QB 7

Question 1

What to remember about heparing subcutaneous injections

Answer 1

Subcutaneous injection sites include the abdomen, thigh, upper arm, and lower lateral back. However, the lower lateral back is less preferred and not an option for thin clients. Subcutaneous injections commonly contain 1 mL of solution (as the prescribed heparin dose), but up to 2 mL can be safely administered by this route.

The nurse should use a 25- to 27-gauge 3/8- to 5/8-inch needle

Don’t massage the area or aspirate the needle as this can cause bruising

Heparin, an anticoagulant, can be administered subcutaneously or intravenously. The subcutaneous route is prescribed for thromboprophylaxis. With this route, alternate sites are selected every 12 hours (e.g., right side of abdomen for morning, left side of abdomen for evening). Monitor the client ’s vital signs and monitor for signs and symptoms of bleeding, such as bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools, hematuria, or hematemesis.

Question 2

What to remember about urinary tract infections

Answer 2

Symptoms commonly reported are dysuria, frequency and urgency.

Urinary tract infections (UTIs) usually begin in the perineum and progress up the urethra and into the bladder. Inflammation occurs and as a result the infection can spread further into the ureters and into the renal parenchyma. Fluid intake is encouraged. Broad-spectrum antibiotics, such as ampicillin or vancomycin, combined with an aminoglycoside are used initially. Bacterial specific antibiotics are used when pathogen is identified. In severe cases hospitalization may be required. If the UTI is related to blockage, surgery may be necessary.

Fluids initially will help flush the system and may relieve some discomfort.

Question 3

What to remember about hemophilia ….

what deformity can occur

Answer 3

With hemophilia, the most frequent site of bleeding is into muscles and joints. Repeated bleeding episodes cause changes in bone and muscles, which can lead to crippling knee and joint deformities.

The knee is the most frequent joint that can bleed in a client with hemophilia. Chronic bleeding causes joint deformity and alters the ability to ambulate and maintain independence

Hemophilia is a medical condition in which the ability of the blood to clot is severely reduced, causing the client to bleed severely from even a slight injury. Complications associated with hemophilia include excessive internal bleeding, damage to joints, infection, and adverse reaction to clotting factor.

Question 4

NCLEX therapeutic response questions:

The nurse’s most important role is not to validate or deny the client’s feelings, but to offer a solution that will positively impact those feelings.

TRUE OR FALSE

Answer 4

TRUE

Question 5

Guidelines for providing IV therapy

Answer 5

When providing intravenous (IV) therapy, the nurse should: Select the prescribed solution and determine the appropriate equipment based on central or peripheral line access, intent of therapy, and intended duration of therapy. Aseptic technique should be used when accessing and managing the IV site and equipment. Maintain the infusion rate as prescribed and check the infusion and infusion equipment hourly. Monitor the client for the effectiveness and potential complications. The nurse will follow the agency policy for the care of the IV site and protocol for changes in the infusion set.

Question 6

What to remember bout anti-embolism stockings, specifically as it relates to sizing

Answer 6

Anti-embolism stockings are elastic stockings that compress the veins in the legs, facilitating return of venous blood to the heart. Applying the anti-embolism stockings before surgery is a measure to prevent the formation of blood clots in the lower legs from inactivity and immobilization. Before applying the stockings, the nurse must first obtain stockings in the appropriate size and length. A tape measure is necessary to determine the correct size.

Anti-embolitic stockings are available in either knee-length or thigh-length. Before obtaining a pair of stockings, the client’s legs are measured to ensure an appropriate fit. For knee-length stockings, the nurse should measure the calf circumference at the widest point as well as determining the length from heel to popliteal space. For thigh-length stockings, the nurse should measure the calf circumference at the widest point as well as determining the length from heel to gluteal fold. The nurse must perform these measurements to determine the proper size for stockings prior to delegating this task to the unlicensed assistive personnel (UAP). It is outside the scope of practice for the UAP to assess the client to determine which size stocking is required.

Question 7

What to remember about fiber and hypercholesterolemia

Answer 7

Increasing fiber in the diet can reduce cholesterol levels by up to 10%.

Atorvastatin is an anti-cholesterol medication, which is used to reduce the amount of lipids in the blood. However, the nurse is aware that medication is only one factor in the management of hyperlipidemia. To maximize the client’s therapeutic response to the medication and aid in the promotion of this client’s health, the nurse should introduce other actions the client can take to reduce blood lipid levels. One such way is to increase the amount of fiber in the diet, since fiber binds with ingested fat and helps eliminate the fat from the body before it is metabolized.

Question 8

What to remember about cholesterol levels

Answer 8

High cholesterol is diagnosed by a blood level of greater than 200 mg/dL (5.2 mmol/L). High density lipoprotein (HDL) levels should be greater than 40 mg/dL (1 mmol/L) for males and 50 mg/dL (1.3 mmol/L) for females. Low density lipoprotein (LDL) levels should be less than 100 mg/dL (2.6 mmol/L) or 70 mg/dL (1.8 mmol/L) for very high risk clients. Triglyceride levels should be less than 150 mg/dL (1.7 mmol/L). Treatment includes the use of cholesterol lowering agents such as atorvastatin. Treatment also includes dietary management, in which the total fat ingested represents 25% to 35% of total calories and dietary fiber is increased. Weight reduction and physical activity can help lower cholesterol levels.

Question 9

What are the 3 levels of health prevention ?

Answer 9

Primary prevention activities promote health and protect against exposure to risk factors that lead to health problems (e.g., immunization). Secondary prevention focuses on activities to stop or slow the progression of disease (e.g., annual screening test). Tertiary prevention includes actions to prevent the progression of negative consequences of chronic conditions, reduce disability, and minimize suffering, as well as preventing complications and deterioration (e.g., cardiac rehabilitation). Before teaching, the nurse should first assess the client ’s baseline knowledge. The teach-back method is used to verify the client ’s understanding. The nurse assesses a client ’s risk and then screens the client for the condition.

Content Refresher

Primary prevention includes activities that promote health and prevent illness, such as nutritious diet, proper exercise, and immunizations. Secondary prevention includes identifying health issues at the earliest opportunity, along with preventing complications, such as biometric screening, physical examination, eye examinations, and mammograms. Tertiary prevention focuses on restoring individuals, families, or communities to their highest level of functioning, such as providing rehabilitation services. Assist clients in identifying specific health risks . Help clients set realistic health goals. Teach about illness prevention specific to the identified individual ’s health risks. Provide support to promote behavior changes.

Question 10

What to remember about Pentamidine and Pneumocystis Jiroveci Pneumonia

Answer 10

Pentamidine is an anti-protozoal agent used to prevent or treat Pneumocystis jiroveci pneumonia, a common opportunistic infection in immunocompromised clients.

The manifestations usually include coughing, fever, dyspnea, fatigue, and weight loss, and crackles are heard in the lungs.

Pneumocystis jiroveci pneumonia (PJP), which was previously known as Pneumocystis carinii pneumonia (PCP), is the most common opportunistic infection among individuals diagnosed with HIV. This form of pneumonia may be lethal and does not respond to typical antifungal treatment. Pentamidine is administered as a nebulized or injectable medication. In the absence of other disease complications, therapeutic effects of pentamidine include decreased work of breathing, resolution of fever, diminishing cough, normalization of heart rate, and reduction or absence of pulmonary crackles or rhonchi. Pentamidine is associated with severe side effects, such as thrombocytopenia and leukemia.

