Kaplan Fundamentals A & B

The nurse helps a client to cough and deep breathe after surgery. It is desirable for the client to assume which position?

Side-lying

Prone

Supine with one pillow

High Fowler’s

High Fowler’s- high Fowler’s is the best position to deep breathe and cough.
Explanation
Side-lying impedes expansion of lungs; ask client to take two slow, deep breaths, inhaling through nose and exhaling through mouth; inhale deeply third time and cough.Prone lying on abdomen; would not be able to expand lungs; lying prone will prevent hip flexion.

Supine with one pillow ask client to splint abdominal wound with pillow; administer analgesic prior to asking client to cough and deep breath

Overview
Cough and Deep Breathe (CDB)- After surgery or immobility for any period of time, client develops pulmonary disorders; coughing and deep breathing (CDB) will alleviate these problems; client might use an incentive spirometer or just take several deep breathes and cough – deep cough; once mucus is disturbed the client will cough it up; CDB is an independent nursing activity; each cycle of CDB includes at least 3 deep breaths and a deep cough; at least 10 cycles every 1-2 hours.

The nurse identifies which diet best meets the needs of a person with multiple wounds?

High-protein, low-fat, high-iron diet

High-vitamin C, high-protein, high-carbohydrate diet

High-vitamin A, high-calcium, high-fat diet

High-vitamin B, high-protein, low-carbohydrate diet

High-vitamin C, high-protein, high-carbohydrate diet- increased vitamin C is essential to wound healing, and high protein is necessary for tissue growth; carbohydrate is needed or energy so the protein is properly utilized for repair of tissue
Explanation
High-protein, low-fat, high-iron diet – increased iron appropriate for client with iron deficiency anemiaHigh-vitamin A, high-calcium, high-fat diet – vitamin A contributes to night vision and growth of bones and teeth; vitamin A found in liver, fish, liver oils, and fortified dairy products

High-vitamin B, high-protein, low-carbohydrate diet – high carbohydrates needed for energy

Overview
Wound Healing Diet
Diet to support wound healing should be high in protein, fat, carbohydrates, vitamins (especially A, C, E), and minerals (including zinc).

