increasing fluid intake.
Which form of therapy is commonly offered for survivors of intimate partner violence ?
What is psychodrama?
Group therapy
Psychodrama is a form of dramatic play in which a client acts out emotional problems and examines subjective experiences to develop new perspectives. It is used with groups of verbal children and adolescents.
The nurse is assigned to provide care to four clients on the medical-surgical unit. After receiving change-of-shift report, which client does the nurse assess first?
- A client admitted 3 hours ago with a gunshot wound and 1.5 cm area of dark red drainage noted on the dressing.
- A client who underwent a mastectomy 2 days ago with 23 mL of serosanguinous fluid noted in the bulb-suction drain.
- A client with a collapsed lung due to an accident and no drainage noted from the chest tube in last 8 hours.
- A client who underwent an abdominal perineal resection 3 days ago and who reports chills.
1) INCORRECT— The client appears to be stable and is not the highest priority for assessment. Acute bleeding typically is bright red in color. The presence of dark red drainage is suggestive of old blood. The amount of drainage on the dressing is minimal.
2) INCORRECT— The client is not the highest priority for assessment. The client’s assessment findings are reflective of an expected outcome. Drainage of serosanguinous fluid is a normal finding for a client who underwent a mastectomy 48 hours earlier.
3) INCORRECT— The client is not the highest priority for assessment. The client’s assessment findings indicate resolution of a health alteration. Absence of drainage from a chest tube suggests healing is likely occurring.
4) CORRECT— This client is the highest priority for assessment. The client’s assessment findings indicate a potential complication may be developing. The client who undergoes abdominal perineal resection is at risk for developing peritonitis. Because chills may indicate infection, immediate assessment of the client is indicated.
As a physical sign, chills almost always signify an acute change in the client’s physical condition. Chills are usually a marker of an infection. The nurse should look for the source of infection and other findings such as an increase in white blood cell count, low or high temperature, and hemodynamic changes. An abdominal infection should be explored for this client.
What to remember about apnea and infants
It is normal for a neonate to have periods of apnea. Apnea lasting longer than 20 seconds should be reported to the health care provider.
Infant apnea is diagnosed for any unexplained episode of the cessation of breathing that lasts 20 seconds or longer or when a shorter respiratory pause is associated with other symptoms (e.g. bradycardia, cyanosis, pallor, and the occurrence of marked hypotonia). While apnea is fairly common in preterm infants, it is rare among full-term healthy infants. When apnea occurs for full-term infants, it is usually an indication of an underlying pathology. The nurse should offer reassurance to parents by explaining the difference between true apnea and periodic breathing (pauses in respiration that last less than 10 seconds). Periodic breathing is not dangerous and no intervention is required.
What are contraindications associated with breastfeeding ?
clients who are HIV positive or have varicella, active tuberculosis that is untreated, or active herpes to the breast. In addition, clients who take certain medications (e.g., chemotherapy or radioactive isotopes), use illicit drugs, or smoke should avoid breastfeeding. Finally, an infant diagnosed with galactosemia should not be breastfed.
During any “ordinary” illness such as a cold, sore throat, flu, or mastitis, the client should continue to breastfeed. Wearing a surgical mask will prevent transmission of respiratory infectious agents to the newborn.
TRUE OR FALSE
TRUE
What to remember about when not to give vaccines to children
After birth, the newborn is protected for a short period of time by the mother’s immunity, which is provided while in utero. For future immunity, the newborn needs to receive vaccinations in order to prevent the development or contraction of certain illnesses. A schedule of immunizations has been created, which identifies the appropriate times when vaccination should be provided. Reasons to withhold the vaccine would be evidence of immunosuppression or allergy to the vaccine.
The Centers for Disease Control and Prevention recommend that children receive vaccinations on schedule, even if they have an ear infection, mild diarrhea, cold symptoms or a cough, or a fever of less than 101° F. Though vaccines may cause mild side effects such as a slight fever or pain and swelling at the injection site, the vaccines are not likely to make a child more ill. Mild illness also does not impair the body’s ability to mobilize a response to vaccines. A child taking an antibiotic may receive vaccines as scheduled, but vaccines should be delayed if a child is taking an antiviral medication.
Provide education to parents regarding newborn care and additional signs and symptoms to report to the health care provider (e.g. ____________________________________________). Instruct parents to monitor for ___ to ________wet diapers per day and that stools will transition to thin green-brown by day 3.
increased respiratory rate, grunting, nasal flaring, intercostal retractions, sunken or bulging fontanelles, fever, hypothermia, or severe hypo- or hyperactivity
6 to 10
What to remember about peptic ulcers ……
How do they develop?
What is the client at risk for ?
What is a telltale sign of peritonitis ?
We know the stomach is the organ where food begins the digestive process. At times, an excess amount of hydrochloric acid in the stomach injures the tissue wall. If left untreated, the injury enlarges, erodes through the tissue, and can progress to a perforation. The body’s immediate response to tissue injury is bleeding, swelling, and pain. Bleeding will be present within the stomach, but also throughout the abdominal cavity. Bleeding into this area will cause the abdominal tissues, organs, and muscles to cramp. The abdomen becomes hard and extremely painful.
Peptic ulcer disease (PUD) is caused by the erosion of the mucosa of the gastrointestinal (GI) tract by hydrochloric acid (HCL) and pepsin. Peptic ulcers can develop in any segment of the GI tract exposed to HCL and pepsin. The most common areas are stomach, lower esophagus, and duodenum. They are categorized as acute or chronic. Erosion of the mucosa may be deeper with prolonged, chronic PUD. When erosion of the mucosa occurs, the client is at risk for hemorrhage (blood in stool, dizziness, and hypovolemic shock), perforation that leads to peritonitis (severe abdominal pain that radiates, rigid abdomen, and fever), and gastric outlet obstruction (epigastric fullness, nausea, and vomiting). They are all emergent situations requiring rapid assessment and treatment.
RSV requires what kind of precautions
contact
Assessment of Peritonitis
Severe Abdominal Pain
Abdominal Rigidity/Rebound Tenderness
Nausea/Vomiting
Abdominal Distension -Ascites
Fever/Leukocytosis
Decreased bowel sounds - possible paralytic ileus
Complications:
Hypovolemic shock (from all the fluid shifts), sepsis, abscess
What is Losartan ?
Losartan, an angiotensin II receptor blocker (ARB), causes dilation of blood vessels, decreases release of aldosterone, and increases renal excretion of sodium and water.
