a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests
When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.
a. Supine with the head of the bed elevated 30 degrees
b. In a high-Fowler’s position with the left arm extended
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as “99.” After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.
a. Elevate the head of the bed to 80 to 90 degrees.
b. Keep the patient NPO until the gag reflex returns.
c. Place on bed rest for at least 4 hours after bronchoscopy.
d. Notify the health care provider about blood-tinged mucus.
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler’s position.
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration heard on inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
a. Notify the health care provider.
b. Document the response to exercise.
c. Administer the PRN supplemental O2.
d. Encourage the patient to pace activity.
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.
a. “I will use my inhaler right before the test.”
b. “I won’t eat or drink anything 8 hours before the test.”
c. “I should inhale deeply and blow out as hard as I can during the test.”
d. “My blood pressure and pulse will be checked every 15 minutes after the test.”
For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.
a. The student starts at the apices of the lungs and moves to the bases.
b. The student compares breath sounds from side to side avoiding bony areas.
c. The student places the stethoscope over the posterior chest and listens during inspiration.
d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.
Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences.
a. Start giving the patient discharge teaching on the day of admission.
b. Have the patient repeat the instructions immediately after teaching.
c. Accomplish the patient teaching just before the scheduled discharge.
d. Arrange for the patient’s caregiver to be present during the teaching.
Hypoxemia interferes with the patient’s ability to learn and retain information, so having the patient’s caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.
a. Start an IV so contrast media may be given.
b. Ensure that the patient has been NPO for at least 6 hours.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to undress to the waist and remove any metal objects.
Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used.
a. “I have not had any acute asthma attacks during the last year.”
b. “I became short of breath an hour before coming to the hospital.”
c. “I’ve been taking Tylenol 650 mg every 6 hours for chest-wall pain.”
d. “I’ve been using my albuterol inhaler more frequently over the last 4 days.”
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.
a. Allergy to shellfish
b. Apical pulse of 104
c. Respiratory rate of 30
d. Oxygen saturation of 90%
Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.
a. The bicarbonate level (HCO3-) is 31 mEq/L.
b. The arterial oxygen saturation (SaO2) is 92%.
c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient’s oxygenation.
a. Weak cough effort
b. Barrel-shaped chest
c. Dry mucous membranes
d. Bilateral crackles at lung bases
Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.
a. Administer bicarbonate.
b. Complete a head-to-toe assessment.
c. Place the patient on high-flow oxygen.
d. Obtain repeat arterial blood gases (ABGs).
Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given. Bicarbonate would worsen the patient’s condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen.
a. A patient with pneumonia who has crackles in the right lung base
b. A patient with possible lung cancer who has just returned after bronchoscopy
c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.
a. Respirations are 36 breaths/minute.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present.
The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.
Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?
b. Tripod positioning
c. Accessory muscle use
d. Reduced chest expansion
The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patient’s chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection.
a. Listen to a patient’s lung sounds for wheezes or rhonchi.
b. Label specimens obtained during percutaneous lung biopsy.
c. Instruct a patient about how to use home spirometry testing.
d. Measure induration at the site of a patient’s intradermal skin test
Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.
a. Patient is claustrophobic.
b. Patient is allergic to shellfish.
c. Patient recently used a bronchodilator inhaler.
d. Patient is not able to remove a wedding band.
e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.
Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).
While listening to the posterior chest of a patient who is experiencing acute shortness of breath, the nurse hears these sounds. How should the nurse document the lung sounds?
Click here to listen to the audio clip
a. Pleural friction rub
b. Low-pitched crackles
c. High-pitched wheezes
d. Bronchial breath sounds
Wheezes are continuous high-pitched or musical sounds heard initially with expiration. The other responses are typical of other adventitious breath sounds.
a. “I can take 800 mg ibuprofen for pain control.”
b. “I will safely remove and reapply nasal packing daily.”
c. “My nose will look normal after 24 hours when the swelling goes away.”
d. “I will keep my head elevated for 48 hours to minimize swelling and pain.”
Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery.
a. Hand washing is the primary way to prevent spreading the condition to others.
b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions.
c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.
d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.
The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinitis (the common cold) can be prevented by washing hands.
a. “I can take acetaminophen (Tylenol) to treat my discomfort.”
b. “I will drink lots of juices and other fluids to stay well hydrated.”
c. “I can use my nasal decongestant spray until the congestion is all gone.”
d. “I will watch for changes in nasal secretions or the sputum that I cough up.”
The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.
a. Encourage increased incentive spirometer use.
b. Encourage the patient to increase oral fluid intake.
c. Put on sterile gloves and use a sterile catheter to suction.
d. Preoxygenate the patient for 3 minutes before suctioning.
This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.
a. Leave the tracheostomy inner cannula inserted at all times.
b. Place the decannulation cap in the tube before cuff deflation.
c. Assess the ability to swallow before using the fenestrated tube.
d. Inflate the tracheostomy cuff during use of the fenestrated tube.
Because the cuff is deflated when using a fenestrated tube, the patient’s risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient’s airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient’s vocal cords when using a fenestrated tube.
a. Use a manometer to ensure cuff pressure is at an appropriate level.
b. Check the amount of cuff pressure ordered by the health care provider.
c. Suction the patient first with a fenestrated inner cannula to clear secretions.
d. Insert the decannulation plug before the nonfenestrated inner cannula is removed.
Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient’s airway is occluded. A health care provider’s order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.
a. “I will need to buy a water bottle to carry with me.”
b. “I should not use any lotions on my neck and throat.”
c. “Until the radiation is complete, I may have diarrhea.”
d. “Alcohol-based mouthwashes will help clean oral ulcers.”
Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.
a. “How much alcohol do you drink in an average week?”
b. “Do you have a family history of head or neck cancer?”
c. “Have you had frequent streptococcal throat infections?”
d. “Do you use antihistamines for upper airway congestion?”
Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient’s symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient’s symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.
a. “You will breathe through a permanent opening in your neck, but you will not be able to communicate orally.”
b. “You won’t be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed.”
c. “You won’t be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally.”
d. “You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.”
Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.
a. The patient lets the spouse provide tracheostomy care.
b. The patient allows the nurse to suction the tracheostomy.
c. The patient asks how to clean the tracheostomy stoma and tube.
d. The patient uses a communication board to request “No Visitors.”
Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.
a. “I must keep the stoma covered with an occlusive dressing at all times.”
b. “I can participate in most of my prior fitness activities except swimming.”
c. “I should wear a Medic-Alert bracelet that identifies me as a neck breather.”
d. “I need to be sure that I have smoke and carbon monoxide detectors installed.”
The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patient’s airway. The other patient comments are all accurate and indicate that the teaching has been effective.
a. Pinch the lower portion of the nose for 10 minutes.
b. Pack the affected nare tightly with an epistaxis balloon.
c. Obtain silver nitrate that will be needed for cauterization.
d. Apply ice compresses over the patient’s nose and cheeks.
The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauterization and nasal packing are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.
a. Monitor for bleeding.
b. Maintain adequate IV fluid intake.
c. Suction tracheostomy every eight hours.
d. Keep the patient in semi-Fowler’s position.
The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler’s position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.
a. Cover stoma with sterile gauze and ventilate through stoma.
b. Attempt to reinsert the tracheostomy tube with the obturator in place.
c. Assess the patient’s oxygen saturation and notify the health care provider.
d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.
The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient’s airway. Assessing the patient’s oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.
a. A 23-year-old who is complaining of a sore throat and has a muffled voice
b. A 34-year-old who has a “scratchy throat” and a positive rapid strep antigen test
c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue
d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed
The patient’s clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.
a. Fever of 100.4° F (38° C)
b. Diffuse crackles in the lungs
c. Sore throat and frequent cough
d. Myalgia and persistent headache
The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake.
a. Assess the patient’s risk for aspiration.
b. Suction the tracheostomy when needed.
c. Teach the patient about self-care of the tracheostomy.
d. Determine the need for replacement of the tracheostomy tube.
Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN.
a. The oxygen saturation is 89%.
b. The nose appears red and swollen.
c. The patient’s temperature is 100.1° F (37.8° C).
d. The patient complains of level 8 (0 to 10 scale) pain.
Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation.
a. Clear nasal drainage
b. Complaint of nasal pain
c. Bilateral nose swelling and bruising
d. Inability to breathe through the nose
Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications.
a. Notify the clinic health care provider.
b. Obtain aerobic culture specimens of the drainage.
c. Ask the patient about how the cotton got into the nose.
d. Have the patient occlude the left nare and blow the nose.
Because the highest priority action is to remove the foreign object from the nare, the nurse’s first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose.
a. Avoid giving patient warm liquids to drink.
b. Assess patient for allergies to penicillin antibiotics.
c. Teach the patient about the need to sleep in a warm, dry environment.
d. Teach patient to “swish and swallow” prescribed oral nystatin (Mycostatin).
Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the “swish and swallow” technique is to expose all of the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin/cephalosporin allergies because Candida albicans infection is treated with antifungals.
a. Teach the patient about the use of expectorants.
b. Use a swab to obtain a sample for a rapid strep antigen test.
c. Discuss the need to rinse the mouth out after using any inhalers.
d. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).
The patient’s clinical manifestations are consistent with streptococcal pharyngitis and the nurse will anticipate the need for a rapid strep antigen test and/or cultures. Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing the mouth out after inhaler use may prevent fungal oral infections, but the patient’s assessment data are not consistent with a fungal infection. NSAIDs are frequently prescribed for pain and fever relief with pharyngitis.
a. Decongestants can be used to relieve swelling.
b. Blowing the nose should be avoided to decrease the nosebleed risk.
c. Taking a hot shower will increase sinus drainage and decrease pain.
d. Saline nasal spray can be made at home and used to wash out secretions.
e. You will be more comfortable if you keep your head in an upright position.
The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter (OTC) sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.
a. A 76-year-old nursing home resident
b. A 36-year-old female patient who is pregnant
c. A 42-year-old patient who has a 15 pack-year smoking history
d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis
e. A 24-year-old patient who has allergies to penicillin and cephalosporins
Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old increases the risk for infection.
The patient is in a side-lying position with the head of the bed flat.
b. The patient is coughing blood-tinged secretions from the tracheostomy.
c. The nasogastric (NG) tube is disconnected from suction and clamped off.
d. The wound drain in the neck incision contains 200 mL of bloody drainage.
The patient should first be placed in a semi-Fowler’s position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.
a. Watch for excess bruising.
b. Check for swollen lymph nodes.
c. Take iron supplements to prevent anemia.
d. Wash hands and avoid persons who are ill.
Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.
a. “Do you take salicylates?”
b. “Are you taking any oral contraceptives?”
c. “Have you been prescribed antiseizure drugs?”
d. “How long have you taken antihypertensive drugs?”
Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia, but not clotting disorders or bleeding. Oral contraceptives increase a person’s clotting risk. Antihypertensives do not usually cause problems with decreased clotting.
a. Hematocrit of 35%
b. Hemoglobin of 11.8 g/dL
c. Platelet count of 400,000/µL
d. White blood cell (WBC) count of 2800/µL
Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient’s immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
a. Elevate the head of the bed to 45 degrees.
b. Apply a sterile 2-inch gauze dressing to the site.
c. Use a half-inch sterile gauze to pack the wound.
d. Have the patient lie on the left side for 1 hour.
To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient’s head.
a. Yellow-tinged sclerae
b. Shiny, smooth tongue
c. Numbness of the extremities
d. Gum bleeding and tenderness
Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
a. “Have you had a recent weight loss?”
b. “Do you have any history of lung disease?”
c. “Have you noticed any dark or bloody stools?”
d. “What is your dietary intake of meats and protein?”
The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease (COPD). The other questions would be appropriate for patients who are anemic.
Activated partial thromboplastin time (aPTT) assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration.
aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.
a. Platelet count
b. Neutrophil count
c. White blood cell count
d. Hemoglobin (Hgb) level
Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person’s clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.
a. A 2-cm nontender supraclavicular node
b. A 1-cm mobile and nontender axillary node
c. An inability to palpate any superficial lymph nodes
d. Firm inguinal nodes in a patient with an infected foot
Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.
a. Hematocrit of 46%
b. Hemoglobin of 13.8 g/dL
c. Elevated reticulocyte count
d. Decreased white blood cell (WBC) count
Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
a. Avoid intramuscular injections.
b. Encourage increased oral fluids.
c. Check temperature every 4 hours.
d. Increase intake of iron-rich foods.
Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.
a. Cool extremities
b. Pallor and weakness
c. Elevated temperature
d. Low oxygen saturation
The term shift to the left indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor/weakness, or cool extremities.
a. Check for any iodine allergy.
b. Insert a large-bore IV catheter.
c. Place the patient on NPO status.
d. Assist the patient to a flat position.
During a liver/spleen scan, a radioactive isotope is injected IV and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter is not needed. The patient is placed in a flat position before the scan.
a. ABO blood typing
b. Bone marrow biopsy
c. Abdominal ultrasound
d. Complete blood count (CBC)
A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or guardian.
a. Monocytes 4%
b. Hemoglobin 13.6 g/dL
c. Platelet count 168,000/µL
d. White blood cells (WBCs) 15,500/µL
The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient’s pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.
a. Platelet count
b. White blood cell count
c. History of abdominal pain
d. Blood pressure and heart rate
The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent, but not as indicative of the need for rapid treatment as the platelet count.
a. a hematocrit (Hct) of 38%.
b. an RBC count of 4,500,000/L.
c. normal red blood cell (RBC) indices.
d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
The patient’s clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.
a. Omelet and whole wheat toast
b. Cantaloupe and cottage cheese
c. Strawberry and banana fruit plate
d. Cornmeal muffin and orange juice
Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.
b. folic acid.
c. cobalamin (vitamin B12).
d. ascorbic acid (vitamin C).
Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
a. need to start eating more red meat and liver.”
b. will stop having a glass of wine with dinner.”
c. could choose nasal spray rather than injections of vitamin B12.”
d. will need to take a proton pump inhibitor like omeprazole (Prilosec).”
Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.
a. provide a diet high in vitamin K.
b. alternate periods of rest and activity.
c. teach the patient how to avoid injury.
d. place the patient on protective isolation.
Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.
a. “I will call my health care provider if my stools turn black.”
b. “I will take a stool softener if I feel constipated occasionally.”
c. “I should take the iron with orange juice about an hour before eating.”
d. “I should increase my fluid and fiber intake while I am taking iron tablets.”
It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. The other patient statements are
a. Potential complication: seizures
b. Potential complication: infection
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema
Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.
a. limit the patient’s intake of oral and IV fluids.
b. evaluate the effectiveness of opioid analgesics.
c. encourage the patient to ambulate as much as tolerated.
d. teach the patient about high-protein, high-calorie foods.
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
a. “Home oxygen therapy is frequently used to decrease sickling.”
b. “There are no effective medications that can help prevent sickling.”
c. “Routine continuous dosage narcotics are prescribed to prevent a crisis.”
d. “Risk for a crisis is decreased by having an annual influenza vaccination.”
Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.
a. Take a daily multivitamin with iron.
b. Limit fluids to 2 to 3 quarts per day.
c. Avoid exposure to crowds when possible.
d. Drink only two caffeinated beverages daily.
Exposure to crowds increases the patient’s risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.
a. Schilling test.
b. bilirubin level.
c. stool occult blood test.
d. gastric analysis testing.
Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.
a. Use low-molecular-weight heparin (LMWH) only.
b. Administer the warfarin (Coumadin) at the scheduled time.
c. Teach the patient about the purpose of platelet transfusions.
d. Discontinue heparin and flush intermittent IV lines using normal saline.
All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.
a. place the patient on bed rest.
b. administer iron supplements.
c. avoid use of aspirin products.
d. monitor fluid intake and output
Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.
a. Assign the patient to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a soft toothbrush for oral care.
d. Restrict activity to passive and active range of motion.
IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.
a. Prothrombin time
b. Erythrocyte count
c. Fibrinogen degradation products
d. Activated partial thromboplastin time
Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.
a. immobilize the joint.
b. apply heat to the knee.
c. assist the patient with light weight bearing.
d. perform passive range of motion to the knee.
The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.
a. platelet count.
b. bleeding time.
c. thrombin time.
d. prothrombin time.
The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.
a. blood transfusion
b. bone marrow biopsy.
c. filgrastim (Neupogen) administration.
d. erythropoietin (Epogen) administration.
Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.
a. Avoid any injections.
b. Check temperature every 4 hours.
c. Omit fruits or vegetables from the diet.
d. Place a “No Visitors” sign on the door.
The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a “no visitors” policy is not needed.
a. Platelet count
b. Reticulocyte count
c. Total lymphocyte count
d. Absolute neutrophil count
Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.
a. “If you do not want to have chemotherapy, other treatment options include stem cell transplantation.”
b. “The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.”
c. “The decision about treatment is one that you and the doctor need to make rather than asking what I would do.”
d. “You don’t need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly.”
This response uses therapeutic communication by addressing the patient’s question and giving accurate information. The other responses either give inaccurate information or fail to address the patient’s question, which will discourage the patient from asking the nurse for information.
a. Infuse the PRBCs slowly over 4 hours.
b. Transfuse only leukocyte-reduced PRBCs.
c. Administer the scheduled diuretic before the transfusion.
d. Give the PRN dose of antihistamine before the transfusion.
TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.
a. emphasize the positive outcomes of a bone marrow transplant.
b. discuss the need for adequate insurance to cover post-HSCT care.
c. ask the patient whether there are any questions or concerns about HSCT.
d. explain that a cure is not possible with any other treatment except HSCT.
Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.
a. Monitor fluid intake and output.
b. Administer calcium supplements.
c. Assess lymph nodes for enlargement.
d. Limit weight bearing and ambulation.
A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient’s calcium level and are not used.
a. check all stools for occult blood.
b. encourage fluids to 3000 mL/day.
c. provide oral hygiene every 2 hours.
d. check the temperature every 4 hours.
Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.
a. Discuss the need for hospital admission to treat the neutropenia.
b. Teach the patient to administer filgrastim (Neupogen) injections.
c. Plan to discontinue the chemotherapy until the neutropenia resolves.
d. Order a high-efficiency particulate air (HEPA) filter for the patient’s home.
The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient’s home environment.
a. The platelet count is 52,000/µL.
b. The patient is difficult to arouse.
c. There are purpura on the oral mucosa.
d. There are large bruises on the patient’s back.
Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.
a. Verify the patient identification (ID) according to hospital policy.
b. Obtain the temperature, blood pressure, and pulse before the transfusion.
c. Double-check the product numbers on the PRBCs with the patient ID band.
d. Monitor the patient for shortness of breath or chest pain during the transfusion.
UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.
a. Draw blood for a new crossmatch.
b. Send a urine specimen to the laboratory.
c. Administer PRN acetaminophen (Tylenol).
d. Give the PRN diphenhydramine (Benadryl).
The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.
a. administer oxygen therapy at a high flow rate.
b. obtain a urine specimen to send to the laboratory.
c. notify the health care provider about the symptoms.
d. disconnect the transfusion and infuse normal saline.
The patient’s symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
a. A patient with chronic heart failure
b. A patient who has viral pneumonia
c. A patient who has right leg cellulitis
d. A patient with multiple abdominal drains
Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
a. The patient with hemochromatosis who reports abdominal pain
b. The patient with neutropenia who has a temperature of 101.8° F
c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours
d. The patient with thrombocytopenia who has oozing after having a tooth extracted
A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.
a. The platelet count is 42,000/L.
b. Petechiae are present on the chest.
c. Blood pressure (BP) is 94/56 mm Hg.
d. Blood is oozing from the venipuncture site.
Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/L unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.
a. Leg bruises
b. Tarry stools
c. Skin abrasions
d. Bleeding gums
Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.
a. Avoid venipunctures.
b. Notify the patient’s physician.
c. Apply sterile dressings to the sites.
d. Give prescribed proton-pump inhibitors.
The patient’s new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.
a. Administer morphine sulfate 4 mg IV.
b. Give acetaminophen (Tylenol) 650 mg.
c. Infuse normal saline 500 mL over 30 minutes.
d. Schedule complete blood count and coagulation studies.
The patient’s blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions also are appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.
a. Assessing the patient for signs and symptoms of infection
b. Teaching the patient the purpose of neutropenic precautions
c. Administering subcutaneous filgrastim (Neupogen) injection
d. Developing a discharge teaching plan for the patient and family
Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice.
a. 44-year-old with sickle cell anemia who says “my eyes always look sort of yellow”
b. 23-year-old with no previous health problems who has a nontender lump in the axilla
c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue
d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement
The patient’s age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.
a. 56-year-old with frequent explosive diarrhea
b. 33-year-old with a fever of 100.8° F (38.2° C)
c. 66-year-old who has white pharyngeal lesions
d. 23-year old who is complaining of severe fatigue
Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.
a. Teach the patient to use iron supplements.
b. Avoid the use of intramuscular injections.
c. Administer iron chelation therapy as needed.
d. Notify health care provider of hemoglobin 11g/dL.
The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.
a. Skin color
c. Liver function
d. Serum iron level
Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient’s iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine.
a. Hematocrit 55%
b. Presence of plethora
c. Calf swelling and pain
d. Platelet count 450,000/L
The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.
a. Potential impact of chemotherapy treatment on fertility
b. Application of soothing lotions to treat residual pruritus
c. Use of maintenance chemotherapy to maintain remission
d. Need for follow-up appointments to screen for malignancy
The chemotherapy used in treating Hodgkin’s lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-year-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin’s lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a concern after treatment.
c. Oral ulcers
d. Lip swelling
Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy, but are not immediately life threatening.
a. Serum calcium level is 15 mg/dL.
b. Patient reports no stool for 5 days.
c. Urine sample has Bence-Jones protein.
d. Patient is complaining of severe back pain.
Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider, but are not life threatening.
a. Discourage deep breathing to reduce risk for splenic rupture.
b. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain.
c. Schedule immunization with the pneumococcal vaccine (Pneumovax).
d. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.
Asplenic patients are at high risk for infection with Pneumococcus and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth and the patient should be encouraged to take deep breaths.
b. Increasing fatigue
d. Frequent constipation
The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leucopenia. The other information may require further assessment or treatment, but does not place the patient at immediate risk for complications.
a. “Do you have to urinate at night?”
b. “Do you have blood in your urine?”
c. “Do you have to urinate frequently?”
d. “Do you have pain when you urinate?”
Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency.
a. send a urine specimen to the laboratory to test for ketones.
b. obtain a clean-catch urine for culture and sensitivity testing.
c. inquire about which medications the patient is currently taking.
d. ask the patient about any family history of chronic renal failure.
Normally the urinalysis will show zero to trace amounts of protein, but some medications may give false-positive readings. The other actions by the nurse may be appropriate, but checking for medications that may affect the dipstick accuracy should be done first.
a. Urinary catheter
b. Cleaning towelettes
c. Large container for urine
d. Sterile urine specimen cup
Because creatinine clearance testing involves a 24-hour urine specimen, the nurse should obtain a large container for the urine collection. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test.
a. renal failure.
b. kidney stones.
d. bladder cancer
Exposure to the chemicals involved with working as a hairdresser and in smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. The patient is not at increased risk for renal failure, pyelonephritis, or kidney stones.
a. ibuprofen (Motrin)
b. warfarin (Coumadin)
c. folic acid (vitamin B9)
d. penicillin (Bicillin LA)
The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function. The nurse also should ask about reasons the patient is taking the other medications, but the medication of most concern is the ibuprofen.
a. Limit fluid intake to no more than 1000 mL/day.
b. Leave a light on in the bathroom during the night.
c. Ask the patient to use a urinal so that urine can be measured.
d. Pad the patient’s bed to accommodate overflow incontinence.
The patient’s age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient’s output is necessary or that the patient has overflow incontinence
a. Obtain a urine specimen to check for hematuria.
b. Document the information on the assessment form.
c. Ask the patient about any history of recent sore throat.
d. Ask the health care provider about scheduling a renal ultrasound.
The kidneys are protected by the abdominal organs, ribs, and muscles of the back, and may not be palpable under normal circumstances, so no action except to document the assessment information is needed. Asking about a recent sore throat, checking for hematuria, or obtaining a renal ultrasound may be appropriate when assessing for renal problems for some patients, but there is nothing in the question stem to indicate that they are appropriate for this patient.
a. Palpate along both sides of the lumbar vertebral column.
b. Strike a flat hand covering the costovertebral angle (CVA).
c. Push fingers upward into the two lowest intercostal spaces.
d. Percuss between the iliac crest and ribs along the midaxillary line.
Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain.
a. 60 mL/min
b. 90 mL/min
c. 120 mL/min
d. 180 mL/min
The creatinine clearance approximates the GFR. The other responses are not accurate.
a. determine kidney position.
b. identify renal artery bruits.
c. check for ureteral peristalsis.
d. assess for bladder distention.
The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm. Auscultation would not be helpful in assessing for the other listed urinary tract information.
a. The patient has not had food or drink for 8 hours.
b. The patient lists allergies to shellfish and penicillin.
c. The patient complains of costovertebral angle (CVA) tenderness.
d. The patient used a bisacodyl (Dulcolax) tablet the previous night.
Iodine-based contrast dye is used during IVP and for many computed tomography (CT) scans. The nurse will need to notify the health care provider before the procedures so that the patient can receive medications such as antihistamines or corticosteroids before the procedures are started. The other information is also important to note and document but does not have immediate implications for the patient’s care during the procedures.
a. “Your doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys.”
b. “Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney.”
c. “Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray.”
d. “Your doctor will inject a radioactive solution into a vein in your arm and the distribution of the isotope in your kidneys and bladder will be checked.”
In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The response beginning, “Your doctor will place a catheter” describes a renal arteriogram procedure. The response beginning, “Your doctor will inject a radioactive solution” describes a nuclear scan. The response beginning, “Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted” describes a retrograde pyelogram.
a. learns to request narcotics for pain.
b. understands to expect blood-tinged urine.
c. restricts activity to bed rest for a 4 to 6 hours.
d. remains NPO for 8 hours to prevent vomiting.
Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on urination is common, but pain that requires opioids for relief is not expected. A good fluid intake is encouraged after this procedure. Bed rest is not required following cystoscopy.
a. Fleet enema
b. Tap-water enema
c. Senna/docusate (Senokot-S)
d. Bisacodyl (Dulcolax) tablets
High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure. The other medications for bowel evacuation are more appropriate
a. have the patient empty the bladder completely, then obtain the next urine specimen that the patient is able to void.
b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.
c. insert a short sterile “mini” catheter attached to a collecting container into the urethra and bladder to obtain the specimen.
d. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container.
This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, “insert a short, small, ‘mini’ catheter attached to a collecting container” describes a technique that would result in a sterile specimen, but a health care provider’s order for a catheterized specimen would be required. Using Betadine before obtaining the specimen is not necessary, and might result in suppressing the growth of some bacteria. The technique described in the answer beginning “have the patient empty the bladder completely” would not result in a sterile specimen.
a. Monitor the urine output after the procedure.
b. Assist with monitored anesthesia care (MAC).
c. Give oral contrast solution before the procedure.
d. Insert a large size urinary catheter before the IVP.
Patients with impaired renal function are at risk for decreased renal function after IVP because the contrast medium used is nephrotoxic, so the nurse should monitor the patient’s urine output. MAC sedation and retention catheterization are not required for the procedure. The contrast medium is given IV, not orally.
a. Check blood glucose to assess for hyperglycemia or hypoglycemia.
b. Insert a urinary catheter and test urine for gross or microscopic hematuria.
c. Monitor the blood urea nitrogen (BUN) and creatinine to assess renal function.
d. Apply a pressure dressing and keep the patient on the affected side for 30 minutes.
A pressure dressing is applied and the patient is kept on the affected side for 30 to 60 minutes to put pressure on the biopsy side and decrease the risk for bleeding. The blood glucose and BUN/creatinine will not be affected by the biopsy. Although monitoring for hematuria is needed, there is no need for catheterization.
a. Notify the patient’s health care provider.
b. Teach correct midstream urine collection.
c. Ask the patient about current medications.
d. Question the patient about urinary tract infection (UTI) risk factors.
A red-orange color in the urine is normal with some over-the-counter (OTC) medications such as phenazopyridine (Pyridium). The color would not be expected with urinary tract infection, is not a sign that poor technique was used in obtaining the specimen, and does not need to be communicated to the health care provider until further assessment is done.
a. Ask about the usual urinary pattern and any measures used for bladder control.
b. Assist the patient to the toilet at scheduled times to help ensure bladder emptying.
c. Check the patient for urinary incontinence every 2 hours to maintain skin integrity.
d. Use intermittent catheterization on a regular schedule to avoid the risk of infection.
Before planning any interventions, the nurse should complete the assessment and determine the patient’s normal bladder pattern and the usual measures used by the patient at home. All the other responses may be appropriate, but until the assessment is complete, an individualized plan for the patient cannot be developed.
a. pH 6.2
b. Trace protein
c. WBC 20 to 26/hpf
d. Specific gravity 1.021
The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation. The other findings are normal.
a. “My urine looks pink.”
b. “My IV site is bruised.”
c. “My sleep was restless.”
d. “My temperature is 101.”
The patient’s elevated temperature may indicate a bladder infection, a possible complication of cystoscopy. The health care provider should be notified so that antibiotic therapy can be started. Pink-tinged urine is expected after a cystoscopy. The insomnia and bruising should be discussed further with the patient but do not indicate a need to notify the health care provider.
a. The heart rate is 58 beats/minute.
b. The patient complains of a dry mouth.
c. The respiratory rate is 38 breaths/minute.
d. The urine output is 400 mL after 2 hours.
The increased respiratory rate indicates that the patient may be experiencing an allergic reaction to the contrast medium used during the procedure. The nurse should immediately assess the patient’s oxygen saturation and breath sounds. The other data are not unusual findings following an IVP.
a. Patient who is scheduled for a renal biopsy after a recent kidney transplant
b. Patient who will need monitoring for several hours after a renal arteriogram
c. Patient who requires teaching about possible post-cystoscopy complications
d. Patient who will have catheterization to check for residual urine after voiding
LPN/LVN education includes common procedures such as catheterization of stable patients. The other patients require more complex assessments and/or patient teaching that are included in registered nurse (RN) education and scope of practice.
a. Teach the patient to take the prescribed Bactrim for 3 more days.
b. Remind the patient about the need to drink 1000 mL of fluids daily.
c. Obtain a midstream urine specimen for culture and sensitivity testing.
d. Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.
Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter (OTC) medications such as phenazopyridine (Pyridium) in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with Bactrim, the patient is likely to need a different antibiotic.
a. “I can use vaginal antiseptic sprays to reduce bacteria.”
b. “I will drink a quart of water or other fluids every day.”
c. “I will wash with soap and water before sexual intercourse.”
d. “I will empty my bladder every 3 to 4 hours during the day.”
Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.
a. Pyridium may cause photosensitivity
b. Pyridium may change the urine color.
c. Take the Pyridium for at least 7 days.
d. Take Pyridium before sexual intercourse.
Patients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Pyridium does not cause photosensitivity. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI.
a. Bladder distention
b. Foul-smelling urine
c. Suprapubic discomfort
d. Costovertebral tenderness
Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.
a. “I should stop having coffee and orange juice for breakfast.”
b. “I will buy calcium glycerophosphate (Prelief) at the pharmacy.”
c. “I will start taking high potency multiple vitamins every morning.”
d. “I should call the doctor about increased bladder pain or odorous urine.”
High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.
a. history of kidney stones.
b. recent sore throat and fever.
c. history of high blood pressure.
d. frequency of bladder infections.
Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by kidney stones, hypertension, or urinary tract infection (UTI).
a. The patient denies pain with voiding.
b. The urine dipstick is negative for nitrites.
c. The antistreptolysin-O (ASO) titer is decreased.
d. The periorbital and peripheral edema is resolved.
Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection.
Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure.
a. Poor skin turgor
b. Recent weight gain
c. Elevated urine ketones
d. Decreased blood pressure
The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.
a. milk and cheese.
b. sardines and liver.
c. legumes and dried fruit.
d. spinach, chocolate, and tea.
Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.
a. using a filter to strain all urine.
b. avoiding dietary sources of calcium.
c. choosing diuretic fluids such as coffee.
d. drinking 2000 to 3000 mL of fluid a day.
A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.
a. preventing bleeding with anticoagulants.
b. monitoring and recording blood pressure.
c. obtaining and documenting daily weights.
d. measuring daily intake and output volumes.
Hypertension is the major symptom of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis.
a. Complications of renal transplantation
b. Methods for treating severe chronic pain
c. Discussion of options for genetic counseling
d. Differences between hemodialysis and peritoneal dialysis
Because a 28-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.
a. recent kidney trauma.
b. gonococcal urethritis.
c. recurrent bladder infection.
d. benign prostatic hyperplasia.
The patient’s clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.
a. kidney stones.
b. bladder cancer.
c. bladder infection.
d. interstitial cystitis.
Cigarette smoking is a risk factor for bladder cancer. The patient’s risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney stones will not be reduced by quitting smoking.
a. Restrict fluids between meals and after the evening meal.
b. Apply absorbent incontinent pads liberally over the bed linens.
c. Insert an indwelling catheter until the symptoms have resolved.
d. Assist the patient to the bathroom every 2 hours during the day.
In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.
a. Assist the patient to the bathroom q3hr.
b. Place a commode at the patient’s bedside.
c. Demonstrate how to perform the Credé maneuver.
d. Teach the patient how to perform Kegel exercises.
Kegel exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.
a. Monitor the patient’s intake and output over night.
b. Have the patient drink small amounts of fluid frequently.
c. Use an ultrasound scanner to check the postvoiding residual volume.
d. Reassure the patient that this is normal after rectal surgery because of anesthesia.
An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient’s history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis and discomfort from a full bladder if the nurse waits to address the problem for several hours.
a. Demonstrate the use of the Credé maneuver.
b. Teach exercises to strengthen the pelvic floor.
c. Place a bedside commode close to the patient’s bed.
d. Use an ultrasound scanner to check postvoiding residuals
Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.
a. “I will buy seven new catheters weekly and use a new one every day.”
b. “I will use a sterile catheter and gloves for each time I self-catheterize.”
c. “I will clean the catheter carefully before and after each catheterization.”
d. “I will need to take prophylactic antibiotics to prevent any urinary tract infections.”
Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.
a. Provide teaching about home care for both catheters.
b. Apply continuous steady tension to the ureteral catheter.
c. Call the health care provider if the ureteral catheter output drops suddenly.
d. Clamp the ureteral catheter off when output from the urethral catheter stops.
The health care provider should be notified if the ureteral catheter output decreases because obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided in order to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Because the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed.
a. Application of ostomy appliances
b. Barrier products for skin protection
c. Catheterization technique and schedule
d. Analgesic use before emptying the pouch
The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.
a. anxiety related to effects of procedure on lifestyle.
b. disturbed body image related to change in function.
c. readiness for enhanced coping related to need for information.
d. self-care deficit, toileting, related to denial of altered body function.
The patient’s unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient. The patient does not appear to be ready for enhanced coping. The patient’s insistence that only the ostomy nurse care for the stoma indicates that denial is not present.
a. The patient is voiding every 4 hours.
b. The patient is using opioids for pain.
c. The patient has seen clots in the urine.
d. The patient is anxious about the cancer.
Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.
a. premedicating to prevent nausea.
b. obtaining wigs and scarves to wear.
c. emptying the bladder before the medication.
d. maintaining oral care during the treatments.
The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not usually experienced with intravesical chemotherapy.
a. Encouraging adequate oral fluid intake
b. Testing urine with a dipstick daily for nitrites
c. Avoiding unnecessary urinary catheterizations
d. Providing frequent perineal hygiene to patients
Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.
a. Poor urine output
b. Bilateral flank pain
c. Nausea and vomiting
d. Burning on urination
Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.
a. Complaint of flank pain
b. Blood pressure 90/48 mm Hg
c. Cloudy and foul-smelling urine
d. Temperature 100.1° F (57.8° C)
The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.
a. Activity intolerance related to rapidly increased weight
b. Excess fluid volume related to low serum protein levels
c. Disturbed body image related to peripheral edema and ascites
d. Altered nutrition: less than required related to protein restriction
The patient has massive edema, so the priority problem at this time is the excess fluid volume. The other nursing diagnoses are also appropriate, but the focus of nursing care should be resolution of the edema and ascites.
a. Insert a urinary retention catheter.
b. Schedule an intravenous pyelogram (IVP).
c. Draw blood for a serum creatinine level.
d. Administer lorazepam (Ativan) 0.5 mg PO.
The patient’s history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient’s agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test but does not need to be done urgently.
a. Administer prescribed analgesics.
b. Monitor temperature every 4 hours.
c. Encourage increased oral fluid intake.
d. Give antiemetics as needed for nausea.
Although all of the nursing actions may be used for patients with renal lithiasis, the patient’s presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.
a. Change the ostomy appliance.
b. Choose the appropriate ostomy bag.
c. Monitor the appearance of the stoma.
d. Assess for possible urinary tract infection (UTI).
Changing the ostomy appliance for a stable patient could be done by UAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for (UTI) symptoms require more education and scope of practice and should be done by the registered nurse (RN).
a. Blood in urine
b. Left flank bruising
c. Left flank discomfort
d. Decreased urine output
Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.
a. Assist the patient to soak in a 15-minute sitz bath.
b. Insert a straight urethral catheter and drain the bladder.
c. Encourage the patient to drink several glasses of water.
d. Teach the patient how to do isometric perineal exercises.
Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids and Kegel exercises are helpful in the prevention of incontinence, these activities would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection (UTI) and should be avoided when possible
a. Taping the catheter to the skin on the patient’s upper inner thigh
b. Cleaning around the patient’s urinary meatus with soap and water
c. Disconnecting the catheter from the drainage tube to obtain a specimen
d. Using an alcohol-based gel hand cleaner before performing catheter care
The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection (UTI). The other actions are appropriate and do not require any intervention.
a. Blood pressure is 102/58.
b. Urine output is 20 mL/hr for 2 hours.
c. Incisional pain level is reported as 9/10.
d. Crackles are heard at bilateral lung bases.
Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.
a. Cloudy appearing urine
b. Hypotonic bowel sounds
c. Heart rate 102 beats/minute
d. Continuous stoma drainage
Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.
a. Infuse 5% dextrose in normal saline at 75 mL/hr.
b. Order regular diet after patient is awake and alert.
c. Give ketorolac (Toradol) 10 mg PO PRN for pain.
d. Draw blood urea nitrogen (BUN) and creatinine in 2 hours.
The nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.
a. Urinary urgency
b. Left-sided flank pain
c. Intermittent hematuria
d. Burning with urination
Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI).
a. Teach the patient about the use of antifungal medications.
b. Tell the patient to avoid tub baths until the symptoms resolve.
c. Instruct the patient to refer recent sexual partners for treatment.
d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).
Monilial urethritis is caused by a fungus and antifungal medications such as nystatin (Mycostatin) or fluconazole (Diflucan) are usually used as treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths and NSAIDS may be used to treat symptoms.
a. Prepare patient for a renal biopsy.
b. Provide preoperative teaching about nephrectomy.
c. Teach the patient about chemotherapy medications.
d. Schedule for a follow-up appointment in 3 months.
The treatment of choice in patients with localized renal tumors who have no co-morbid conditions is partial or total nephrectomy. A renal biopsy will not be needed in a patient who has already been diagnosed with renal cancer. Chemotherapy is used for metastatic renal cancer. Because renal cell cancer frequently metastasizes, treatment will be started as soon as possible after the diagnosis.
a. Blood urea nitrogen level is 70 mg/dL.
b. Urine output over the last 2 hours is 30 mL.
c. Audible crackles bilaterally over the posterior chest to the midscapular level.
d. Elevated level of antiglomerular basement membrane (anti-GBM) antibodies.
Crackles heard to a high level indicate a need for rapid actions such as assessment of oxygen saturation, reporting the findings to the health care provider, initiating oxygen therapy, and dialysis. The other findings will also be reported, but are typical of Goodpasture syndrome and do not require immediate nursing action.
a. Check blood pressure and heart rate.
b. Administer morphine sulfate 4 mg IV.
c. Transport to radiology for an intravenous pyelogram.
d. Insert a urethral catheter and obtain a urine specimen.
Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions are also important once the patient’s cardiovascular status has been determined and stabilized.
a. Patient with a urethral stricture who has not voided for 12 hours
b. Patient who has cloudy urine after orthotopic bladder reconstruction
c. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg
d. Patient who voided bright red urine immediately after returning from lithotripsy
The patient information suggests acute urinary retention, a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will also be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or possible intervention.
Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones.
a. Ask family members about the patient’s health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the patient is better oriented to ask questions.
d. Obtain only the physiologic neurologic assessment data.
When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient’s health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information.
c. No sensation
d. Hyperactive reflexes
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.
a. sensation on the left side of the body.
b. voluntary movements on the right side.
c. reasoning and problem-solving abilities.
d. understanding written and oral language.
The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.
a. dry mouth.
d. urinary retention.
Inhibition of the fight or flight response leads to a decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.
a. shine a light into the patient’s pupil.
b. check for unilateral eyelid drooping.
c. touch a cotton wisp strand to the cornea.
d. have the patient read a magazine or book
The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.
a. Withhold oral fluid or foods.
b. Provide highly seasoned foods.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour.
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes.
After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain if a lumbar puncture is performed. The other orders are appropriate.
a. enforce NPO status for 4 hours.
b. transfer the patient to radiology.
c. administer a sedative medication.
d. help the patient to a lateral position.
For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration
a. cerebellar injury.
b. a brainstem lesion.
c. frontal lobe damage.
d. a temporal lobe lesion.
Expressive speech is controlled by Broca’s area in the frontal lobe. The temporal lobe contains Wernicke’s area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech.
a. prevent falls.
b. stabilize mood.
c. avoid aspiration.
d. improve memory.
Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
a. Acute pain
b. Risk for falls
c. Acute confusion
d. Ineffective thermoregulation
A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for orientation, thermoregulation, or discomfort.
a. Cerebral angiography
b. Evoked potential studies
c. Electromyography (EMG)
d. Electroencephalography (EEG)
Seizure disorders are usually assessed using EEG testing. Evoked potential is used for diagnosing problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.
a. Monitor for headache and photophobia.
b. Keep patient NPO until gag reflex returns.
c. Check pulse and blood pressure frequently.
d. Assess orientation to person, place, and time.
Because a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography.
a. Sharp pin
b. Tuning fork
c. Reflex hammer
d. Calibrated compass
Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination
a. Triceps reflex response graded at 1/5
b. Unintended weight loss of 20 pounds
c. 10 mm Hg orthostatic drop in systolic blood pressure
d. Patient complaint of chronic difficulty in falling asleep
Although changes in appetite are normal with aging, a 20-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.
a. The new nurse tests for light touch before testing for pain.
b. The new nurse has the patient close the eyes during testing.
c. The new nurse asks the patient if the instrument feels sharp.
d. The new nurse uses an irregular pattern to test for intact touch
When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.
a. Specific gravity 1.007
b. Protein 65 mg/dL (0.65 g/L)
c. Glucose 45 mg/dL (1.7 mmol/L)
d. White blood cell (WBC) count 4 cells/L
The protein level is high. The specific gravity, WBCs, and glucose values are normal.
a. The patient is anxious about the test.
b. The patient has an allergy to shellfish.
c. The patient has back pain when lying flat.
d. The patient drank apple juice 4 hours earlier.