Essential Nursing Care
Proper nutrition is one of the most important factors to effect wound healing, and can be assessed by monitoring urinary and bowel elimination patterns.
Purpose
. Promotes wound healing
. Prevents infection
. Influences balanced diet
Sample Associated Nursing Dx
. Imbalanced Nutrition
. Risk for Imbalanced Nutrition
. Anxiety
. Risk for Impaired Fluid Volume
. Delay in Wound Healing
. Deficient Knowledge
. Disturbed Body Image
. Impaired Skin Integrity
. Impaired Tissue Integrity
. Risk for Infection
Implementation
. Postoperative Assessment and Interventions
. Assess wound drainage and maintain prescribed IV fluid infusion rates
. Assess skin turgor and mucous membranes for dehydration
. Monitor weight and postoperative dietary progression (i.e., from clear to full liquids, and soft to regular foods)
. Identify nutritional needs and monitor for nutritional risks. Encourage food and fluid intake according to dietary progression or as prescribed.
. Double the patient’s recommended dietary allowance of protein (from 0.8/kg/day) before tissue even begins to heal
. Supply fruit juices and high-fiber foods
. Adjust the patient’s general intake of carbohydrates, fats, vitamins (especially A, C, and E), and minerals (including zinc) according to needs
. Ensure that patient’s environment is clean, neat, and free of odors to promote appetite
. Encourage patient to sit up in bed or chair for meals, and encourage family participation in meals
. Provide privacy when patient is using the bedpan, urinal, commode, or bathroom
. Monitor patterns of intake and output and assess patient’s ability to pass flatus and stool
. Palpate above the symphis pubis if:
. Patient has not voided within 8 hours after surger
. Patient has been voiding frequently in amounts of less than 50mL
. Notify physician of abnormalities
. Auscultate bowel sounds every 4 hours when the patient is awake to assess for return of peristalsis
. If bowel sounds not audible, or high-pitches, assess abdominal distention
. Administer suppositories, enemas, or medications, and encourage oral fluid intake as prescribed
Expected Outcomes
. Patent successfully makes transition from fluids to solid foods and maintains normal elimination pattern
. Patient’s wound(s) heal without complication
. Patient adheres to dietary needs following release from the hospital
(Adapted from Fundamentals of Nursing Made Incredibly Easy, pp. 410-411; Fundamentals of Nursing, Sixth edition, by Taylor et al., pp. 903-904)
Background for Nursing Care
Proper nutrition is one of the most important factors to effect wound healing, and can be assessed by monitoring urinary and bowel elimination patterns
Patient Teaching
. Encourage patient to actively participate in nutrition intake preoperatively
. Manage fluid balance; adjust fluid/food intak
. Avoid alcohol and certain medication; can alter body;s use of nutrients
. Discuss with patient postoperative complications as direct relation to nutrition
. Inform that severity of complications as direct relation to nutrition
. Delayed wound healing, wound infection and disruption in integrity of wound
. Fluid imbalances (from fluid loss during surgery, wound drainage, or surgical stress response)
. Provide patient with pamphlets/other educational resources
. Discuss ways that a standard diet needs to be adjusted to influence wound healing
Special Considerations
. General Considerations
. An obese patient has less resistance to infection; poor blood supply; increased risk for respiratory, cardiovascular, and gastrointestinal problems
. Pediatric Considerations
. Discuss with parents or guardians ways to implement a healthy diet into a pediatric patient’s meal plan
. Pediatric patient are especially at risk for imbalances in fluid volume (deficits or excess) following surgery
. Geriatric Considerations
. Older patients are especially at risk for fluid imbalances (deficits or excess) and malnutrition following surgery
(Adapted from Fundamentals of Nursing, Sixth edition, by Taylor et al.; pp. 883, 886-891, 897-905; 1189, 1192-1193, 1428-1433; Fundamentals of Nursing Made Incredibly Easy, pp. 410-411

The nurse identifies which lab finding reflects the signs and symptoms of infection?

Serum creatinine level of 2.4 mg/dL

AST (SGOT) 15u/L

White blood cell count of 16,000/mm3

White blood cell count of 4,000/mm3

White blood cell count of 16,000/mm3 – normal range is 5,000-10,000/mm3; elevation indicates infection

Serum creatinine level of 2.4 mg/dL – measures renal function; normal is 0.5-1.5 mg/dL; elevated in acute kidney injury and chronic kidney disease

AST (SGOT) 15u/L – measures damage to liver and heart; normal is 10-40 u/L

White blood cell count of 4,000/mm3 – indicates patient becoming immunosuppressed

Overview
Infection
Presence and growth of a microorganism that causes tissue damage; chain of infection includes an infectious agent, reservoir where pathogen can live, portal of exit that allows the organism to exit one host, mode of transmission, portal of entry into the new host, and susceptible host. If an infection is localized, indications include pain, tenderness and redness at the wound site. If infection is systemic, indications include fever, fatigue, nausea/vomiting, malaise, enlarged, tender lymph nodes. Treatment: obtain culture and sensitivity of wound, antibiotics/antifungal agents specific to organism(s). While waiting for the culture and sensitivity, broad-based antibiotic/antifungal might be used until the results are obtained and then switched to the antibiotic/antifungal appropriate for the organism(s).
Nursing considerations: obtain culture and sent to laboratory before starting medication. Client education: take medication as ordered and entire course of medication, return for follow-up.

The nurse understands which behavior is helpful to facilitate a client to have a bowel elimination?