Losartan lowers blood pressure and can cause orthostatic hypotension.
A low dose of this medication is initially prescribed and then increased or changed according to the status of the client’s heart failure
What is Cyclosporine ?
immunosuppressant medication used for anti-rejection in organ transplants
AE: hypertension, nephrotoxicity, infections
some causes of dehydration and S/S
Dehydration is caused by a variety of disorders including inadequate fluid intake, diarrhea, vomiting, and disorders that result in fluid losses (diabetes mellitus, diabetes insipidus, fluid shifts, burns, hemorrhage, and certain medications such as diuretics). Thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy are clinical manifestations of dehydration.
The home health nurse visits a client diagnosed with heart failure who is prescribed a diuretic. Which client statement causes the nurse to assess the client further? (Select all that apply.)
- “I’m hardly making urine, but I haven’t been drinking well”
- “I take my water pill in the morning because I urinate so much.”
- “I have a bowel movement every other day.”
- “I’ve been dizzy, and I almost passed out yesterday.”
- “I’m noticing that I bruise really easily.”
1) CORRECT — Failure to make urine, especially while on a diuretic, may indicate kidney insufficiency due to lack of perfusion.
2) INCORRECT— Taking diuretics in the morning is advised because an expected side effect of diuretics is frequent urination.
3) INCORRECT— Constipation is a minor side effect of diuretics caused by dehydration. Having a bowel movement every other day indicates adequate hydration. Although daily bowel movements are ideal, this is not typical for every person.
4) CORRECT — Dizziness and near syncope indicate dehydration and decreased perfusion. The client may require a dose adjustment, alteration in activities or activity level, or further instruction about hydration and safety while on diuretics.
5) CORRECT — Bruising indicates a potential coagulation issue, possibly due to liver insufficiency secondary to decreased perfusion or medication toxicity.
Heart failure is a complex disease. Both the condition and the treatment pose challenges. The nurse should monitor the client closely for impending decompensation, end organ damage, and respiratory distress. Signs of low cardiac output, such as oliguria and fainting, should be addressed immediately. Prevention of heart failure exacerbation includes maintaining normal blood pressure, diuretic and inotropic therapy, and controlling diabetes and coronary artery disease. The nurse should also suggest to the provider to obtain a brain natriuretic peptide (BNP) level.
What is basal cell carcinoma ?
Basal cell carcinoma is a type of skin cancer that most often develops on areas of skin exposed to the sun.
Exposure to the sun increases the risk of skin cancer. The nurse should urge the client to use sunscreen with SPF (solar protection factor) to block harmful rays and reapply sunscreen every 2 hours or after swimming. The client should also use lip balm with sunscreen protection and avoid sun exposure during peak sun hours.
What is the number one risk for skin cancer?
The nurse should understand that exposure to the sun’s ultraviolet rays is the number one risk factor for skin cancer.
The risk for skin cancer increases with sun exposure
Water also magnifies the intensity of the sun, which could hasten the development of a cancerous lesion.
When performing skin assessment/screening, the nurse should be aware of genetic predispositions such as fair skin coloration, light colored eyes, and red or blond hair.
____________are the most common cause of increased intracranial pressure (ICP). As intracranial pressure increases, the client’s___________________decreases.
Head injuries; level of consciousness
What to remember about Apgar scoring
An Apgar score of 0 to 3 is poor, a score of 4 to 6 is fair, and a score of 7 to 10 is excellent.
Apgar scores between 7 and 10 indicate the newborn needs routine care. Apgar scores of 4 to 6 indicate the need to provide some degree of support to maintain the newborn’s airway and breathing. Apgar scores of less than 4 signal the need for emergency intervention. The Apgar score is reassessed 5 minutes after birth. If the newborn client’s follow-up Apgar score at 5 minutes is less than 7, the client stays with nursing staff for monitoring and intervention
Apgar scoring is used to evaluate a newborn’s physical health immediately after delivery. A score is given at 1 minute and again at 5 minutes following the birth. Assess the newborn’s heart rate and assign 0 to 2 points (0 = no heart rate, 1 = heart rate less than 100, 2 = heart rate above 100). Assess the newborn’s respiratory effort and assign 0 to 2 points (0 = not breathing, 1 = weak cry, 2 = strong cry). Assess the newborn’s muscle tone and assign 0 to 2 points (0 = flaccid, 1 = some flexion of extremities, 2 = actively moving). Assess the newborn’s reflex response and assign 0 to 2 points (0 = no response, 1 = grimace upon stimulation, 2 = crying). Assess the newborn’s skin color and assign 0 to 2 points (0 = blue/pale, 1 = blue extremities with pink body, 2 = pink).
What to remember about myelomeningocele and protective interventions
the nurse understands that a part of the spinal cord developed outside of the body and is encased within a membranous sac or pouch. The nurse is aware the area needs to be protected from accidental injury and should be covered with a sterile moist dressing. The area should have limited manipulation to prevent rupture of the sac.
After delivery, the nurse should cover the pouch on the neonate’s back with a sterile dressing and place the neonate on the stomach to protect the pouch
Covering the lesion with a moist sterile dressing is the nurse’s priority. Meticulous care is taken to prevent sac rupture, because any opening greatly increases the risk of infection to the central nervous system. The neonate is usually placed in an incubator or radiant warmer so the temperature can be maintained without clothing and blankets to prevent irritation of the lesion.
Surgical repair of myelomeningoceles and meningoceles takes place within 24 to 48 hours after birth.
One of the rights of clients is the right to refuse medical treatment.
TRUE OR FALSE
TRUE
18 or older is legal age to be able to refuse medical treatment
What to remember about TB precautions
Clients with pulmonary or laryngeal tuberculosis (TB) are placed on airborne precautions, in addition to standard precautions. The nurse and all staff members should wear an N95 mask (fit-tested size). Ideally, the client should have a private room with a negative pressure. Discontinue precautions only when the likelihood of infectious TB disease is deemed negligible and either there is another diagnosis that explains the clinical syndrome or the results of three sputum smears for acid-fast bacillus (AFB) are negative. Each of the three sputum specimens should be collected 8 to 24 hours apart, and at least one should be an early morning specimen.
Two general tyopes of seizures
Focal or partial seizures may involve only one area of the body and usually no loss of consciousness. Repetitious behaviors and experiencing smells, tastes, or sights that are not real may be part of a focal seizure.
Generalized seizures may follow an aura and include tonic-clonic (jerking muscle spasms and loss of consciousness), absent (staring into space), myoclonic (jerking of upper body or extremities), or atonic (loss of muscle tone) types. Amnesia and confusion usually follow after a seizure.