Question 11

What to remember about the age toilet training begins

Answer 11

Voluntary control over sphincters is achieved at 18 to 24 months.

Pediatric clients are not ready for toilet training until several developmental capabilities are achieved. These capabilities include standing and walking well, pulling pants up and down, recognizing the need to eliminate, and being able to wait until reaching the bathroom. The pediatric client typically achieves these capabilities during the toddler stage of development

Micturition (voiding) is a voluntary act. The bladder has sensory fibers to help with cognitive recognition of the need to void, and bladder detrusor muscles and sphincters allow control over urine elimination. In addition, the parasympathetic nervous system helps to transmit the signal for voiding from the bladder to the brain. Most children are ready to start toilet training during the late toddler stage of development.

Question 12

What to remember about the procedure for when a client dies

Answer 12

The staff’s priority is to provide care for the deceased client and family.

The nurse needs to mentally ask, “How can the family’s visit be made more pleasant?” The answer is to make the client’s appearance to appear peaceful, and the environment as medically neutral as possible. The nursing staff should be focused on preparing the deceased client by performing post mortem care. The client should have a fresh gown, clean linen, and have any tubes or devices removed. If the client is having an autopsy, tubes and devices will not be removed. Hair should be combed, dentures inserted, and a pillow placed under the head. A soft light should be on in the client’s room. Medical equipment should be removed whenever possible. Chairs should be placed around the client’s bed and disposable tissues should be available.

Question 13

What to remember about glycerin mouthwash

Answer 13

A mouthwash with glycerin causes dehydration and irritation of the oral tissues. The nurse should intervene and provide the UAP and client with a non-glycerin mouthwash.

Glycerin swabs or mouthwash dehydrate oral tissues, leading to breakdown in the mucous membranes. The UAP should be directed to use agents that are non-irritating and non-drying when assisting a client with mouth care.

Question 14

What to remember about Carbamezapine and anesthesia

Answer 14

Carbamazepine can lead to markedly reduced duration of activity of the aminosteroidal muscle relaxants, particularly those that are primarily excreted via the liver (e.g., vecuronium and pancuronium). The amount of muscle relaxants should be reduced when the client is also taking carbamazepine. Ongoing teaching would also include reminding the client that grapefruit and grapefruit juice may increase the effects of carbamazepine by increasing the amount of the medication in the body.

Question 15

What to remember about client confidentiality

Answer 15

Confidentiality is described as a right whereby client information may be shared only with those involved in the care of the client, or with persons identified by the client. Discussing a client’s condition with someone not directly involved in the client’s care (as well as discussing protected health information in a public area) violates client confidentiality. Confidentiality is one element of fidelity that is based on traditional healthcare professional ethics. Violation of the security and privacy rules of HIPPA (Health Insurance Portability and Accountability Act of 1996) has serious consequences for staff and clients. The nurse must always consider the actions necessary to protect the client’s information and privacy.

Content Refresher

Confidentiality is the right of a client to have personal, identifiable medical information kept private. Unless otherwise instructed to do so by the client, nurses do not discuss or share information regarding client care or diagnosis with family, friends, coworkers, other nurses, insurance providers, or financial aid organizations. The nurse should hold self and colleagues accountable when it comes to respecting client privacy. Provide the client and family written and verbal information about the protection of privacy and personal health information in the clinical setting.

Question 16

What to remember about Gabapentin

Answer 16

Gabapentin is an anticonvulsant medication.

Gabapentin is a gamma-aminobutyric acid (GABA) neurotransmitter analog that interacts with GABA cortical neurons. It is classified as an antiseizure medication that is used off-label to manage neuropathic pain and postherpetic neuralgia (Pain along the course of a nerve, which can be caused by pressure, toxins, or inflammation) . Fatigue is an expected side effect of this medication. To maximize effectiveness, gabapentin is prescribed to be given in three divided doses each day.

Question 17

What to remembera about anaphylaxis

Answer 17

A vaccination is used to immunize against a specific antigen. Some people may have an unknown allergy to the vaccine and develop symptoms of anaphylaxis, which include airway swelling, rapid heart rate, feeling of impending doom, and low blood pressure as a sign of developing shock.

Content Refresher

Anaphylaxis is an immediate reaction to an antigen within minutes of exposure. Clinical manifestations include erythema, urticaria, angioedema, pruritus, wheals, wheezing, bronchospasms, stridor, hypotension, tachycardia, and arrhythmias.

Question 18

The nurse administers an immunization to an adult client. Which observations made after the injection cause the nurse to immediately intervene? (Select all that apply.)

1. The client is clearing the throat and coughing.
2. The client has nasal drainage and sneezing.
3. The client is anxious and exhibits rapid breathing.
4. The client is feverish and sweating profusely.
5. The client reports dizziness upon standing.
6. The client has a diffuse rash across the trunk.

Answer 18

1) CORRECT – An anaphylactic reaction may begin with the client clearing the throat and coughing due to swelling in the airway. The nurse should assess the client for other signs of anaphylaxis and be prepared to intervene.
2) INCORRECT - These symptoms are indicative of an atopic reaction, and they do not require immediate intervention by the nurse.
3) CORRECT – Tachypnea and feelings of impending doom occur with anaphylaxis. This client needs immediate assessment and care.
4) INCORRECT - These symptoms are indicative of a febrile illness, not anaphylaxis. Although this client is ill, the client does not require immediate assessment by the nurse.
5) CORRECT – Dizziness upon standing may be indicative of hypotension, which occurs with anaphylaxis and shock. The nurse should immediately assess this client’s vital signs.
6) INCORRECT - A diffuse rash is not indicative of anaphylaxis and does not begin immediately after injection when it is related to the medication. This client does not require immediate assessment by the nurse.

A vaccination is used to immunize against a specific antigen. Some people may have an unknown allergy to the vaccine and develop symptoms of anaphylaxis, which include airway swelling, rapid heart rate, feeling of impending doom, and low blood pressure as a sign of developing shock.

Question 19

What to remember about Metoclopramide

Answer 19

The Federal Drug Administration (FDA) has ordered a “black box” warning for medications that contain metoclopramide. Tardive dyskinesia (TD) can occur if a client takes metoclopramide in high doses, takes the medication long-term, and even after the medication has been stopped. Signs of TD include involuntary and repetitive movements of the extremities, grimacing, impaired movement of the fingers, lip smacking, puckering, pursing of the lips, rapid eye movements or blinking, and tongue protrusion.

Signs and symptoms of TD include involuntary movements of the face, arms, and legs.

Question 20

Any instance of medication administration that does not adhere to the prescription is a medication error.

TRUE OR FALSE

Answer 20

TRUE

The error needs to be documented on an occurrence report (also known as an incident report) and the health care provider notified. Changing the prescription in any way is outside of the scope of nursing practice and must not be done.

Question 21

What medication class is aminophylline ?

Answer 21

Aminophylline belongs to a group of medicines known as bronchodilators. Bronchodilators are medicines that relax the muscles in the bronchial tubes (air passages) of the lungs. They relieve cough, wheezing, shortness of breath, and troubled breathing by increasing the flow of air through the bronchial tubes

tachycardia and anxiety are adverse effects of aminophylline.