Engage in sedentary activity

Increase dietary bulk

Decrease fluid intake

Use oral laxatives

Increase dietary bulk – foods that contain cellulose, suck as whole wheat bread, fruits, and other grains, will increase the bulk in the stool

Engage in sedentary activity – should engage in regular exercise

Decrease fluid intake – constipation caused by decrease in fluid intake; encourage client to drink adequate amounts of fluid

Use oral laxatives – chronic laxative abuse exacerbates constipation

Overview
Bowel elimination
To promote adequate bowel elimination, encourage diet high in fiber (fruits, vegetables, nuts, and whole-grains), daily fluid intake of 2,000-3,000mL, engage in regular exercise to improve muscle tone and GI motility, encourage client to establish a regular time for defecating.

The nurse knows which statement is an important fact about warfarin?

It has a prolonged action

It is never given for prolonged periods of time

It must be given several times a day to be effective

It can only be given parenterally

It has a prolonged action – duration is 2-5 days

It is never given for prolonged periods of time – it is given for up to 6 months after a DVT

It must be given several times a day to be effective – is given once daily

It can only be given parenterally – is given orally; heparin is given parenterally

Overview
Warfarin
Anticoagulant; action: interferes with synthesis of vitamin K-depending on clotting factors; side effects: hemorrhage, alopecia (hair loss); nursing considerations: monitor prothrombin test, therapeutic level is 1.5-2 times the control, observe for petechiae, bleeding gums, bruises, and dark stools; antidote- vitamin K

To promote evening rest and sleep for clients who are immobilized and in bed, it is most important for the nurse to provide which care?

Privacy

Back rubs

Daily baths

Daytime activities

Daytime activities – particularly important for the immobilized and bedridden client. It causes them to nap less during the day, and provides relief from tension. It enables the client to relax and sleep at night

Privacy – more important that clients maintain daytime activity

Back rubs – will help the client relax, but daytime activity is more important

Daily baths – bathing and skin care are part of hygiene of the client

Overview
Rest and Sleep
Rest is a basic physiological need that allows the body to repair damaged cells, enhances removal of waste products from the body, restores tissue to maximum functional ability before another activity is begun. Sleep restores balance among different parts of the CNS, mediates stress, anxiety and tension, and helps a person cope with daily activities. Disturbances in rest and sleep are caused by stress, medication (hypnotics, antidepressants, stimulants, caffeine, beta-adrenergic blockers, barbiturates, diuretics, and alcohol), unfamiliar and/or noisy and/or bright environments, daytime sleeping, working shifts, and overeating. Nursing care includes establishing a database about the client’s pattern or rest and sleep, give care in blocks to allow for uninterrupted periods of rest and sleep, avoid unnecessary lights and noises, comfortable room temperature, non-stimulating beverages, promote bedtime routine, encourage daytime activity, limit daytime naps, reposition client, straighten and replace wrinkled or soiled linens, administer pain mediation, provide diversionary and occupational activities during the day to relieve boredom and utilize nighttime for sleep.

A client with acute pain has a health care provider’s order for morphine 8 mg IV every 3-4 hrs prn for pain. The client asks the nurse for medication at bedtime. Prior to administering the pain medication, the nurse should take which action?

Assume the pain is psychological

Check to see if the client has a history of addiction

Try several other pain relief measures

Assess location, character, and intensity of pain

Assess location, character, and intensity of pain – Determine onset, duration, and sequence of pain as well as location and intensity

Assume the pain is psychological – pain is “whatever the person says it is, and it exists whenever the person says it does”. Assume the client’s pain is real.

Check to see if the client has a history of addiction – assessment answer, the nurse should assess the characteristic of the client’s pain

Try several other pain relief measures -appropriate to use a variety of relief measures, such as relaxation, guided imagery, listening to music, biofeedback. Prior to implementing any measures for pain relief the nurse must assess the client.