Iodine-containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the postmyelogram orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient’s anxiety should be addressed, but this is not as important as the iodine allergy.
a. reflex reaction time.
b. pupil reaction to light.
c. level of consciousness.
d. respiratory rate and rhythm.
Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information will also be collected by the nurse, but it is not as urgent.
a. Patient with a transient ischemic attack (TIA) returning from carotid duplex studies
b. Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram
c. Patient with a seizure disorder who has just completed an electroencephalogram (EEG)
d. Patient prepared for a lumbar puncture whose health care provider is waiting for assistance
Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse, blood pressure, and the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible, but monitoring for hemorrhage after cerebral angiogram has a higher priority.
a. Assess for graphesthesia.
b. Observe arm swing with gait.
c. Perform the finger-to-nose test.
d. Check ability to push against resistance.
e. Determine ability to sense heat and cold.
The cerebellum is responsible for coordination and is assessed by looking at the patient’s gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment.
cerebral aneurysm clipping.
heparin intravenous infusion.
oral low-dose aspirin therapy.
tissue plasminogen activator (tPA).
The patient’s symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient’s symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
The patient has dysphasia.
The patient has atrial fibrillation.
The patient reports that symptoms began with a severe headache.
The patient has a history of brief episodes of right-sided hemiplegia.
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
Hyperactive left-sided tendon reflexes
Difficulty comprehending instructions
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
to monitor and record the blood pressure daily.
that Plavix will dissolve clots in the cerebral arteries.
that Plavix will reduce cerebral artery plaque formation.
to call the health care provider if stools are bloody or tarry.
Clopidogrel (Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots
“The obstructing plaque is surgically removed from an artery in the neck.”
“The diseased portion of the artery in the brain is replaced with a synthetic graft.”
“A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed.”
“A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.”
In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, “The diseased portion of the artery in the brain is replaced” describes an arterial graft procedure. The answer beginning, “A catheter with a deflated balloon is positioned at the narrow area” describes an angioplasty. The final response beginning, “A wire is threaded through the artery” describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.
Keep head of bed elevated at least 30 degrees.
Infuse normal saline intravenously at 75 mL/hr.
Administer tissue plasminogen activator (tPA) per protocol.
Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
intravenous heparin administration.
tissue plasminogen activator (tPA) infusion.
The patient’s history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
ask questions that the patient can answer with “yes” or “no.”
develop a list of words that the patient can read and practice reciting.
have the patient practice her facial and tongue exercises with a mirror.
prevent embarrassing the patient by answering for her if she does not respond.
Communication will be facilitated and less frustrating to the patient when questions that require a “yes” or “no” response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
risk for injury related to denial of deficits and impulsiveness.
impaired physical mobility related to right-sided hemiplegia.
impaired verbal communication related to speech-language deficits.
ineffective coping related to depression and distress about disability.
The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
Apply an eye patch to the right eye.
Approach the patient from the right side.
Place objects needed on the patient’s left side.
Teach the patient that the left visual deficit will resolve.
During the acute period, the nurse should place objects on the patient’s unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
Provide a wide variety of food choices.
Provide oral care before and after meals.
Assist the patient to eat with the right hand.
Teach the patient the “chin-tuck” technique.
Because the nursing diagnosis indicates that the patient’s imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
Apply intermittent pneumatic compression stockings.
Assist to dangle on edge of bed and assess for dizziness.
Encourage patient to cough and deep breathe every 4 hours.
Insert an oropharyngeal airway to prevent airway obstruction.
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
order a varied pureed diet.
assess the patient’s appetite.
assist the patient into a chair.
offer the patient a sip of juice.
The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
Interrupted family processes related to effects of illness of a family member
Situational low self-esteem related to increasing dependence on spouse for care
Disabled family coping related to inadequate understanding by patient’s spouse
Impaired nutrition: less than body requirements related to hemiplegia and aphasia
The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.
Limit fluid intake to 1200 mL daily to reduce urine volume.
Assist the patient onto the bedside commode every 2 hours.
Perform intermittent catheterization after each voiding to check for residual urine.
Use an external “condom” catheter to protect the skin and prevent embarrassment.
Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown
Document that the aspirin was refused by the patient.
Tell the patient that the aspirin is used to prevent a fever.
Explain that the aspirin is ordered to decrease stroke risk.
Call the health care provider to clarify the medication order.
Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient’s refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
Following a transient ischemic attack (TIA), patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
use a calm voice to ask the patient to stop the crying behavior.
explain to the family that depression is normal following a stroke.
have the family members leave the patient alone for a few minutes.
teach the family that emotional outbursts are common after strokes.
Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient’s outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient’s control and asking the patient to stop will lead to embarrassment.
The patient is 25 pounds above the ideal weight.
The patient drinks a glass of red wine with dinner daily.
The patient’s usual blood pressure (BP) is 170/94 mm Hg.
The patient works at a desk and relaxes by watching television.
Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.
The patient’s speech is difficult to understand.
The patient’s blood pressure is 144/90 mm Hg.
The patient takes a diuretic because of a history of hypertension.
The patient has atrial fibrillation and takes warfarin (Coumadin).
The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient’s care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated
Complete blood count (CBC)
Chest radiograph (Chest x-ray)
12-Lead electrocardiogram (ECG)
Noncontrast computed tomography (CT) scan
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
Impaired physical mobility related to weakness
Disturbed sensory perception related to brain injury
Risk for impaired skin integrity related to immobility
Risk for aspiration related to inability to protect airway
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time
The patient complains of having a stiff neck.
The patient’s blood pressure (BP) is 90/50 mm Hg.
The patient reports a severe and unrelenting headache.
The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
Assess the patient’s gag and cough reflexes.
Determine when the stroke symptoms began.
Administer the prescribed short-acting insulin.
Infuse the prescribed IV metoprolol (Lopressor).
Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).
A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed
A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin)
A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.
The pulse rate is 102 beats/min.
The patient has difficulty speaking.
The blood pressure is 144/86 mm Hg.
There are fine crackles at the lung bases.
Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths
Monitor the blood pressure.
Send the patient for a computed tomography (CT) scan.
Check the respiratory rate and effort.
Assess the Glasgow Coma Scale score.
The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.
a. Obtain computed tomography (CT) scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
“I can take the (Topamax) as soon as a headache starts.”
“A glass of wine might help me relax and prevent a headache.”
“I will lie down someplace dark and quiet when the headaches begin.”
“I should avoid taking aspirin and sumatriptan (Imitrex) at the same time.”
It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.
throbbing, bilateral facial pain.
Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
Insert an oral airway during the seizure to maintain a patent airway.
Restrain the patient’s arms and legs to prevent injury during the seizure.
Time and observe and record the details of the seizure and postictal state.
Avoid touching the patient to prevent further nervous system stimulation.
Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure
“You might benefit from some psychologic counseling.”
“Epilepsy usually can be well controlled with medications.”
“You will want to contact the Epilepsy Foundation for assistance.”
“The Department of Vocational Rehabilitation can help with work retraining.”
The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.
Inspect the oral mucosa.
Listen to the lung sounds.
Auscultate the bowel tones.
Check pupil reaction to light.
Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.
The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.
assess for the presence of chest pain.
inquire about urinary tract problems.
inspect the skin for rashes or discoloration.
ask the patient about any increase in libido.
Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS
“MS symptoms may be worse after the pregnancy.”
“Women with MS frequently have premature labor.”
“MS is associated with an increased risk for congenital defects.”
“Symptoms of MS are likely to become worse during pregnancy.”
During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS
Recommendation to drink at least 4 L of fluid daily
Need to avoid driving or operating heavy machinery
How to draw up and administer injections of the medication
Use of contraceptive methods other than oral contraceptives
Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.
The patient has relapsing-remitting MS.
The patient walks a mile a day for exercise.
The patient complains of pain with neck flexion.
The patient has an increased serum creatinine level.
Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered
Decrease the patient’s evening fluid intake.
Teach the patient how to use the Credé method.
Suggest the use of adult incontinence briefs for nighttime only.
Assist the patient to the commode every 2 hours during the day.
The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.
Instruct the patient in activities that can be done while lying or sitting.
Suggest that the patient rock from side to side to initiate leg movement.
Have the patient take small steps in a straight line directly in front of the feet.