Question 22

What to remember about renal biopsy

Complications, Contraindications, Postoperative Procedures

Answer 22

Prior to kidney biopsy, the nurse follows a pre-procedure checklist to review the client’s medical surgical history, coagulation status (e.g., prothrombin time, international normalized ratio, partial thromboplastin time), complete blood count, and metabolic profile. The nurse should also monitor that anticoagulants and antiplatelet drugs (e.g., aspirin or warfarin) were discontinued 2 to 3 days before the procedure in order to decrease the possibility of post-procedure bleeding. Because a renal biopsy involves obtaining kidney tissue by puncture with a large bore needle, the nurse is aware that bleeding is a possible complication. Pain starting at the procedure site and radiating to the flank area and around to the front indicates bleeding.

Following renal biopsy, a pressure dressing may be applied on the affected side for 30 to 60 minutes, and the client is placed on bed rest. Vital signs are monitored frequently according to protocol.

Content Refresher

After a renal biopsy, apply a pressure dressing and have the client lie on the affected side for 30 to 60 minutes. The client should remain on bed rest for 24 hours. Postoperatively, monitor vital signs every 5 to 10 minutes for the first hour. Inspect the biopsy site for bleeding. Instruct the client to avoid heavy lifting for 5 to 7 days and not to take anticoagulant medications until instructed to do so by the health care provider. Absolute contraindications for a renal biopsy include bleeding disorders, only one kidney, and uncontrolled hypertension.

Question 23

What to remember about myelomeningocele

Answer 23

For a client with a myelomeningocele, the prone position prevents pressure on the sac-like protrusion on the back. Placing pressure on this area would result in increased intracranial pressure or it may rupture the sac, leading to an infection. The area should be covered with a moist sterile dressing.

The spinal cord is normally protected by surrounding bone, which prevents spinal cord injury. In the case of myelomeningocele, the client is at risk for exposure of the spinal cord, which is protected only by a thin, fragile membrane. For the neonate diagnosed with myelomeningocele, key interventions are aimed at preventing irritation and damage of the sac that contains the spinal cord. Impaired integrity of the sac may lead to cerebrospinal fluid leakage, which requires emergent surgical intervention. Complications related to exposure of the spinal cord to a nonsterile environment include infection and death.

Content Refresher

Myelomeningocele, also known as a severe form of spina bifida, is a malformation of the neural tube in which a pouch protrudes through the vertebrae. The protruding pouch contains a section of the spinal cord along with cerebrospinal fluid. Risk factors for myelomeningocele include a possible genetic link and intrauterine exposure to some seizure and acne medications or alcohol. Risk factors for development of myelomeningocele include maternal history of poor folic acid intake, diabetes mellitus, or obesity during pregnancy. Assess the neonate for neurological and motor deficits. Assess urinary and bowel elimination (urinary catheterizations may be needed). Closely monitor vital signs and respiratory status.

Question 24

An anaphylactic reaction can impact the client’s airway

TRUE OR FALSE

Answer 24

TRUE

Question 25

normal aPTT levels

Answer 25

The lower limit of normal is 20 to 25 seconds. The upper limit of normal is 32 to 39 seconds.

Therapeutic levels increase the aPTT 1.5 to 2 times the control value. The nurse should give the medication.

Question 26

Non-pharmacologic interventions should not be used as a first resort for treatment of the client who experiences moderate to severe pain.

TRUE OR FALSE

Answer 26

TRUE

Instead, non-pharmacologic interventions should be implemented as adjuncts when pain medication does not fully alleviate pain or while waiting for pain medication to take effect. Ultimately, if the client’s pain is not relieved by a prescribed analgesic regimen, the nurse strongly advocates for a safe, evidence-based increase in the medication dosage amount or frequency of administration. While mild pain or discomfort may be effectively relieved by way of non-pharmacologic interventions, for moderate to severe pain, adequate pharmacologic treatment is essential.

Question 27

Talk about pain - what is it, what manifestations can there be in the client experiencing pain and what interventions are available

Answer 27

Pain is an unpleasant feeling conveyed to the brain by sensory neurons in response to injury, disease, and actual or potential tissue damage. The client who experiences pain may exhibit increased blood pressure, rapid respirations, increased perspiration, increased muscle tension, increased neuromuscular activity, nausea, vomiting, and irritability. Treatment for pain includes medications, relaxation techniques, meditation, yoga, distraction, guided imagery, herbal remedies, biofeedback, acupuncture, heat or cold applications, therapeutic touch, massage, and hypnosis. Surgical intervention may be indicated, depending on the underlying cause of pain.

Question 28

What to remember about acetaminophen and toxicity

Answer 28

Acetaminophen is potentially toxic to the liver in doses that exceed recommendations. Adults should have no more than 4000 mg per day. For the pediatric client, acetaminophen is dosed based on weight and should not exceed five doses in a 24-hour period.

When the pediatric client comes in having recently had a dose of acetaminophen, the next dose should be administered 4 to 6 hours after the reported time of the last dose. If the time of the last dose is uncertain, the medication amount was incorrect or uncertain, and the child needs a fever or pain reducer, the nurse advocates to the health care provider for an alternate medication, such as ibuprofen.

Question 29

What to remember about shock

Answer 29

Shocki s 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. 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.

Question 30

Proper surgical hand scrub is essential to reduce the risk of infections.

What is the correct order to wash hands preoperatively ?

Answer 30

The first step is to remove all jewelry for thorough skin cleaning. Items such as rings present a serious infection risk and cannot be cleaned thoroughly enough to be considered safe. Second, turn on the water using knee or foot controls to eliminate re-contamination of hands. Third, remove debris from under finger nails. Artificial nails are not permitted. Next, apply the antimicrobial scrub agent to the hands and forearms with a soft sponge, and then scrub for 3 to 5 minutes using gentle friction to reduce contaminants. Finally, rinse the hands and forearms, holding the hands above the forearms to prevent water from running back onto cleaned hands.

Question 31

A closed head injury, usually caused by trauma, can lead to increased_____________- pressure. As swelling increases, cerebral blood flow is reduced and ________occurs. The body attempts to compensate by raising the ______________. However, as the condition progresses, the body loses its ability to autoregulate and the edematous mass causes increased pressure. Intracranial pressure can also be raised by an elevation in carbon dioxide levels, as well as a decrease in venous outflow. Use the ______________to assess level of consciousness. The client may have ____________________________(known as the Cushing triad). The client may also have an unequal pupil response, weakness, slow or slurred speech, and seizures.

Answer 31

intracranial; ischemia; blood pressure; Glasgow Coma Scale; bradycardia, hypertension with a widened pulse pressure, and irregular breathing

Question 32

The intensive care unit (ICU) nurse receives a phone call stating a client diagnosed with a head trauma must be admitted. There are no empty beds. Which client is most stable and eligible for a transfer to the step-down neurological unit?

1. A client with increased intracranial pressure (ICP) and a Glasgow Coma Scale of 8.
2. A client diagnosed with a cervical spinal injury 3 days ago with halo traction.
3. A client diagnosed with a cerebrovascular accident (CVA) and subdural hematoma 1 day ago.
4. A client with increased intracranial pressure (ICP) and a tracheostomy.

View Explanation

Answer 32

1) INCORRECT – A client with an increased ICP and a Glasgow Coma Scale of 8 or less (indicates coma) are indications for ICP monitoring. This client should not be transferred.
2) CORRECT – The halo traction provides immobilization and allows early ambulation. This client can be safely transferred.
3) INCORRECT – A second stroke may occur up to 72 hours after the first one. A hematoma adds a complication that needs to be resolved before transferring this client.
4) INCORRECT – This client requires close monitoring and cannot be transferred.