What is the goal of IV therapy ?
Intravenous therapy (IV) is a method of treatment used to manage fluid disturbances for clients. Select the prescribed solution and determine the appropriate equipmentbased on central or peripheral line access, intent of therapy, and intended duration of therapy. Maintain the infusion rate as prescribed and check the infusion and infusion equipment hourly along with monitoring the IV access site. The goal is that the client will demonstrate improvement in fluid volume while exhibiting no signs of complications.
Pain assessment can be done by the UAP.
TRUE OR FALSE
FALSE
Pain assessment must be done by the nurse.
Venipuncture can be done by the UAP.
TRUE OR FALSE
FALSE
Venipuncture must be performed by the nurse or by a trained phlebotomist from the lab.
What are the five rights of delagation ?
The five rights of delegation include right task, right circumstances, right person, right communication, and right supervision.
The nurse can delegate components of client care but cannot delegate the nursing process itself. Core nursing functions of assessment, planning, evaluation, and formulation of nursing judgments cannot be delegated.
Digoxin decreases the heart rate and ___________the heart’s force of contraction. The combination of digoxin with a potassium-wasting medication increases the client’s risk for_________________ toxicity. Digoxin toxicity can cause_________________ and, conversely, hypokalemia can cause digoxin toxicity.
increases; digoxin; hyperkalemia
In the hospital setting, potassium imbalances and digoxin toxicity are treated aggressively to prevent cardiac conduction abnormalities, which may range from dysrhythmias to cardiac arrest. Home-based clients who take furosemide and digoxin together are educated about the signs of digoxin toxicity and instructed to seek care immediately if digoxin toxicity is suspected.
Signs of hypokalemia
muscle weakness, paresthesias, muscle cramps, palpitations, anorexia, and ECG changes (e.g., prominent U wave, ST-segment depression, and peaked P wave)
What is a low fat diet and what kind of diseases is it recommended for ?
A diet in which 25% of daily calorie intake comes from fats. It is recommended in managing cardiovascular diseases, elevated cholesterol levels, and diabetes mellitus.
the client needs to eat fewer foods that contain fat and find appropriate substitutes to foods that are high in fat.
What is important when performing a physical examination with an adolescent ?
Privacy and allowing time for questions without the parent present in the room
Adolescents should be transitioning to Erikson identity versus the role confusion stage. Determine mental health issues or concerns. Determine the need for immunizations and currency of dental, vision, and hearing screenings. Provide the client education about healthy living (e.g., nutrition, exercise, sleep patterns, and personal habits) and avoiding high-risk behaviors (e.g., use of tobacco, alcohol, or drugs; risky sexual practices). If high-risk behaviors are identified, intervene appropriately. Encourage interaction with peer groups that align with moral and spiritual values. Obtain a room to promote privacy when interviewing, examining, and educating the adolescent.
What to remember about radioactive iodine treatment for hyperthyroidism ?
The most common side effect of radioactive iodine may seem ironic, yet it makes perfect sense—hypothyroidism. The radioactive iodine often kills an excessive amount of thyroid cells, leaving the thyroid unable to produce enough hormones—the opposite problem you had before.
Lethargy, sensitivity to cold, dry skin, weight gain, and depression indicate hypothyroidism, which is a complication of I-130 therapy.
Clinical manifestations associated with hypothyroidism include
Name at least 4
fatigue, dry skin, weight gain, feeling cold all the time, constipation, depression, myxedema, and confusion
What to remember about hyperglycemic hyperosmolar syndrome (HHS)
In HHS, blood glucose is greater than 600 mg/dL (33.3 mmol/L), pH is greater than 7.30 or normal, serum bicarbonate is greater than 18 mEq/L or normal, and urine ketones absent to small
The nurse assists a graduate nurse with the care of a client whose blood glucose is 525 mg/dL (29.14 mmol/L), pH is 7.1, and serum bicarbonate level is 14 mEq/L (14 mmol/L) and has ketonuria. The nurse intervenes if the graduate nurse makes which statement? (Select all that apply.)
- “I should add 5% dextrose to the IV fluids when the client’s blood glucose drops below 100 mg/dL (5.55 mmol/L).”
- “The client’s potassium level will increase as the blood glucose decreases.”
- “The client’s laboratory results are characteristic of hyperglycemic hyperosmolar syndrome (HHS).”
- “The client requires a STAT electrocardiogram (ECG).”
- “I should check the client’s blood glucose every 2 hours.”
1) CORRECT – Once the client’s blood glucose level falls below 250 to 300 mg/dL (13.88 to 16.65 mmol/L), 5% dextrose should be added to IV fluids. Therefore, the nurse needs to intervene with this statement.
2) CORRECT – As the client’s blood glucose drops, potassium level will drop. Low serum potassium levels may result from rehydration, increased urinary excretion of potassium, movement of potassium from the extracellular fluids into the cells with insulin administration, and restoration of the cellular sodium-potassium pump. Therefore, the nurse needs to intervene with this statement.
3) CORRECT – The client’s lab results are indicative of diabetic ketoacidosis. In HHS, blood glucose is greater than 600 mg/dL (33.3 mmol/L), pH is greater than 7.30 or normal, serum bicarbonate is greater than 18 mEq/L or normal, and urine ketones absent to small. Therefore, the nurse needs to intervene with this statement.
4) INCORRECT - The nurse does not need to intervene with this statement. The client requires an ECG because myocardial infarction is a possible cause of diabetic ketoacidosis (DKA). The nurse should also monitor cardiac rhythm because of potassium shifts.
5) CORRECT – The client’s blood glucose should be monitored hourly. Therefore, the nurse needs to intervene with this statement.
Based upon the symptoms, the client is experiencing diabetic ketoacidosis, as there are ketones in the urine. Treatment begins with normal saline fluid replacement until the blood glucose level reaches 250 mg/dL (13.9 mmol/L), at which time dextrose is added to the fluid (to avoid the development of cerebral edema) With fluid volume replacement, the client’s potassium level will decline. Potassium replacement will be prescribed. In order to closely monitor the effects of treatment, the blood glucose should be assessed every hour. An electrocardiogram is indicated to closely monitor the effects of an elevated potassium level on the electrical activity of the heart.