Overview
Pain Management
Pain is often referred to as the fifth vital sign and is defines as, “Whatever the person says it is, and it exists whenever the person says it does.” Pain can be acute or chronic. Culture and past experiences with pain are major factors influencing pain experiences. Indications include increased blood pressure and pulse, rapid irregular respiration, pupil dilation, increased perspiration, increased muscle tension, apprehension and irritability, grimacing, guarding, and verbalization of pain. Nursing interventions include establishing a therapeutic relationship, establishing a 24-h pain profile, teach the patient about pain and it’s relief, reduce anxiety an fears, provide comfort measures, administer pain medications, and refer for alternative methods of pain relief. With regard to pain medication, use the preventive approach (if pain is expected to occur throughout most of a 24-h period a regular schedule is better than prn because it usually takes smaller doses to alleviate mild pain or to prevent occurrence of pain.

Which action is essential for the nurse to take after administration of preoperative medication to a client?

Raise the side rails of the bed – this will prevent injury to the client

Ensure the operative permit is signed – cannot be signed once preoperative medication is administered

Discuss the client’s feelings about surgery – safety takes priority over psychosocial needs

Tell the client what to expect in the operating room – this is part of the preoperative teaching and occurs prior to administering preoperative medication

Overview
Preoperative Checklist
Preoperative checklist includes ensuring that informed consent is signed and attached to the chart, all lab tests, chest x-ray, and EKG have all been completed, performing skin and bowel prep, NPO, administering preoperative medications (sedation, antibiotics), removing dentures, jewelry, and nail polish.

A nurse explains to a client how to eat enough protein. The client indicates the choice of food. Based on the client’s choice, the nurse determines that the client needs more teaching. What kind of food does the client choose to eat?

Spaghetti and meat sauce

Orange juice and white toast

Rice and red beans

Peanut butter on whole wheat bread

Orange juice and white toast- juice contains little protein, most of it is in the pulp. Bread is made from white flour and is also limited in protein content

Peanut butter on whole wheat bread- both peanut butter and whole wheat bread contain protein

Rice and red beans- red beans contain some protein

Spaghetti and meat sauce- meat sauce contains some protein

Overview
Increased Protein Diet
Diet in which protein is increased from the normal expected amounts. Protein is used during tissue repair and rebuilding. This diet is used after surgery, fractures, stress to the body, cancers, and other times when increase repair is required. Foods which are high in protein include: meat, fish, nuts, cheese, protein powder, and peanut butter.

On the first postoperative day, a client develops a fever. The nurse auscultates crackles bilaterally in the lower lobes. The nurse understands which complication of surgery is probably developing?

Heart failure

Thrombophlebitis

Pulmonary embolism

Atelectasis

Atelectasis- the most probable cause for crackles because secretions block the bronchioles and the alveoli collapse, causing hypoventilation

Heart failure- failure of the cardiac muscle to pump sufficient blood to meet the body’s metabolic needs. Manifestations include dyspnea, orthopnea (the sensation of breathlessness when in the recumbent position), pleural effusion, dependent edema, and bounding pulses.

Thrombophlebitis- manifestations include unilateral edema, warmth and tenderness of lower extremity, swelling tenderness, and localized redness over a vein with an intravenous catheter. Thrombophlebitis (throm-boe-fluh-BY-tis) occurs when a blood clot blocks one or more of your veins, typically in your legs. Rarely, thrombophlebitis (sometimes called phlebitis) can affect veins in your arms or neck. The affected vein may be near the surface of your skin, causing superficial thrombophlebitis, or deep within a muscle, causing deep vein thrombosis (DVT). Thrombophlebitis can be caused by trauma, surgery or prolonged inactivity. Superficial thrombophlebitis may occur in people with varicose veins. A clot in a deep vein increases your risk of serious health problems, including the possibility of a dislodged clot (embolus) traveling to your lungs and blocking an artery there (pulmonary embolism). Deep vein thrombosis is usually treated with blood-thinning medications. Superficial thrombophlebitis is sometimes treated with blood-thinning medications, too.