Question 33

A client with peripheral vascular disease, either arterial or venous, should not do what with their legs ?

Answer 33

Crossing the legs at the knees constricts venous return, increasing the risk for lower extremity edema, unnecessary pain, and discomfort due to the pooling of blood, which hinders systemic circulation.

The client with peripheral vascular disease (PVD), either venous or arterial, should sit with feet flat on the floor or comparable surface and avoid crossing the legs or wearing constrictive clothing. Crossing the legs at the knee interferes with blood flow, diminishing arterial flow to the feet and reducing venous return to the heart.

Clinical manifestations of peripheral vascular disease (PVD) include pain during walking or activity, numbness, burning, non-healing wounds, skin color changes that can include pallor, redness or cyanosis, and hair loss to extremities. The nurse should assess the strength of distal pulses and the color and temperature of extremities. Assess for any non-healing wounds. Ask client about symptoms occurring with walking or activities and instruct the client about positions that impede and those that improve blood flow.

Question 34

Clients with GERD should not drink carbonated beverages.

TRUE OR FALSE

Answer 34

TRUE

clients diagnosed with GERD should not drink carbonated beverages because they cause increased pressure in the stomach.

Question 35

What to remember about cardioversion

should the client be NPO before?

what is the goal of cardioversion ?

Answer 35

Cardioversion is the application of an external electrical charge over the myocardium in efforts to change the cardiac rhythm. Because this procedure can be uncomfortable, a sedative is provided.

Content Refresher

Cardioversion is the delivery of one or more electrical shocks that are synchronized with the electrocardiogram to stop life threatening dysrhythmias and restore perfusion. The client should have nothing by mouth for 12 hours before the procedure except for specific medications that can be taken with a sip of water. Start an intravenous line. Give medications as prescribed. Plan education regarding medications and cardioversion. Have an anesthesiologist available to administer sedation and monitor airway and breathing.

Question 36

A client exeriencing acute manua demonstrates …………

Answer 36

exaggerated or agitated behaviors. These behaviors include delusions of grandeur, euphoria, and difficulty concentrating. In addition, this client will have difficulty completing a task or following directions, is unable to sit still for meals, and has a limited need for sleep.

Clinical manifestations of mania include an extremely elevated and labile affect, thought disturbances, constant motor activity, refusal of foods or fluids, impaired sleep, socially inappropriate behavior, disinhibition, and, occasionally, perceptual disorders.

Bipolar disorder is a chronic mental health disorder with two subtypes. Type I is characterized by one or more episodes of mania, with or without depression, and type II is characterized by episodes of major depression and hypomania.

Question 37

What to remember about Holter monitors

Answer 37

the main aim of a Holter monitor study is to analyze the electrical activity of the heart outside of the clinical setting—that is, as a person goes about his or her normal daily activities.

When a person has a Holter monitor study, they wear the monitoring device for either 24 or 48 hours, and the ECG recorded during this time is subsequently analyzed for any cardiac arrhythmias that might have occurred during the monitoring period, as well as for any signs of cardiac ischemia.2

The Holter monitor study is very effective in diagnosing cardiac arrhythmias, as long as they occur with sufficient frequency. The test is very safe.

The nurse is aware that ambulatory cardiac monitoring can be used to determine if cardiac medications are working, to evaluate symptoms such as dizziness or palpitations, and to catch the heart ’s intermittent conduction abnormalities. The client wearing a Holter monitor should engage in whatever activities are normally included in the daily routine, such as drinking coffee, exercising, working, and resting. This point should be emphasized by the nurse, as clients often behave differently when they know they are under observation. The client must record all episodes of chest pain, shortness of breath, palpitations, dizziness, or other bothersome symptoms so this can be correlated with the heart rhythm and rate.

The client should not bathe or shower while wearing the device. A sponge bath is permitted as long as the monitor stays dry.

Question 38

what to remember about physiological jaundice

Answer 38

A normal development in many newborns that occurs between 2 to 4 days after birth, arising from the slow breakdown and transformation of unconjugated bilirubin for gastrointestinal excretion. The liver of the newborn is immature and cannot process the unconjugated bilirubin efficiently.

. Signs of physiological jaundice begin 24 hours after birth and are not present at birth. Total serum bilirubin levels will rise during the first few days postnatally, peaking at day 5 and declining after that time. Mild jaundice may be noted in the sclera and skin of the neonate. Total or direct serum bilirubin levels measure the amount of bilirubin that is produced when the liver breaks down red blood cells and are used to determine the severity of the presenting jaundice.

Phototherapy is considered for the neonate with a total serum bilirubin greater than 15 mg/dL (257 µmol/L) at 72 hours of age. The upper limit for the breastfed neonate is 15 mg/dL (257 µmol/L)

Question 39

What is the most common cause of acute glomerulonephritis ?

Answer 39

Streptococcal infection is the most common cause of acute glomerulonephritis

The nurse should be aware that acute glomerulonephritis is commonly a complication caused by the beta-hemolytic streptococcus bacteria.

Other risk factors for acute disease include bacterial endocarditis and viral infections such as human immunodeficiency virus (HIV), hepatitis B, and hepatitis C. Risk for chronic disease increases as a result of autoimmune disorders such as lupus, diabetes, vasculitis, Goodpasture’s syndrome, primary glomerular diseases such as IgA nephropathy, and chronic hypertension. Additional risks are being older, male, and African-American. The nurse should monitor vital signs, daily weights, edema, intake and output, and blood/urine analysis to determine fluid and electrolyte balance. Monitor response to medications, diet and fluid restrictions.

Question 40

What to remember about chemotherapy side effects

Answer 40

Chemotherapy involves the use of antineoplastic medications that interfere with cellular function and reproduction, resulting in the destruction of cancer cells.

Clients receiving chemotherapy are at risk for nausea, vomiting, malnutrition, electrolyte imbalances, alopecia, stomatitis (Painful swelling and sores inside mouth) , fatigue, and bone marrow suppression.

Assess client’s dietary intake and fluid and electrolyte status; provide anti-emetic medications if needed; allow rest periods; monitor blood chemistries for anemia, neutropenia, thrombocytopenia, and renal function; provide mouth care; and provide emotional support.

Clients with an implanted infusion port should be monitored closely for signs of central line–associated bloodstream infection (CLABSI). Due to immunosupression, the client receiving chemotherapeutic agents should be monitored for overt and covert signs and symptoms of infection. The nurse should check the client’s complete blood count (CBC) result daily. Assess a client’s hydration and ability to take adequate nourishment, which can be compromised due to nausea, vomiting, and diarrhea. All chemotherapeutic agents may potentially cause serious skin and mucus membrane damage if extravasated.

Question 41

Clients receiving chemotherapy may not have fever even though they are ill because of bone marrow depression.

TRUE OR FALSE

Answer 41

TRUE

Question 42

A common, subjective response to a perceived or actual threat. It may range from vague discomfort to total panic, leading to loss of control.

Answer 42

Anxiety

Question 43

The nurse should assess any client for toxicity who regularly uses aspirin. Assess the client for

Answer 43

excessive bruising, unexplained and excessive bleeding from cuts or injuries, swelling, pain or tightness in joints, blood in the urine or stool, and nosebleeds without a known cause.