Caring for a postoperative client with a brain tumor
Depending upon the location of the brain tumor, the client may demonstrate a change in motor or sensory function or an alteration in vital signs. The nurse is aware that pressure on the brain stem is a complication of brain surgery. Therefore, it is important for the nurse to report the elevated temperature to the health care provider so that the client can be further evaluated.
When caring for a post-operative client with a brain tumor, the nurse should assess for signs and symptoms that indicate damage to different parts of the brain. An appropriate nursing diagnosis is Ineffective cerebral tissue perfusion or Risk of injury. The nurse should assess for and report changes in level of consciousness, abnormal posturing, seizures, and vomiting.
Brain injury or insult will most likely be present. Monitor for altered respiratory patterns and rise in systolic blood pressure. Elevated temperature may indicate brainstem injury. Assess using the Glasgow Coma Scale.
The nurse prepares a toddler-age client for placement of tympanostomy tubes. Which action is most important for the nurse to take?
- Use bright objects to distract the client during the preoperative assessment.
- Allow the client to play with a toy stethoscope before auscultation.
- Demonstrate the use of the stethoscope before auscultation.
- Give choices when possible during the preoperative assessment.
1) INCORRECT— Using bright objects as a distraction is more appropriate for an infant than a toddler.
2) CORRECT— Allowing the toddler to play with a toy stethoscope helps the child become familiar with the equipment. This decreases the fear of an unfamiliar object. The nurse should explain the procedure by saying what the toddler will see, hear, taste, and feel.
3) INCORRECT— Demonstrating the use of a stethoscope is ineffective because of the client’s developmental age. This approach is more appropriate for a preschool-age client.
4) INCORRECT— Giving choices is more appropriate for a school-age client.
A toddler-age client is discovering the environment and is highly curious. When this client is placed in an environment where separation from the parents occurs, it is stressful for the client due to being developmentally unable to handle fear of the unknown. The nurse builds a rapport with the client to help reduce the client’s fears. Providing the client with safe equivalents of the equipment used for care helps reduce the toddler’s fear while supporting curiosity and enhancing feelings of safety. Simple explanations about what the equipment is used for, and how it is used, further increases the client’s comfort.
What to remember about air embolism?
What are at least S/S?
This is a complication of IV therapy and Central venous catheter insertion.
S/S: tachycardia, cyanosis, chest pain and dyspnea, hypotension, decreased LOC, cough, crackles, wheezing,
During the insertion of a central venous catheter, there is a risk that an air embolism may be introduced into the circulation. Because the pulmonary arteries are located on the right side of the heart and the nurse wants to minimize the air occluding the pulmonary arteries, the client exhibiting these signs should be turned onto the left side with the head lowered. Supplemental oxygen should be provided until the symptoms subside.
Placing the client in the left lateral position prevents the air embolism from entering the right atrium and pulmonary artery, which would create a right ventricular outflow obstruction (air lock) and stop the heart. The client should be kept in this position for 20–30 minutes.
If air embolism is suspected, clamp the tubing, turn the client on the left side with the head of the bed lowered (Trendelenburg position) to trap the air in the right atrium and notify the HCP.
An air embolism is an occlusion caused by an air bubble in the pulmonary arteries. During and after insertion of a central venous catheter, the client is at risk for developing an air embolism. Clinical manifestations include dyspnea, chest wall pain, cough, hypoxemia, tachypnea, tachycardia, confusion, hemoptysis, crackles, and wheezing.
Encouraging staff leadership describes the approach of a ___________________–leader.
transformational
What is the expected head circumference of a newborn ?
32-36 cm
If the head circumference is exceptionally large or outside normal parameters, the nurse should suspect that hydrocephalus is occuring
The chest circumference is usually less than the head circumference.
What to remember about the rupture of membranes during labor …………….. shold we ambulate after rupture ?
During the labor process, spontaneous breaking of the amniotic sac is used as an indication of pending delivery. Once this fluid is expelled from the body, the watery cushion supporting the fetus is gone. Should the client be permitted to ambulate once the amniotic fluid is expelled, the uterine structures can shift, increasing the risk of umbilical cord constriction or prolapse. For this very reason, the client should not be permitted to ambulate until after delivery.
Rupture of membranes is a procedure performed by a health care provider to hasten labor progression and can also occur naturally during the progression of labor. The most serious complication of ruptured membranes is a prolapsed cord, so assessment of the cord is priority. After educating the client about the procedure, place the client in a supine position. Perform a sterile vaginal exam and assess that the fetal head is at a station that will minimize cord prolapse. Observe for a prolapsed cord and, if present, intervene immediately by pushing against the presenting part to relieve pressure on the cord and place the client in the Trendelenburg or knee-chest position. Monitor fetal heart rate before, during, and after the procedure. Document the procedure, client tolerance, characteristics of fluid (e.g., color, clarity, odor, amount), and uterine and fetal responses.
Where is the most frequent location for wound dehiscence and evisceration ?
Name at least 4 risk factors that delay wound healing
the Abdomen
Evisceration only occurs with abdominal or thoracic surgical sites, as it entails the protrusion of internal organs from the wound.
Risk factors include the surgical site being in the right lower abdominal quadrant, an existing diagnosis of type 2 diabetes mellitus, and obesity.
Poor blood flow, inadequate nutritional stores of protein or insufficient calories, diabetes, or infection contribute to prolonged wound healing.
Risk factors that delay wound healing include advanced age, arterial or venous insufficiency, obesity, anemia, neuropathy, infection, diabetes mellitus, smoking, and malnutrition.
What to remember about Diabetes insipidus
There is a decrease in the secretion of Antidiuretic hormone by the pituitary, which leads to excessive fluid excretion and dehydration.
Diabetes insipidus (DI), can increase the client’s risk for an elevated sodium level. With DI, fluid is excreted from the body without an adjustment in the body’s sodium level; fluid is lost and sodium is retained.
S/S: excretion of large amounts of dilure urine, decreased urine osmolarity and specific gravity (less than 1.005), increased serum sodium and osmolarity, weight loss, dehydration, hypotension, and tachycardia.
Medical therapy is directed at increasing ADH levels by administration of desmopressin (synthetic form of vasopressin), preventing further dehydration, and promoting fluid and electrolyte balance.
The symptoms of early-stage Alzheimer disease include recent _____________loss and changes in motor activity, such as _______________________-
memory; continuous pacing, wandering, and agitation.
increased muscle tone and rigidity, and shuffling gait are are symptoms of Parkinson disease, rather than Alzheimer disease.
Swallowing usually is easiest with semisolid foods of medium consistency.