Teach the patient to keep the feet in contact with the floor and slide them forward.
Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.
The patient has a chronic dry cough.
The patient has four loose stools in a day.
The patient develops a deep vein thrombosis.
The patient’s blood pressure is 92/52 mm Hg.
Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.
perform physically demanding activities early in the day.
anticipate the need for weekly plasmapheresis treatments.
do frequent weight-bearing exercise to prevent muscle atrophy.
protect the extremities from injury due to poor sensory perception.
Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used.
Ibuprofen (Motrin, Advil)
Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome
Assist with active range of motion (ROM).
Observe for agitation and paranoia.
Give muscle relaxants as needed to reduce spasms.
Use simple words and phrases to explain procedures.
ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient’s ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.
use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms.
prophylactic antibiotics to decrease the risk for aspiration pneumonia.
option of genetic testing for the patient’s children to determine their own HD risks.
lifestyle changes of improved nutrition and exercise that delay disease progression.
Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.
magnetic resonance imaging (MRI).
electroencephalogram (EEG) testing.
The diagnosis of Parkinson’s is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson’s disease, and corticosteroid therapy is not used to treat it.
Teach about the use of triptan drugs.
Refer the patient for stress counseling.
Ask the patient to keep a headache diary.
Suggest the use of muscle-relaxation techniques.
The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.
Morphine sulfate (Roxanol)
Butalbital and aspirin (Fiorinal)
The patient’s symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.
Discuss the need to stop taking the acetaminophen.
Suggest the use of biofeedback for headache control.
Describe the use of botulism toxin (Botox) for headaches.
Teach the patient about magnetic resonance imaging (MRI).
The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if the headaches persist.
The patient drinks 1 to 2 cups of coffee daily.
The patient had a recent acute myocardial infarction.
The patient has had migraine headaches for 30 years.
The patient has taken topiramate (Topamax) for 2 months.
The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it indicates that sumatriptan would be an inappropriate treatment
assess the patient for a possible head injury.
give the scheduled dose of divalproex (Depakote).
document the timing and description of the seizure.
notify the patient’s health care provider about the seizure.
The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.
Give phenytoin (Dilantin) 100 mg IV.
Monitor level of consciousness (LOC).
Obtain computed tomography (CT) scan.
Administer lorazepam (Ativan) 4 mg IV.
To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
Make referrals to appropriate community agencies.
Place medications in the home medication organizer.
Teach the patient and family how to manage seizures.
Assess for use of medications that may precipitate seizures.
LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.
Tremor at rest
Cogwheel rigidity of limbs
Uncontrolled head movement
Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson’s disease.
Self-care deficit: toileting
Ineffective self-health management
Imbalanced nutrition: less than body requirements
The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson’s disease, but the data do not indicate that they are current problems for this patient.
Level of consciousness
Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.
Auscultate the patient’s bowel sounds.
Notify the patient’s health care provider.
Administer the prescribed PRN antiemetic drug.
Give the scheduled dose of prednisone (Deltasone).
The patient’s history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.
Start the ordered PRN oxygen at 6 L/min.
Put a moist hot pack on the patient’s neck.
Give the ordered PRN acetaminophen (Tylenol).
Notify the patient’s health care provider immediately.
Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.
Teach about the use of antihistamines to improve sleep.
Suggest that the patient exercise regularly during the day.
Make a referral to a massage therapist for deep massage of the legs.
Assure the patient that the problem is transient and likely to resolve.
Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms and RLS is likely to progress in most patients.
Patient has generalized tonic-clonic seizures.
Patient experiences an aura before seizures.
Patient’s most recent blood pressure is 156/92 mm Hg.
Patient has minor elevations in the liver function tests.
Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.
Patient with myasthenia gravis who is reporting increased muscle weakness
Patient with a bilateral headache described as “like a band around my head”
Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin)
Patient with Parkinson’s disease who has developed cogwheel rigidity of the arms
Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed, but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.
The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed’s side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.
Use an elevated toilet seat.
Cut patient’s food into small pieces.
Provide high-protein foods at each meal.
Place an armchair at the patient’s bedside.
Observe for sudden exacerbation of symptoms.
Because the patient with Parkinson’s has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson’s is a steadily progressive disease without acute exacerbations.
“Are you able to feed yourself without difficulty?”
“Do you have difficulty when you are putting on a shirt?”
“Are you able to sleep through the night without waking?”
“Do you ever have trouble lowering yourself to the toilet?”
The patient’s pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not affect the patient’s ability to feed himself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping.
the synovial membrane that lines the joint.
a small, fluid-filled sac found at some joints.
the fibrocartilage that acts as a shock absorber in the knee joint.
any connective tissue that is found supporting the joints of the body.
Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa.
magnetic resonance imaging (MRI).
dual-energy x-ray absorptiometry (DXA).
The decreased height and the patient’s age suggest that the patient may have osteoporosis and that bone density testing is needed. Discography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoporosis.
The patient sprained her ankle at age 13.
The patient’s mother became shorter with aging.
The patient takes ibuprofen (Advil) for occasional headaches.
The patient’s father died of complications of miliary tuberculosis.
A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient’s current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.
The patient takes a multivitamin daily.
The patient dislikes fruits and vegetables.
The patient is 5 ft 2 in and weighs 180 lb.
The patient prefers whole milk to nonfat milk.
The patient’s height and weight indicate obesity, which places stress on weight-bearing joints. The use of whole milk, avoiding fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal problems.
The patient takes a daily multivitamin and calcium supplement.
The patient takes hormone therapy (HT) to prevent “hot flashes.”
The patient has severe asthma and requires frequent therapy with oral corticosteroids.
The patient has migraine headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).
Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.
A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance.
having the patient move the extremities against resistance.
feeling for the presence of crepitus during joint movement.
observing the patient’s body build and muscle configuration.
checking active and passive range of motion for the extremities.
The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of abnormal areas. The other assessments are also included in the assessment but are usually done after inspection.
Raise the patient’s legs to a 60-degree angle from the bed.
Place the patient initially in the prone position on the exam table.
Have the patient dangle both legs over the edge of the exam table.
Instruct the patient to elevate the legs and tense the abdominal muscles.
When performing the straight leg-raising test, the patient is in the supine position and the nurse passively lifts the patient’s legs to a 60-degree angle. The other actions would not be correct for this test.
explain the procedure.
start an IV line for contrast medium injection.
give an oral sedative 60 to 90 minutes before the procedure.
screen the patient for allergies to shellfish or iodine products.
DXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Because the procedure is painless, no antianxiety medications are required.
The patient has a pacemaker.
The patient is claustrophobic.
The patient wears a hearing aid.
The patient is allergic to shellfish.
Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI.
Crackling sounds and a grating sensation that accompany movement are described as crepitus or crepitation. Torticollis is a twisting of the neck to one side, subluxation is a partial dislocation of the joint, and epicondylitis is an inflammation of the elbow that causes a dull ache that increases with movement.
Symmetric joint swelling of fingers
Decreased right knee range of motion
Report of left hip aching when jogging
History of recent loss of balance and fall
A history of falls requires further assessment and development of fall prevention strategies. The other changes are more typical of bone and joint changes associated with normal aging.
Scant thin fluid
Pale yellow fluid
The presence of purulent fluid suggests a possible joint infection. Normal synovial fluid is scant in amount and pale yellow/straw-colored.
Grade leg muscle strength for a patient with back pain.
Obtain blood sample for uric acid from a patient with gout.
Perform straight-leg-raise testing for a patient with sciatica.
Check for knee joint crepitation before arthroscopic surgery.
Drawing blood specimens is a common skill performed by UAP in clinic settings. The other actions are assessments and require registered nurse (RN)-level judgment and critical thinking.
Tack down scatter rugs in the home.
Most falls happen outside the home.
Buy shoes that provide good support and are comfortable to wear.
Range-of-motion exercises should be taught by a physical therapist.
Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries
wearing a left wrist splint.
modifying arm movements.
Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.
obtain a keyboard pad to support the wrist.
do stretching exercises before starting work.
wrap the wrists with compression bandages every morning.
avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.
Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling.
Keep the ankle loosely wrapped with gauze.
Apply a heating pad to reduce muscle spasms.
Use pillows to elevate the ankle above the heart.
Gently move the ankle through the range of motion.
Elevation of the leg will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.
“You will not be able to serve a tennis ball again.”
“You will work with a physical therapist tomorrow.”
“The doctor will use the drop-arm test to determine the success of surgery.”
“Leave the shoulder immobilizer on for the first 4 days to minimize pain.”
Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent “frozen shoulder.” A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion (ROM). The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.
for several months.
for at least 3 weeks.
until swelling of the wrist has resolved.
until x-rays show complete bony union.
Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.
loosen the traction and help the patient turn onto the unaffected side.
place a pillow between the patient’s legs and turn gently to each side.
turn the patient partially to each side with the assistance of another nurse.
have the patient lift the buttocks by bending and pushing with the right leg.
The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.
Avoid placing the patient in prone position.
Ask the patient about abdominal discomfort.
Discuss remaining on bed rest for several weeks.
Use the cast support bar to reposition the patient.
Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.
keep the left arm in dependent position.
avoid handling the cast using fingertips.
place gauze around the cast edge to pad any roughness.
cover the cast with a small blanket to absorb the dampness.
Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.
“I can get the cast wet as long as I dry it right away with a hair dryer.”
“I should avoid moving my fingers and elbow until the cast is removed.”
“I will apply an ice pack to the cast over the fracture site off and on for 24 hours.”
“I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.”
Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.
The patient moves the right crutch with the right leg and then the left crutch with the left leg.
The patient advances the left leg and both crutches together and then advances the right leg.
The patient uses the bedside chair to assist in balance as needed when ambulating in the room.
The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.
Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.
Notify the health care provider.
Assess the incision for redness.
Reposition the left leg on pillows.
Check the patient’s blood pressure.
The patient’s clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.
The patient states that the pelvis feels unstable.
Abdomen is distended and bowel sounds are absent.
There are ecchymoses across the abdomen and hips.
The patient complains of pelvic pain with palpation.
The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.
Check peripheral pulses.
Ask about hip pain level.
Assess for hip contractures.
Monitor for hip dislocation.
Buck’s traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck’s traction
“You will need to check and clean the pin insertion sites daily.”
“The external fixator can be removed for your bath or shower.”
“You will need to remain on bed rest until bone healing is complete.”
“Prophylactic antibiotics are used until the external fixator is removed.”
Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used
Use a mechanical lift to transfer the patient from the bed to the chair.
Check the postoperative orders for the patient’s weight-bearing status.
Avoid administration of pain medications before getting the patient up.
Delegate the transfer of the patient to nursing assistive personnel (NAP).
The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.
administration of nasogastric tube feedings.
how and when to cut the immobilizing wires.
the importance of high-fiber foods in the diet.
the use of sterile technique for dressing changes.
The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw.
“You are upset, but you may lose the foot anyway.”
“Many people are able to function with a foot prosthesis.”
“Tell me what you know about your options for treatment.”
“If you do not want an amputation, you do not have to have it.”
The initial nursing action should be to assess the patient’s knowledge level and feelings about the options available. Discussion about the patient’s option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient’s current level of knowledge and emotional state.
Explain the reasons for the phantom limb pain.
Administer prescribed analgesics to relieve the pain.
Loosen the compression bandage to decrease incisional pressure.
Inform the patient that this phantom pain will diminish over time.
Phantom limb sensation is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.
“I should elevate my residual limb on a pillow 2 or 3 times a day.”
“I should lay flat on my abdomen for 30 minutes 3 or 4 times a day.”
“I should change the limb sock when it becomes soiled or each week.”
“I should use lotion on the stump to prevent skin drying and cracking.”
The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture
“I should not cross my legs while sitting.”
“I will use a toilet elevator on the toilet seat.”
“I will have someone else put on my shoes and socks.”
“I can sleep in any position that is comfortable for me.”
The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.
Avoid extension of the right knee beyond 120 degrees.
Use a compression bandage to keep the right knee flexed.
Teach about the need to avoid weight bearing for 4 weeks.
Start progressive knee exercises to obtain 90-degree flexion.
After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.
“This procedure will correct the deformities in my fingers.”
“I will not have to do as many hand exercises after the surgery.”
“I will be able to use my fingers with more flexibility to grasp things.”
“My fingers will appear more normal in size and shape after this surgery.”
The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.
Keep the left shoulder elevated on a pillow or cushion.
Keep the hand immobile to prevent soft tissue swelling.
Call the health care provider for increased swelling or numbness of the hand.
Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.
Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.
Use surgical net dressing to hang the arm from an IV pole.
Immobilize the fingers of the left hand with gauze dressings.
Assess the left axilla and change absorbent dressings as needed.
Assist the patient in passive range of motion (ROM) for the right arm.
The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.
The patient uses crutches with a swing-to gait.
The patient leans over to pull shoes and socks on.
The patient sits straight up on the edge of the bed.
The patient bends over the sink while brushing teeth.
Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.
Stay with the patient and offer reassurance.
Administer the prescribed PRN oxygen at 4 L/min.
Check the patient’s legs for swelling or tenderness.
Notify the health care provider about the symptoms.
The patient’s clinical manifestations and history are consistent with a pulmonary embolus, and the nurse’s first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.
There is bruising at the shoulder area.
The patient reports arm and shoulder pain.
The right arm appears shorter than the left.
There is decreased shoulder range of motion.
A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.
Take the patient to have x-rays.
Wrap the ankle and apply an ice pack.
Administer naproxen (Naprosyn) 500 mg PO.
Give acetaminophen with codeine (Tylenol #3).
Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.
Reposition the patient every 1 to 2 hours.
Assess for skin irritation on the patient’s back.
Teach the patient quadriceps-setting exercises.
Determine the patient’s pain level and tolerance.
Repositioning of orthopedic patients is within the scope of practice of UAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.
a knee immobilizer.
gentle knee flexion.
monitored anesthesia care.
physical activity restrictions.
The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care (MAC), formerly called conscious sedation. Immobilization, gentle range-of-motion (ROM) exercises, and discussion about activity restrictions will be implemented after the knee is realigned.
Elevate the leg on 2 pillows.
Apply a compression bandage.
Check leg pulses and sensation.
Place ice packs on the lower leg.
The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate, based on what is observed during the assessment.
elevate the right leg.
splint the lower leg.
check the pedal pulses.
verify tetanus immunizations.
The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.
activity intolerance related to deconditioning.
risk for constipation related to prolonged bed rest.
risk for impaired skin integrity related to immobility.
risk for infection related to disruption of skin integrity.
A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.
Take the blood pressure.
Assess patient orientation.
Check the oxygen saturation.
Observe for facial asymmetry.
The patient’s history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange.
Ecchymosis of the left thigh
Complaints of severe thigh pain
Slow capillary refill of the left foot
Outward pointing toes on the left foot
Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.
place the patient in a prone position.
check the surgical site for hemorrhage.
remove the prosthesis and wrap the site.
keep the residual leg elevated on a pillow.
The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.
Observe the status of the incisional drain device.
Administer the ordered oral opioid pain medication.
Instruct the patient about the benefits of ambulation.
Change the hip dressing and document the wound appearance.
The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient’s willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.
weakness in the right little finger.
tingling in the right thumb and fingers.
burning in the right elbow and forearm.
tremor when gripping with the right hand.
Testing for Tinel’s sign will cause tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome.
Encourage bed rest for 24 to 48 hours.
Avoid palpation or movement of the knee.
Apply a knee immobilizer to the affected leg.
Administer intravenous narcotics for pain relief.
A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray’s test). The pain associated with a meniscus injury will not typically require IV opioid administration; nonsteroidal antiinflammatory drugs (NSAIDs) are usually recommended for pain relief.
Swelling is noted around the wrist.
The patient is reporting severe pain.
The wrist has a deformed appearance.
Capillary refill to the fingers is prolonged.
Swelling, pain, and deformity are common findings with a Colles’ fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.
Patient refuses to be turned due to back pain.
Patient has been incontinent of urine and stool.
Patient reports lumbar area tenderness to palpation.
Patient frequently uses oral corticosteroids to treat asthma.
Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient’s diagnosis and do not require immediate intervention.
Assess for nasal bleeding and pain.
Apply ice to the face to reduce swelling.
Use a cervical collar to stabilize the spine.
Check the patient’s alertness and orientation.
Patients who have facial fractures are at risk for cervical spine injury and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.
Patient with a Colles’ fracture who has right wrist swelling and deformity
Patient with a intracapsular left hip fracture whose leg is externally rotated
Patient with a repaired mandibular fracture who is complaining of facial pain
Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic
Swelling and bruising after a femoral shaft fracture suggest hemorrhage and risk for compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries, but do not require immediate intervention.
Monitor the skin under the traction boot for redness.
Ensure that the weight for the traction is off the floor.
Check for intact sensation and movement in the affected leg.
Offer reassurance that hip and leg pain are normal after hip fracture.
UAP can be responsible for maintaining the integrity of the traction once it has been established. Assessment of skin integrity and circulation should be done by the registered nurse (RN). UAP should notify the RN if the patient experiences hip and leg pain because pain and effectiveness of pain relief measures should be assessed by the RN.
a. Obtain x-rays.
b. Check pedal pulses.
c. Assess lung sounds.
d. Take blood pressure.
e. Apply splint to the leg.
f. Administer tetanus prophylaxis.
C, D, B, E, A, F
The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.