Long-term use of aspirin can cause bleeding, even during minor procedures such as a biopsy

Aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure.

Question 44

In a newborn, symptoms of an infection may include an elevated temperature, the ability to be consoled, and slow responses to stimulation.

TRUE OR FALSE

Answer 44

FALSE

In a newborn, symptoms of an infection may include an elevated temperature, the inability to be consoled, and slow responses to stimulation.

Question 45

Myelomeningocele

• what complications could be present in the newborn exhibiting this

Answer 45

Myelomeningocele, or spinal bifida, is a malformation of the neural tube in which a pouch protrudes through the vertebrae. The pouch contains a section of the spinal cord along with cerebrospinal fluid (CSF). This malformation can occur anywhere along the spinal column, but is commonly seen at the lumbar or sacral regions of the spine. Clinical manifestations depend on the location of the malformation and range from paralysis to weakness of legs and/or trunk along with bowel, bladder, and cognitive dysfunction. In addition, neonates may have trouble feeding due to impaired swallowing and/or respiratory difficulties. Surgical intervention is needed 24 to 48 hours after birth to repair this malformation. After delivery, cover the pouch on the newborn’s back with sterile dressing and place the neonate on the stomach to protect the pouch.

Question 46

characterized by insufficient force of cardiac contraction (i.e. systolic failure) and/or inadequate filling of the heart with blood (i.e. diastolic failure).

Answer 46

Heart Failure

Right-sided heart failure typically produces systemic effects such as peripheral edema, jugular venous distention (JVD), weight gain, ascites, hepatomegaly, and S3 gallop on auscultation. Treatment includes administration of inotropic drugs, diuretics, vasodilators, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blocking drugs (ARBs), and aldosterone-blocking agents. Clients with severe HF may require coronary artery bypass grafting or percutaneous coronary intervention (PCI).

Question 47

What class of medications is Sulindac ?

Answer 47

sulindac is a non-steroidal anti-inflammatory drug (NSAID). One of the major risks associated with NSAIDs is the risk of bleeding, and the nurse needs to assess for any manifestations that indicate abnormal bleeding. The client should be instructed to contact the health care provider with any evidence of bleeding, which includes skin bruising.

Question 48

What is superior vena cava syndrome - when does it occur ?

Answer 48

The superior vena cava is a major vein in a person’s body. It carries blood from the head, neck, upper chest, and arms to the heart. Superior vena cava syndrome (SVCS) occurs when a person’s superior vena cava is partially blocked or compressed. Cancer is usually the main cause of SVCS.

Swelling of the face and eyes and distention of neck and chest veins are signs of superior vena cava syndrome.The nurse should assess for this obstructive emergency and notify the health care provider immediately.

Question 49

Neutropenic, febrile clients can progress to septic shock within minutes to a few hours

TRUE OR FALSE

Answer 49

TRUE

Question 50

What is a laminectomy ?

what is a herniated disk?

Answer 50

a surgical operation to remove the back of one or more vertebrae, usually to give access to the spinal cord or to relieve pressure on nerves. It can be done to treat a herniated disk.

Also known as a ruptured or slipped disk, a herniated disk occurs when the nucleus pulposus (inner part of disk) protrudes or ruptures through the annulus fibrosus (outer ring of disk). Herniated disks are treated either medically or through surgical interventions. The following surgical procedures may be performed: laminectomy, discectomy (microdiscectomy), spinal fusion, foraminotomy, and intradiscal electrothermal therapy. Some herniated discs cause no symptoms. Others can irritate nearby nerves and result in pain, numbness, or weakness in an arm or leg.

Since the herniated disk likely occurred due to injury, the client will need to learn proper body mechanics, such as proper lifting techniques, to prevent re-injury.

The spine will need to be kept in proper anatomical alignment after a laminectomy until healing is complete.

Question 51

Risk factors for post-operative respiratory complications include

Answer 51

increased age, history of smoking, certain surgical procedures, and lung trauma.

Question 52

What to remember about the risk for surgery and anesthesia postoperative complications

Answer 52

Complications are more likely for clients who are older, who smoke, are obese, have sleep or seizure disorders, have co-morbid hypertension or diabetes mellitus, and are undergoing complex and/or lengthy surgical procedures.

Complications associated with local and regional anesthesia can result in bleeding or injury at the injection site. The most common complications of general anesthesia include sore throat and nausea/vomiting. Less common complications include confusion, memory loss, pneumonia, seizures, coma, and death.

Question 53

What is macrosomia ?

What are maternal risk factors?

Characteristics of newborn with macrosomia include

Answer 53

Fetal macrosomia describes a newborn who is significantly larger than average. Regardless of gestational age, babies diagnosed with fetal macrosomia have birth weights of more than 8 pounds, 13 ounces (4000 grams). During prenatal care, the nurse screens the client for risks of macrosomia, such as diabetes mellitus, obesity, excessive weight gain during pregnancy, and previous pregnancy. The mother is informed about possible complications, labor difficulties, postpartum hemorrhage, genital tract laceration, and uterine rupture

Typical characteristics of an infant with macrosomia include a round, flushed face; chubby body; enlarged internal organs (e.g., hepatosplenomegaly, cardiomegaly); and increased body fat, especially around the shoulders. Insulin, proposed as the primary growth hormone for intrauterine development, does not cross the blood-brain barrier. As a result, the brain is the only organ that is not enlarged. During pregnancy, excess nutrients cross the placenta, and the fetal pancreas produces insulin to match the energy supply. After delivery, the infant is at risk for hypoglycemia.

Question 54

TRUE OR FALSE

Vomiting should not occur with a nasogastric tube in place that is attached to suction

Answer 54

TRUE

A client with a functioning nasogastric tube should not vomit.

the nurse will assess the nasogastric tube patency and suction since vomiting should not occur with this tube attached to suction.

The nurse immediately raises the head of the bed to prevent aspiration of stomach contents. Once the airway is protected, the nurse assesses the nasogastric tube for function and integrity. Dark brown emesis is often indicative of a intestinal obstruction or gastrointestinal bleed; therefore, the nurse monitors the client’s vital signs, abdominal girth, and bowel sounds and notifies the health care provider with any abnormal findings.

Question 55

What to remember about HIV testing

Answer 55

The nurse is aware a newborn may be exposed to the human immunodeficiency virus (HIV) in utero. Should exposure be suspected or confirmed by the diagnosis of the mother, a Western blot test will be done to confirm if the newborn has antibodies to HIV. However, the test may just indicate the newborn has antibodies from the mother. An additional test must be done to determine if the infant is positive for HIV. One test used to make this confirmation is the CD4+ count. Based upon the results of this test, further intervention will be prescribed.

Infections in infants are confirmed with a CD4+ count, a virus culture of HIV, or polymerase.

Content Refresher

Human immunodeficiency virus (HIV) is a virus spread through certain body fluids that attacks the body’s immune system, specifically the CD4 cells, often called T cells. Acquired immune deficiency syndrome (AIDS) is the most severe phase of HIV infection. Human immunodeficiency virus is most commonly diagnosed by testing the blood or saliva for antibodies to the virus. A newer type of test that checks for the HIV antigen, a protein produced by the virus immediately after infection, can quickly confirm a diagnosis soon after infection. Other staging tests include CD4 count and viral load. No effective cure currently exists for HIV. However, HIV can be controlled and treated with antiretroviral therapy (ART).