TRUE OR FALSE
TRUE
Peanut butter is to be avoided because it is sticky in the mouth and throat, and is difficult to swallow.
The nurse in the neurology unit provides care for the client diagnosed with a stroke with hemiplegia and dysphagia. As discharge approaches, the nurse discusses nutritional planning with the client’s spouse. Which statement by the spouse indicates to the nurse that further teaching is necessary?
- “I will have him sit up for 20 minutes before he eats and for about 1 hour afterward.”
- “Casseroles are one of my favorite things to make, and he loves them.”
- “I will plan to prepare six meals a day rather than our usual three.”
- “A peanut butter sandwich and glass of milk at midday is easy and nutritious.”
View Explanation
1) INCORRECT – Sitting, particularly in high Fowler’s position at 90 degrees, lessens aspiration risk by utilizing the pressure of gravity to pass food through the stomach and into the duodenum. Sitting before a meal allows for a rest period before eating, which helps minimize fatigue, helping the client’s desire to eat and enhancing swallowing efforts. Sitting up afterward helps esophageal motility.
2) INCORRECT – Swallowing usually is easiest with semisolid foods of medium consistency.
3) INCORRECT – Six small meals versus three large ones can increase swallowing-muscle strength and are easier to chew and complete before becoming fatigued.
4) CORRECT – Peanut butter is to be avoided because it is sticky in the mouth and throat, and is difficult to swallow.
What to remember about Licorice
Licorice is an herb that is used as complementary and alternative therapy to treat gastric ulcers and elevated cholesterol levels. However, this herb adversely interacts with potassium chloride and can cause hypokalemia. Licorice also enhances the effects of diuretics and should not be given with furosemide. Licorice has been known to increase the effects of corticosteroids and should not be given with prednisone.
Avoid use with digoxin, loop diuretics and corticosteroids
What to remember about Hypoxia ………
S/S
Treatment
Hypoxia is the state of insufficient oxygen in the cells, tissues, and organs to meet their metabolic demands. Factors that contribute to hypoxia include pain, weakness, disease processes with thickened alveolar membranes, bronchial constriction, excessive mucous production, and obstructed lung tissue.
Signs and symptoms of hypoxia include dyspnea, tachycardia, tachypnea, shallow inhalations, anxiety, restlessness, dizziness, change in mental status, and confusion. The choice of treatment for hypoxia depends on the cause.
Adequate oxygen must be available for gas exchange to occur so supplemental oxygen is expected. Bronchodilators, anti-inflammatory agents, mucolytic agents, and antitussive agents may be prescribed.
A newly admitted client receives a lithium prescription for treatment of bipolar disorder. The client’s serum lithium level is 1.7 mEq/L (1.7 mmol/L). Which action does the nurse take first?
- Administer the next dose on time.
- Increase the client’s oral fluid intake.
- Notify the health care provider.
- Encourage the client to rest.
1) INCORRECT – The level is too high, and the dose should be withheld. The health care provider (HCP) should be notified.
2) INCORRECT – Increasing the client’s fluid intake does not address the issue of the toxic level of medication. Encourage a client taking lithium to drink 2,000 to 3,000 mL of fluid daily and have a moderate sodium intake. Notify the HCP if the client’s serum lithium level exceeds the therapeutic range.
3) CORRECT – The therapeutic range of lithium for initial management is 1 to 1.5 mEq/L (1 to 1.5 mmol/L). Toxic manifestations may occur at levels greater than 1.5 mEq/L (1.5 mmol/L), and the HCP should be notified. Observe for vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, and muscle twitching. The therapeutic range of lithium for maintenance is 0.8 to 1.2 mEq/L (0.8–1.2 mmol/L).
4) INCORRECT – This does not address the issue of a toxic level of the medication. Notify the HCP, and observe for vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, and muscle twitching.
The client’s lithium level is elevated, which should be reported to the health care provider. Increasing oral fluids will not affect the serum blood level of the medication. Administering the next dose of the medication would be malpractice and should not be done. Resting will not decrease the serum level of the medication or prevent the development of symptoms of lithium toxicity.
Lithium is a mood stabilizing agent that stimulates neuronal growth and reduces brain atrophy in people with long-standing mood disorders. Lithium levels are monitored two to three times a week when therapy is initiated. When maintenance dose is achieved, the lithium levels are monitored every 3 months. If the dose of lithium is not well controlled, the client can experience side effects and signs/symptoms associated with toxicity.
Interventions for fever include
promoting comfort (controlling room temperature and applying cool cloth to forehead) and administering prescribed medications such as an antipyretic to reduce fever.
All medication errors require the nurse to notify the health care provider.
TRUE OR FALSE
All medication errors require the nurse to notify the health care provider.
Assessment of a persistent nosebleed
The client experiencing prolonged epistaxis requires assessment to ensure stability of airway, breathing, and circulation (ABCs). Persistent bleeding into the oropharyngeal cavity may compromise airway patency. Further assessment is needed to allow for estimating the client’s blood loss and to determine the presence of circulatory compromise. If the client’s vital signs and respiratory status are stable, the health care provider may attempt a tamponade in an effort to promote hemostasis. A severe nosebleed may be reflective of a serious pathophysiological condition and will require careful assessment.
Complications associated with diabetes mellitus may include :
name at least 4
hypo and hyperglycemia, ketoacidosis, coronary artery disease, hypertension, stroke, peripheral vascular disease, nephropathy, retinopathy, and neuropathy.
After a stroke, The head of the bed should be at a 15- to 20-degree angle
TRUE OR FALSE
TRUE
what to remember about COPD-
Chronic obstructive pulmonary disease (COPD) is a chronic lung disease that includes chronic bronchitis (An airway disease that presents with cough and sputum production for a minimum of 3 months per year for 2 consecutive years) and emphysema (A chronic, progressive disease in which the alveoli become overdistended, resulting in loss of elasticity with eventual destruction) .
Treatment is directed at risk-reduction practices, such as smoking cessation and occupational preventive strategies to reduce inhalation of irritating substances.
Medications to aid in bronchodilation are prescribed and may include short-acting and long-acting bronchodilators and corticosteroids.
Additionally, mucolytics and anticholinergics may be prescribed. Oxygen therapy may be necessary, as well as methods to reduce oxygen demands (e.g., pacing activities, eating small frequent meals, positioning, and pursed lip breathing).
A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse assesses a BP of 162/100 mm Hg, P 78 beats/min, R 30 breaths/min, and labored respiratory effort with wheezing. The nurse questions which prescribed medication?
- Theophylline 0.7 mg/kg/hr continuous IV infusion.
- Tetracycline hydrochloride 250 mg IM daily.
- Ipratropium bromide 2 inhalations four times daily.
- Propranolol hydrochloride 40 mg PO twice daily.
1) INCORRECT - Theophylline is the drug of choice for acute asthma and is administered as an infusion or as a loading dose.
2) INCORRECT - Tetracycline is a broad spectrum antibiotic and is not contraindicated.
3) INCORRECT - Ipratropium bromide blocks parasympathetic stimulation and decreases mucus and is an important medication in COPD and asthma.
4) CORRECT— Propranolol is a beta-blocker, which means it blocks beta adrenergic impulses to the bronchial tree that cause bronchodilation, resulting in increased bronchoconstriction. If the client’s airways are narrowed, the exacerbation will worsen significantly.
Propranolol is a non-selective beta-adrenergic receptor blocking agent. This means it blocks both beta 1 (heart) and 2 (lungs) receptors. Propranolol is contraindicated in cardiogenic shock; sinus bradycardia and greater than first degree heart block; and bronchial asthma. In general, clients with bronchospastic lung disease (e.g., chronic obstructive pulmonary disease [COPD]) should not receive beta blockers. Therefore, the nurse questions this medication prescription. Propranolol should be administered with caution in this setting because it may provoke a bronchoconstriction by blocking bronchodilation produced by endogenous and exogenous catecholamine stimulation of beta receptors.
TRUE OR FALSE
Accurate history taking and documentation of allergies are the first line of defense in preventing unnecessary reactions in medication administration
TRUE
A client experiencing retrosternal chest pain and shortness of breath has a blood pressure of 110/70 mm Hg, an irregular heart rate of 100 beats/min, and a respiratory rate of 28 breaths/min. Which prescription will the nurse implement first?
- Obtain a 12-lead electrocardiogram.
- Administer oxygen per nasal cannula.
- Administer subcutaneous morphine sulfate.
- Implement a fluid and sodium restriction.
1) INCORRECT– A 12-lead electrocardiogram is used to assess the client ’s current heart status. This is not the first action that the nurse should take.
2) CORRECT– Applying oxygen via nasal cannula ensures adequate oxygenation of the cardiac muscle and is a priority.
3) INCORRECT– Morphine sulfate will reduce cardiac preload and afterload and relieve pain. This is the second action that the nurse should take.
4) INCORRECT– A fluid and sodium restriction is a long-term action that will not help alleviate the client ’s current symptoms.
Retrosternal chest pain angina and shortness of breath, tachycardia, and tachypnea suggest acute coronary syndrome (ACS). The nurse’s priority in ACS is to monitor and support ABCs. The priority nursing action is to give the client the prescribed supplemental oxygen. If O 2 saturations are less than 90%, start oxygen at 4 L/min and titrate accordingly. Next, check vital signs and oxygen saturation frequently. Other priorities include establishing IV access; performing a brief, targeted history and physical exam; reviewing the fibrinolytic checklist; obtaining initial cardiac marker levels, electrolyte and coagulation studies; and obtaining a portable chest X-ray.
Content Refresher
The nurse should assess the client who is experiencing chest pain, or angina, using the “PQRST ” mnemonic to collect information including: Precipitating events (what the client was doing when the pain, discomfort, or symptoms started); Quality (what the pain feels like); Radiation (location of the pain and whether it radiates to any other areas); Severity (pain rating using a 0-to-10 scale, with 0 being no pain and 10 being the worst imaginable pain); Timing (onset of symptoms).
Priority interventions include promoting adequate oxygenation and administering supplemental oxygen as prescribed. Administer prescribed medications, which may include nitrates, clotting inhibitors, anti-hypertensive agents, lipid-lowering agents, morphine, and thrombolytic agents.
What are the different levels of health promotion?
One role of the nurse is to provide health promotion and disease prevention teaching. Prior to this teaching, the nurse should recall the different levels of prevention. Primary prevention includes activities to prevent the development of disease. This would include making lifestyle adjustments such as increasing daily exercise. Secondary prevention includes activities to detect and then treat disease. Tertiary prevention includes activities to recover from disease. In this scenario, the nurse is endorsing the use of exercise facilities as a primary prevention action.
Content Refresher
Health promotion refers to the process of enabling people to increase control over, and to improve, their health. Sedentary lifestyle, poor nutrition, family history, obesity, smoking, secondhand smoke, high levels of stress, high total cholesterol, and hypertension are risk factors for illness. Primary prevention refers to measures such as diet, proper exercise, and immunizations to prevent the occurrence of a specific disease.
Secondary prevention refers to early detection of disease that can lead to interventions to prevent disease progression (e.g., biometric screening, physical examination, eye examinations, mammogram).
Tertiary prevention refers to activities that limit disease progression, such as rehabilitation.
Combining regular insulin and NPH or intermediate acting insulin- what is the correct procedure
If insulins are to be mixed, the regular or short-acting insulin should be withdrawn first and then the NPH or intermediate-acting insulin second.
Combining two types of insulin in one syringe preserves the subcutaneous tissue for future injection sites. Using aseptic technique, the nurse first injects air into the NPH vial. The amount of air should be equal to the prescribed dose of NPH insulin. The air should be injected into the NPH vial without drawing up or touching the needle to the insulin. The nurse then removes the needle from the NPH vial. Next, the nurse injects air (equal to the prescribed dose of regular insulin) into the regular insulin vial. The nurse then withdraws the prescribed dose of regular insulin. Using aseptic technique, the nurse then reinserts the needle into the NPH insulin vial, withdraws the prescribed dose, and withdraws the needle. Accuracy is essential. The nurse will teach the procedure and have the client demonstrate the skill.
The nurse prepares a client newly diagnosed with diabetes mellitus (DM) for discharge. The client is on a regimen of regular and NPH insulin. Which statement made by the client indicates that teaching is successful?
- “I will take the bottles out of the refrigerator and shake them thoroughly before I withdraw the medication.”
- “I will use the same types and sources of insulin, but I will stock up on whatever insulin syringes I can find on sale.”
- “If I see that the injection site becomes red, itchy, and swollen, I will contact the health care provider immediately.”
- “I will put a piece of tape with a ‘1’ on it on the regular insulin bottle and a piece of tape with a ‘2’ on it on the NPH insulin bottle.”
1) INCORRECT– Regular insulin bottles do not need to be manipulated. NPH insulin bottles should not be shaken but gently rolled in the palms of the hands to warm the insulin and to resuspend or mix the insulin.