Question 56

Immediately after delivery, the newborn assessment should include

Answer 56

Immediately after delivery, clamp the umbilical cord and assess the newborn ’s Apgar score at the 1 and 5 minute mark (0 to 3 is poor, 4 to 6 is fair, 7 to 10 is normal). Assess for normal newborn vital signs (axillary temperature 97.7 ° to 99.7 °F [36.5 ° to 37.6 °C], heart rate 120 to 160 beats per minute while awake, respiration 30 to 60 breaths per minute, blood pressure 65/41 mm Hg). Assess for the presence of newborn reflexes (e.g., rooting and sucking, palmar grasp, plantar grasp, Moro, Babinski). Ensure prophylactic medications have been administered (e.g., eye prophylaxis and IM vitamin K).

Question 57

Acrocyanosis is normal for 2 to 6 hours post-delivery due to poor peripheral circulation.

TRUE OR FALSE

Answer 57

TRUE

Question 58

Crying causes increased intracranial pressure; therefore, the anterior fontanel bulging is normal and expected

TRUE OR FALSE

Answer 58

TRUE

Question 59

___________________(SVT) is the most common arrhythmia diagnosed in pediatric clients. The newborn exhibiting tachycardia, especially at rest, requires further examination and should be seen by the nurse first. The nurse first compares the current readings with the baseline. Any abnormalities in vital signs during the neonatal period, especially with heart rate and respiration, may be indicative of ______________. When assessing the newborn client, both the heart rate and respiratory rate should be counted for a full 60 seconds. The nurse should keep in mind that__________cardia in pediatric clients is an ominous sign, usually a result of ____________-, requiring prompt intervention.

Answer 59

Supraventricular tachycardia; infection; bradycardia; hypoxia

Question 60

Safety interventions for IV therapy

Answer 60

Maintain aseptic technique when accessing and managing the IV site, and monitor the IV for signs of infiltration and phlebitis. Assess for expected outcomes and adverse effects, such as signs and symptoms of fluid volume overload (e.g. bounding pulse, hypertension, dyspnea, or crackles).

The nurse must closely monitor the client who is prescribed an IV fluid infusion. Most institutions require an hourly check to monitor the amount of fluid infused, along with a site check assessing for symptoms indicative of infection or inflammation.

The nurse must have an accurate estimation of how much fluid infuses during a specific period of time to plan for hanging a new IV bag when the current bag is empty.

Question 61

What to remember about psychiatric involuntary admission

Answer 61

Involuntary commitment is made without the client’s consent because the person is a danger to self or others, is in need of psychiatric treatment, or is unable to meet basic needs. Involuntary commitment is ordered by a judge. Clients cannot leave while under involuntary commitment.

When communicating with a client who is involuntary admitted, the nurse must provide accurate information. Generally, involuntary admission occurs by way of one of three processes. The first process, which is medical certification, requires client examination by two physicians and certification of the need for involuntary care and treatment in a psychiatric facility. The second process involves certification by a director of community services, or by an examining physician designated by the director of community services, in which the examiner states the individual is diagnosed with a mental illness that is likely to result in serious harm to self or others and for which immediate inpatient care and treatment is appropriate. The third process is an emergency admission based on the claim that the person has a mental illness that is likely to result in serious harm to self or others and for which immediate observation, care, and treatment in a psychiatric center is warranted.

Question 62

What to remember about suctioning

Answer 62

Hyperoxygenation is an essential activity prior to suctioning to prevent hypoxia and other hypoxia-related complications, such as dysrhythmia and agitation.

In the conscious and cooperative client, this can be achieved by having the client take deep breaths.

For clients attached to a ventilator, hyperoxygenation can be done automatically using a hyperoxygenation function.

Since suctioning can be hazardous and causes discomfort, it is not recommended in the absence of apparent need. The nurse should assess the breath sounds before and after suctioning.

Content Refresher

When caring for the client who requires suctioning, the nurse should wash hands and use personal protective equipment. Hyperoxygenate client with 100% oxygen to prevent hypoxia. Attach suction catheter to suction tubing and gently introduce the suction catheter into the tracheostomy tube, nose, or mouth to the pre-measured depth. Apply suction and gently rotate the catheter while withdrawing. Suction should not be applied longer than 5 to 10 seconds. Assess the client’s respiratory rate, skin color, and/or oximetry reading to ensure tolerance. Repeat the suction if indicated.

Question 63

What to remember about UTIs

Answer 63

A urinary tract infection (UTI) can occur anywhere along the urinary tract. The most common pathogens are bacteria; however, fungal and parasitic infections can occur. When assessing for UTI, the nurse will assess for recent history of nausea, vomiting, chills, changes in urinary elimination, and costovertebral tenderness. Also note any recent urinary catheterization. Other symptoms consistent with UTI include subjective reports of burning, frequency of urination, and dysuria. Urine appears cloudy and may exhibit a foul smell. Assess urinalysis for white blood cells, leukocyte esterase, and bacteria.

The client should drink adequate oral fluids to flush bacteria from the urinary tract.

Previous urinary trauma or infection increases the risk of a UTI.

The normal urine specific gravity range is 1.010 to 1.030. The higher the number, the more concentrated the urine, suggesting the client may not be drinking enough urine.

Question 64

What to remember about spinal anesthesia - what are complications to look out for

Answer 64

Spinal anesthesia is used for pain relief.

The presence of an spinal anesthesia used for pain management increases the risk for respiratory depression, hypotension, and alterations in bowel and bladder function.

Content Refresher

Spinal anesthesia is used to control pain and anxiety during labor, to block pain signals during surgery to the abdomen or lower extremities, and to reduce postoperative pain after major chest or abdominal surgery. Possible complications include nausea, vomiting, inadequate analgesia, headaches, and respiratory complications. The nurse should monitor vital signs, being especially alert to possible hypotension, assess effectiveness of the anesthetic, maintain hydration, observe puncture site for leaking of cerebrospinal fluid (CSF), and maintain bedrest to avoid headache.

Question 65

The presence of an spinal anesthesia used for pain management increases the risk for respiratory depression, hypotension, and alterations in bowel and bladder function.

TRUE OR FALSE

Answer 65

TRUE

Question 66

Which two class of medications should we remember are held before surgery ?

Answer 66

Anticoagulants are withheld prior to surgery in order to prevent excessive bleeding intraoperatively.

Diuretics are withheld prior to surgery, as they increase the client’s risk for hypovolemia and hypokalemia.

Question 67

The nurse provides care for a client scheduled for surgery the following morning. The preoperative prescriptions include NPO after midnight. No medications are prescribed to be withheld before surgery. Which medication causes the nurse to question its administration prior to surgery? (Select all that apply.)

1. Valsartan 80 mg given daily for hypertension.
2. Clonazepam 2 mg given twice daily to prevent seizures.
3. Triamterene 50 mg given every morning for hypertension.
4. Prednisone 5 mg given once daily for asthma.
5. Dabigatran 75 mg given daily for atrial fibrillation.
6. Quetiapine 50 mg given at bedtime for insomnia.

View Explanation

Answer 67

1) INCORRECT - Except for diuretics, cardiac medications, especially those prescribed for hypertension, are not withheld prior to surgery.
2) INCORRECT - Benzodiazepines are not withheld prior to surgery. This medication provides anxiolysis, which may be beneficial prior to surgery.

3) CORRECT – Diuretics are withheld prior to surgery, as they increase the client’s risk for hypovolemia and hypokalemia.