2) INCORRECT– The client should use the same insulin types and sources, because changing insulins may affect blood glucose control. Serious changes in blood glucose control can also occur due to inaccurate measurement of insulin caused by manufacturing variations of the syringes; therefore, the client should use the same type of insulin syringe.
3) INCORRECT– Redness, itching, and swelling at the injection site indicate a localized reaction. For localized insulin reactions, spontaneous desensitization usually occurs in a few weeks. If local irritation persists or is severe, the client contacts the health care provider (HCP).
4) CORRECT– If insulins are to be mixed, the regular or short-acting insulin should be withdrawn first and then the NPH or intermediate-acting insulin second. Writing ‘1’ and ‘2’ on the bottles will remind the client of the order in which the insulins should be withdrawn.
What to remember about physiological jaundice
Physiological jaundice is caused by immature hepatic function and occurs after 24 hours, peaks at 72 hours, and lasts 5–7 days.
Physiologic jaundice occurs in a newborn when the immature liver cannot clear broken down red blood cells, bilirubin accumulates in the blood, and consequently the skin and sclera turn the characteristic yellow color associated with jaundice. Although the parent may become alarmed by this condition, it typically resolves within a week.
Physiological jaundice occurs normally in many newborns 2 to 4 days after birth. Jaundice results when the newborn’s immature liver cannot process efficiently the unconjugated bilirubin.
If the neonate cannot eliminate bilirubin efficiently from the body, the serum level rises placing the neonate at risk for a form of neurotoxicity, known as kernicterus. As the serum level rises, the skin becomes saturated with bilirubin, causing the characteristic yellow coloration of the skin and sclera.
What to remember in a situation where the client is experiencing acute shortnesss of breath
Remember, “When in distress, do not assess.”
Acute shortness of breath can be scary for the client and requires quick action by the nurse. The client’s condition involves nursing action to promote respiratory function. The nurse should understand that during some emergent situations, the nursing process does not apply. Actions to maximize respiratory effort are the priority and include raising the head of the bed and applying oxygen. The nurse can then assess the client further by auscultating lung sounds and measuring oxygenation with pulse oximetry. After the assessment, the health care provider should be notified for additional evaluation and intervention.
Content Refresher
When ventilatory effort is diminished (due to pain or weakness), adequate oxygen is not taken into the lungs and limits the amount that is available for gas exchange at the alveolar level. When caring for a client experiencing symptoms of respiratory distress, the nurse needs to position the client in a way that facilitates lung expansion and supplemental oxygen should be administered at the prescribed rate and method. Monitor the client’s breathing pattern and report symptoms as needed. Failure to respond immediately and appropriately can cause complications related to compromised respiratory function or respiratory arrest.
When prioritizing medication administration, consider the _______________ of the medication, the _________, and the client ____________. Antiseizure medications need to be maintained at a ____________blood level and should be provided first. Intravenous antibiotics also require a constant blood level. However, for client safety, antiseizure medication should be provided first.
purpose; half-life; condition; constant
Half life of hydrochlorothiazide
Half life of Digoxin
Digoxin has a half life of 36-48 hours
Hydrochlorothiazide has a half-life of 6 to 15 hours.
The nurse provides care for a client who delivered a neonate at 30 weeks’ gestation. The client has one child at home who was delivered at 41 weeks. The client has had two abortions, one spontaneous at 7 weeks’ gestation, and one induced at 9 weeks’ gestation. Which number, using the 5-digit system, should the nurse record as the client’s gravidity and parity?
GTPAL
Gravidity Term Preterm Abortion Living
41122
The first digit of the 5-digit system accounts for the number of times the uterus has been pregnant. The second digit represents the number of term deliveries, whereas the third digit represents the number of preterm deliveries. The fourth digit accounts for the number of abortions, either spontaneous or induced, and the fifth digit represents the number of living children. This is the correct number to record because the client had 4 pregnancies, 1 term delivery, 1 preterm delivery, 2 abortions, and 2 living childre
What is Gout ?
Name 3 medications that would be used for gout
A form of arthritis characterized by severe pain, redness, and tenderness in joints.
Pain and inflammation occur when too much uric acid crystallizes and deposits in the joints.
Symptoms of gout include severe pain, redness, and swelling in joints, often the big toe. Attacks can come suddenly, often at night.
Allopurinol, Colchicine, Probenecid
all reduce uric acid production and increase uric acid secretion
Antigout medications should be used cautiously with GI, renal, cardiac or hepatic disease
Name 3 medication risk factors for Peptic ulcer disease
and 3 lifestyle factors
Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, anticoagulants, and selective serotonin reuptake inhibitors (SSRIs) increase the risk for developing PUD. Lifestyle factors, such as smoking, alcohol consumption, and stress also can contribute to the development of PUD.
Manifestations of Pancreatic cancer
Clients diagnosed with pancreatic cancer commonly report abdominal pain, itching, anorexia, and nausea. Rapid and progressive weight loss, jaundice, bleeding from body orifices and mucous membranes, and extreme, unrelenting pain as the disease extends into the retroperitoneal tissue and nerve plexuses may be present. Explain procedures and provide pain management. Provide emotional support, seek ways to stimulate appetite, and administer pancreatic enzymes. Offer frequent and supplemental feedings. Manage nausea and vomiting with antiemetics.
Nutrition and hydration are a major focus for clients with pancreatic cancer, partly because anorexia is a common symptom and because keeping the client NPO is part of acute management. The nurse expects to collaborate with the dietitian to recommend appropriate nutritional adjustments. In severe cases of acute pancreatitis, the client may receive jejunostomy feedings or total parenteral nutrition (TPN). The nurse should monitor the client’s laboratory test results including serum electrolytes, albumin, and complete blood count (CBC). The nurse should monitor the client’s weight as well.
What to remember about shock ?
Shock is defined as inadequate tissue and organ perfusion as a result of inadequate blood volume or inability to circulate blood. Types of shock include hypovolemic, cardiogenic, neurogenic, anaphylactic, and septic. Irreversible organ damage can occur if shock is not diagnosed quickly. Signs and symptoms include hypotension; cool, pale skin; decreasing urinary output; tachycardia; restlessness; hypoxia; tachypnea; dyspnea; and respiratory and metabolic acidosis. Diagnostic testing may include complete blood count, blood cultures, procalcitonin level, arterial blood gases, lactic acid level, chest x-ray, electrocardiogram, and hemodynamic monitoring. Treatment depends on the type of shock that the client is experiencing. Septic shock is treated with antibiotics and fluid replacement.