4) INCORRECT - Corticosteroids are not withheld prior to surgery, as they avoid adrenal insufficiency and augment anti-inflammatory effects.

5) CORRECT – Anticoagulants are withheld prior to surgery in order to prevent excessive bleeding intraoperatively.

6) INCORRECT - Mood stabilizers are not withheld prior to surgery. There are no adverse effects related to surgery regarding this class of medication.

Question 68

What are coping mechanisms ?

What are some examples ?

What are examples of ego defense mechanisms ?

Answer 68

Coping mechanisms are behaviors, thoughts, or feelings that enhance control or bring psychological comfort to a person experiencing stress. There are positive coping mechanisms (e.g., exercise, listening to music, talking to a close friend, or doing a creative activity) and negative coping mechanisms (e.g., smoking, eating or drinking too much, abusing drugs, or self-criticizing). Assess the client’s previous methods of coping with stress. Assess the client’s support system. Identify triggers that cause stress. Provide effective communication, emotional support, and a list of community resources that may be able to help decrease stress.

The use of ego defense mechanisms can be both adaptive and maladaptive. They may be used to manage anxiety.

Rationalization is the justification of an unreasonable act or idea to make it appear reasonable. Rationalizations are usually plausible, but not the reasons for the behavior.

Attributing one’s feelings, impulses, thoughts, or wishes to another person is projection. Pointing out that someone else was driving faster and is more deserving of a speeding ticket is another example.

Denial is failure to acknowledge an intolerable thought, feeling, experience, or reality. Claiming to be a social drinker is an example of denial.

Intellectualization is the excessive use of reasoning or logic to prevent a person from feeling. Explaining how the client might not really have an addiction is an example of intellectualization.

Question 69

How to protect a newborn undergoing phototherapy for hyperbilirubinemia

Answer 69

PROTECT THEIR EYES

The eyes of a newborn must be completely covered when using phototherapy to treat jaundice from hyperbilirubinemia. Since the yellow color is diminished around the eyes and nose, this indicates that the eye covering is not appropriately applied. The eye coverings need to be immediately adjusted so that the newborn is not being exposed to a situation that increases risk for retinal damage.

Question 70

When caring for a newborn with physiological jaundice, the nurse should:

Answer 70

Encourage the mother to breastfeed frequently.

Monitor the neonate for six wet diapers and three stools per day as an indication of elimination of bilirubin. .

Observe for jaundice (sclera and skin) and monitor diagnostic bilirubin tests.

Initiate phototherapy and exchange transfusion as prescribed if levels of bilirubin are severe. Loose, greenish stools and increased urine output reflect increased excretion of bilirubin, which indicates that the phototherapy is working

Teach parents about physiological jaundice, signs of hyperbilirubinemia, and actions to take.

Question 71

The nurse knows that when performing cardiopulmonary resuscitation (CPR) on an adult client, the __________-artery is used to assess for a pulse. The nurse also understands the importance of using the______________as soon as available, if the client’s rhythm is shockable (ventricular fibrillation or pulseless ventricular tachycardia).

Answer 71

carotid; automatic external defibrillator (AED)

Content Refresher

Cardiopulmonary resuscitation (CPR) is the use of chest compressions and ventilations for clients in cardiac arrest. To determine if CPR is needed, the nurse must determine if the client is unresponsive while palpating the carotid pulse for 5 to 10 seconds. If no pulse is felt (palpate carotid pulse for 5 to 10 seconds) and the client is not breathing, start chest compressions using the compressions-airway-breathing (CAB) approach. Administer 30 compressions to two breaths. If two rescuers are performing CPR, they should perform a pulse check and change roles every 2 minutes. Ensure the client is placed on a hard, flat surface while delivering chest compressions.

Question 72

Antibiotics can decrease the effectiveness of oral contraceptives.

TRUE OR FALSE

Answer 72

TRUE

Question 73

Use of a contraceptive diaphragm is linked to an increased risk for developing a UTI

TRUE OR FALSE

Answer 73

TRUE

Question 74

Hormonal contraception refers to birth control methods that act on the ___________-system. Almost all methods are composed of steroid hormones. Hormonal methods of birth control include birth control pills, contraceptive implants, injectable contraception, skin patches, vaginal rings, and a specific intrauterine device (IUD). Complications associated with hormonal contraceptives include (name at least 4)

Answer 74

endocrine; blood clots, breast tenderness, decreased libido, headaches, intermenstrual spotting, missed periods, mood changes, nausea, and weight gain.

Question 75

What is Mean Arterial Pressure ?

Answer 75

MAP is the average arterial pressure throughout one cardiac cycle, systole, and diastole

Doctors usually consider anything between 70 and 100 mmHg to be normal. A MAP in this range indicates that there’s enough consistent pressure in your arteries to deliver blood throughout your body

Question 76

the LVN/LPN can administer IV medications.

TRUE/FALSE

Answer 76

FALSE

The nurse retains responsibility for administering IV medications.

Question 77

Diarrhea commonly occurs with antibiotic therapy

TRUE OR FALSE

Answer 77

TRUE

Question 78

The client with diabetes experiencing a “quivering” feeling in the abdomen could be developing a hypoglycemic reaction.

TRUE OR FALSE

Answer 78

TRUE

A quivering feeling indicates hypoglycemia. Additional symptoms include tachycardia, cold and clammy skin, weakness, and pallor.

Question 79

What to remember about Pancreatitis

Acute and chronic symptoms

• what are risk factors

Answer 79

For the client with pancreatitis, bed rest is needed to decrease the metabolic rate and the secretion of pancreatic enzymes.

- requires aggressive nursing management

Pancreatitis requires aggressive nursing management. IV fluids are required, with careful intake and output measurements. Clients experiencing acute pancreatitis are NPO. Nursing interventions include administering antibiotics as prescribed and encouraging deep breathing to prevent atelectasis. To help manage pain, which may be exacerbated by coughing and deep breathing, the nurse advocates for scheduled analgesic doses in addition to PRN doses. Laboratory testing includes serial glucose, amylase, and lipase. Increased pancreatic enzyme secretion causes pain due to pancreatic auto-digestion and inflammation, increasing the risk of shock. Monitor the client for signs of shock and jaundice.

Content Refresher

Severe abdominal pain is a common clinical manifestation of acute and chronic pancreatitis. Acute symptoms include nausea, vomiting, jaundice, and decreased or absent bowel sounds. With severe pancreatitis, hemorrhage may lead to shock. Chronic symptoms include weight loss and constipation. Chronic pancreatitis also may lead to diabetes mellitus.

Risk factors for pancreatitis include chronic alcohol use, being middle aged, smoking, family history of pancreatitis, pancreatic trauma, pregnancy, infection, hyperlipidemia, and certain medications (e.g., diuretics, estrogen, and NSAIDs).

Question 80

Signs of hyperglycemia

Answer 80

polyuria, polydipsia, polyphagia, lethargy, malaise, headache, or blurred vision

Question 81

signs of hypoglycemia

Answer 81

shakiness,irritability, cool skin, difficulty in concentrating, decreased level of consciousness (LOC), slurred speech, and reports of hunger, nausea, and headache

Question 82

Non pharmaceutical strategies for combating diarrhea

Answer 82

eating a low-residue diet, which may include white bread, waffles, and refined cereals.

Consumption of room-temperature fluids is an appropriate strategy for helping alleviate diarrhea. Drinking ice water may irritate the bowel and cause elimination issues, including diarrhea or constipation.

Over-the-counter probiotic pills or powders add healthy bacteria to the gastrointestinal tract, which aids in digestion and helps prevent diarrhea. Food sources of probiotics include yogurt with live cultures, aged soft cheeses, and dark chocolate.

Question 83

What are nasal polyps ?

Answer 83

Nasal polyps, small noncancerous growths, can block the nasal passages, interfere with the sense of smell, and cause frequent infections.

Question 84

What to remember about mastoiditis and mastoidectomy

Answer 84

Mastoiditis is a serious infection in the mastoid process, which is the hard, prominent bone just behind and under the ear. Ear infections that people fail to treat cause most cases of mastoiditis.

Mastoiditis may cause vertigo (a spinning sensation). Vertigo may cause a loss of balance, increasing the client’s risk for falling

Question 85

Insertion of a central venous catheter is a sterile procedure. The catheter is contaminated if it comes into contact with anything other than the sterile field. The catheter needs to be replaced.

TRUE OR FALSE

Answer 85

TRUE

Question 86

SIADH and lung cancer

Answer 86

Syndrome of Inappropriate Anti-diuretic hormone secretion

Excessive ADH results in fluid retention and fluid overload. The most common cause of SIADH is cancer, especially lung cancer.

Lung cancer is known for causing paraneoplastic syndromes (A group of signs and symptoms caused by a substance that is produced by a tumor or in reaction to a tumor.), which involve damage to organs or tissues distant from the cancerous region. Tumors may produce hormones, enzymes, or other substances that can precipitate undesirable and dangerous physiologic responses. Tumors may also trigger the unnecessary release of hormones by other organs. Lung cancer can cause various secondary health alterations, including syndrome of inappropriate antidiuretic hormone (SIADH). Initial treatment is directed at the paraneoplastic syndrome and how it is expressed. Ultimately, eradication of the cancer is the only way to reverse the symptoms of a secondary syndrome.

Question 87

Caring for the patient with SIADH

Answer 87

Causes of syndrome of inappropriate antidiuretic hormone (SIADH) include neoplasms in the lungs and the colon, pulmonary disorders (emphysema), traumatic brain injury, stroke, meningitis, and adverse effects of anesthetics, barbiturates, or selective serotonin reuptake inhibitors (SSRIs). Monitor vital signs, intake and output, and mental status. Report urine output of less than 30 mL per hour, increase in edema, weight gain, significant changes in serum electrolytes or osmolality, increasing blood pressure, or change in heart or lung sounds. Fluid restriction is the first-line treatment for the client diagnosed with SIADH.

Question 88

What to remember about epiglottitis

Answer 88

It is a MEDICAL EMERGENCY that can rapidly progress to airway obstruction

This condition occurs as a result of a bacterial invasion that causes the epiglottis to swell resulting in an obstruction of air flow into the lungs. This condition typically occurs between the ages of 2 and 8 years and can progress rapidly with complete obstruction of the airway occurring within hours of initial symptoms.

For any pediatric client manifesting symptoms indicative of epiglottis, it is essential to avoid visual inspection of the mouth and throat as this can cause laryngospasm and airway obstruction.

The client who is leaning forward with the mouth open, tongue protruding, and drooling is exhibiting manifestations of acute epiglottitis. The client sits upright to breathe better. Tongue protrusion increases pharyngeal movement. Drooling is caused by difficulty swallowing because of pain and excessive secretions.

Question 89

Nothing should be inserted into the mouth of a client experiencing a seizure.

TRUE OR FALSE

Answer 89

TRUE

Question 90

The first action to take for a client having a tonic-clonic seizure is to _____________________. Calling for help can be done after the client’s safety is ensured. ___________________should be placed in the mouth of a client who is having a seizure. The client’s extremities should not be _____________during a seizure. This can cause harm to both the client and nurse.

Answer 90

protect the client from injury; Nothing; restrained

When providing care for a client with a seizure, the nurse should prevent injury by maintaining seizure precautions and plan education about disease and medications to treat disease. During an observed seizure, the nurse should monitor and document seizure activity and client ’s level of consciousness before, during, and after the seizure. Have oxygen and suction equipment at the bedside. Turn client on side and protect from injury during the seizure. Administer oxygen using face mask during seizure. Note duration of seizure. Following seizure, ask client if aura was present.

Question 91

What to remember about vaginitis

Answer 91

Vaginal itching, discharge, burning, and painful urination are symptoms of vaginitis

Risk factors for vaginitis include hormonal changes; sexual activity; sexually transmitted infections; medications (e.g., antibiotics, steroids); uncontrolled diabetes mellitus; use of bubble bath, vaginal deodorants, and sprays; and frequent douching.

The client diagnosed with vaginitis is reminded to maintain proper hygiene, but vaginal sprays or heavily-perfumed soaps are not recommended. An infection could spread or hide if the client douches. Furthermore, douching may cause irritation, and it removes healthy vaginal bacteria. The nurse should teach the client to avoid clothes that hold in heat and moisture. Also, yeast infections can develop if the client wears non-breathable gym shorts or leggings, nylon underwear, pantyhose without a cotton panel, or tight jeans. The client should be screened for sexually transmitted infections and treated accordingly.

Question 92

what to remember about congenital melanocytic nevi

Answer 92

One of several known risk factors for the eventual development of melanoma.

A congenital melanocytic nevi requires follow up due to the potential for malignancy.

The newborn with congenital melanocytic nevi requires further evaluation because as the child reaches adolescence, the incidence of melanoma increases substantially, with a rate of 13.2 cases per million children aged 15 to 19 years. A referral for dermatologic consult is warranted when a congenital melanocytic nevi is noted.

Question 93

What are vesicants?

Answer 93

Drugs that can result in tissue necrosis or formation of blisters when accidentally infused into tissue surrounding a vein

Question 94

What to remember about PICCs

Answer 94

A peripherally inserted central catheter (PICC) is a long-term IV access device. PICCs often have multiple lumens, which allow for simultaneous infusion of multiple medications into the fast, voluminous flow of the superior vena cava. Nothing smaller than a 10 mL syringe is used when flushing (unless the syringe is specially designed to generate low pressure) or administering medications through this device, as the pressure will damage the tip, potentially causing a catheter embolism or causing the catheter to collapse. (A catheter embolism occurs with catheter rupture and may result from using too much pressure when flushing the line. … Other causes of catheter embolism include migration and catheter breakage from internal and external causes.)

Frequent normal saline flushing is required to maintain patency.

Content Refresher

A peripherally inserted central catheter (PICC) is inserted into a large vein in the arm and may stay in place for several days to months. The distal tip of the catheter should be located in the superior vena cava. A chest X-ray is used to confirm correct PICC placement. Monitor for potential PICC complications, including malpositioning of the catheter, pneumothorax, dysrhythmias, nerve or tendon damage, catheter embolism, and thrombophlebitis. Do not measure blood pressure or draw blood from the extremity with the PICC.

Question 95

What to remember about the HPV vaccine

Answer 95

“This vaccine is recommended for males and females at 11 –12 years of age before sexual activity occurs

The HPV vaccine reduces the risk of cervical cancer

The human papillomavirus (HPV), which is a common sexually transmitted infection, usually causes no symptoms and can spontaneously resolve, but can lead to serious complications. Individuals such as adolescents need to know that there are three vaccines available to protect against HPV.