What to remember about Parkinson disease
In Parkinson disease (PD), pathological changes result in a reduction in dopamine in the basal ganglia with an associated increase in acetylcholine, an excitatory neurotransmitter. Progressive motor dysfunction occurs as a result of this imbalance. There is no cure for PD. Physical, occupational, and speech therapy should be part of the interdisciplinary team. A number of medications such as carbidopa/levodopa can reduce the effects of PD, especially when treatment begins at the earliest opportunity. For severe PD, surgical implantation of a nerve stimulator may be warranted. Stem cell implantation is currently being tested. Coping strategies, proper nutrition, and adequate rest can promote health.
Carbidopa/levodopa is used to improve muscle rigidity and bradykinesis caused by Parkinson disease. An improvement in movement indicates the medication is effective. It may also improve tremors associated with the disease.
Insufficient oxygen in the cells, tissues, and organs to meet metabolic demands. There is a direct correlation with hypoxemia, which is a reduction of oxygen levels in the blood.
HYPOXIA
Intubation is performed when the client is at risk for hypoxia
Adequate oxygen must be available for gas exchange to occur
The nurse provides care for a client who has just been intubated in preparation for mechanical ventilation. Which action does the nurse take next?
- Assess lung sounds.
- Call for a stat x-ray.
- Obtain arterial blood gases.
- Suction the endotracheal tube.
1) CORRECT— The priority is to assess for bilateral lung sounds and bilateral chest excursions. Always assess before implementing.
2) INCORRECT - A chest x-ray is obtained for radiographic confirmation after an initial verification of placement by auscultation.
3) INCORRECT - Arterial blood gases will not demonstrate meaningful change until the client is ventilated. Without needed ventilation, ABG values will continue to deteriorate.
4) INCORRECT - The nurse ensures the tube is providing an adequate airway and then suctions secretions from the tube if needed.
Think Like A Nurse: Clinical Decision Making
The priority is to verify proper placement of the endotracheal (ET) tube immediately after intubation. The most reliable method is to obtain a chest radiography to verify placement of the ET tube. While waiting for the chest x-ray, the nurse can listen for bilateral breath sounds and adequate air entry. Quantitative waveform capnography (monitoring the partial pressure of carbon dioxide CO 2) can also be obtained if the equipment is available.
Four clients arrive in the emergency department within a 5-minute period. Which client does the nurse see first?
- A client, pale and diaphoretic, who reports sudden and severe pain radiating from the flank to the scrotum.
- A client with right lower quadrant abdominal pain of 24 hours’ duration and which is relieved by flexing the legs.
- A client, jaundiced and nauseated, who reports pain in the right shoulder and has a temperature of 100°F (37.8°C).
- A client with sudden epigastric pain and nausea who is vomiting blood and has an odor of alcohol on the breath.
1) INCORRECT— The client is experiencing symptoms of kidney pain, which may be due to pyelonephritis or renal calculi (kidney stones). The client requires quick attention to diagnose and manage the pain, but there is another client who requires priority attention.
2) INCORRECT— The client is experiencing symptoms of probable appendicitis. The client will need to be assessed and prepared for diagnostic testing. But another client requires priority attention.
3) INCORRECT— The client is experiencing symptoms of chronic cholecystitis. Insidious symptoms may occur with this disorder, resulting in the client not seeking medical help until late symptoms appear, such as jaundice, dark urine and clay-colored stools. The client requires further assessment and preparation for diagnostic testing. But another client requires priority attention.
4) CORRECT — The client is experiencing symptoms of acute gastritis or ruptured esophageal varices related to excessive alcohol intake. This client is vomiting blood and is at risk for hypovolemic shock and aspiration of blood. This client should be seen and stabilized first.
The client who is vomiting blood has a current circulatory risk and is the priority. The symptoms of right lower quadrant abdominal pain that is relieved with flexing of the knees is characteristic of appendicitis. Although this client should be assessed soon to ensure that the appendix does not rupture, the client who is actively bleeding is the priority.
Content Refresher
The client with esophageal varices may experience hypovolemic shock. Signs and symptoms of impending shock include hypotension, cool and pale skin, decreasing urinary output, tachycardia, restlessness, hypoxia, tachypnea, and dyspnea. Clients with shock who are successfully diagnosed early and treated can recover without complications. Management of shock requires diligent assessment and prompt treatment.
What to remember about ventricular tachycardia
Treatment of ventricular tachycardia with a pulse requires treatment of reversible causes. The nurse prepares for possible synchronized cardioversion. The client might require sedation prior to the procedure. The client’s hemodynamic status should be monitored closely while promoting airway patency. The nurse is expected to draw a serum metabolic profile to verify if electrolyte imbalances caused the ventricular tachycardia. If the client becomes pulseless, the cardiac arrest team should be summoned (e.g., “call a code”).
Content Refresher
Ventricular tachycardia (VT) is characterized by a run of three or more consecutive premature ventricular complexes (PVCs). During an episode of VT, the ventricles take control as the pacemaker of the heart maintaining a ventricular rate of 150 to 250 beats/min. P waves are usually not visible, and the rhythm may be regular or irregular. If the client has a pulse, IV drugs (e.g., procainamide, sotalol, or amiodarone) are prescribed. If drugs are ineffective, synchronized cardioversion is prescribed. If the client does not have a pulse, administer cardiopulmonary resuscitation (CPR) and prepare for rapid defibrillation.
What to remember about Addisons disease ?
In this disease process, there is a lack of glucocorticoids in the body, which need to be replaced. The glucocorticoids deficiency causes the sodium and glucose level to be low and the potassium level to be elevated.
In Addison disease, the outer cortex of the adrenal glands are slowly destroyed, most often as a result of the development of antibodies against the cells of the adrenal cortex. As plasma cortisol is reduced, there is an accompanying increase in the secretion of adrenocorticotropic hormone (ACTH) from the pituitary. When aldosterone is deficient, sodium and water are lost and hypotension and tachycardia occur. In most cases, symptoms appear when about 90% of the functional capacity of the adrenal cortex has been lost. They include progressive fatigue and weakness, muscle spasm, irritability and depression, confusion, tremors, nausea, and a craving for salty foods. Other signs include postural hypotension, tachycardia, weight loss, and tanned or darkened skin not associated with sun exposure. Ensure the client/family know how to prevent, recognize, and obtain treatment for Addisonian crisis.