Pulmonary embolism – Manifestations include: dyspnea, tachypnea, and pleuritic chest pain

Overview
Postoperative (Post Op) Care
Full system assessment required because anesthesia, immobility, and surgery can affect any system in the body. Neuropsychosicial (stimulates client post anesthesia) monitor level of consciousness. Cardiovascular (monitor vital signs every 15 minutes x4 (1 hour), every 30 minutes x2 (1 hour), every hour x2 (2 hours), then every hour or prn) check potassium level, monitor central venous pressure. Respiratory (check airway and breath sounds) turn, cough, and deep breathe (unless containdicated i.e. brain, spinal, or eye injury), splint wound, offer pain mediction, teach how to use incentive spirometer (hhold mouthpiece in mough, exhale normally, seal lips and inhale slowly and deeply, keep balls or cylinder elevated, exhale and repeat). Gastrointestinal (check bowel sounds in all four quadrants for 5 minutes each if nothing is heard and keep NPO until bowel sounds are present) provide good mouth care while NPO, provide antiemetics for nausea nd vomiting, check abdomen for distention, check for passage of flatus and stool. Genitourinary (monitor intake and output, encourage to void, check for bladder distention, notify healtcare provider if unable to void within 8 hours, catherize if needed), monitor for complicaitons (hemorrhage, paralytic ileus, atelectasis, pneumonia, embolism, infection of wound, dehiscence, evisceration, venous thromboembolism (VTE), psychosis). Musculoskeltal get out of bed as soon as possible and ambulate as much as possible.

A nurse explains to a client about vitamin C. Which juice contains the most vitamin C?

Frozen grapefruit juice

Canned tomato juice

Fresh orange juice

Canned apple juice

Fresh orange juice- canned juice is processed in such a way that the vitamin is partially destroyed. This also happens in freezing, but not as much as with canned juice. Fresh foods contain more vitamins. Citrus fruits are a good source of vitamin C and orange juice contains more vitamin C than any other citrus fruit.

Canned apple juice- contain negligible amounts of vitamin C

Canned tomato juice- contains more vitamin C than apple juice, but much less than orange juice

Frozen grapefruit juice- contains vitamin C, but less than orange juice

Overview
Vitamin C (Ascorbic Acid)
Necessary for formation of cartilage in connective tissue and essential to maintenance of integrity of intercellular cement in many tissues, especially capillary walls. Deficiency: scurvy, imperfect formation of fetal skeleton, defective teeth, pyorrhea (Periodontitis), anorexia, anemia, injury potential to bones, cells, and blood vessels. RDA for adults is 60mg/day. Excessive high doses can interfere with B12 absorption, cause uricosuria (uric acid in the urine), promote formation of oxalate renal calculi. Food sources include: raw cabbage, young carrots, lettuce, celery, onions, tomatoes, radishes, green peppers, citrus fruits, rutabagas, strawberries, apples, pears, plums, peaches, pineapples, and apricots.

A client comes to the emergency room after puncturing a foot with a dirty, rusty nail. The client states the last Td immunization was 6 years ago. Which of the following actions should the nurse take FIRST?

Administer tetanus toxoid

Determine how many Td immunizations the client has received

Administer tetanus immune globulin (TIG)

Monitor for lockjaw

Determine how many Td immunizations that client has received- if the client received at least 3 doses of Td, administer tetanus toxoid booster to prevent development of tetanus. If less than 3 doses has been received administer Td AND tetanus immune globulin (TIG)

Administer tetanus toxioid- should first determine immunization history because tetanus is a fatal disease caused by a bacterium that can live for a long time in soil and dirt. It can enter the blood via wounds and can affect the CNS. After a dirty wound, a tetanus toxoid booster (TIG) is given to ensure protection against tetanus

Administer tetanus immune globulin (TIG)- appropriate action if client received less than 3 doses of Td or has developed tetanus

Monitor for lockjaw- Lockjaw is the first sign of generalized tetanus. Other manifestations include opisthotonus, muscle rigidity, cramps, and muscle spasms. Give tetanus toxoid to prevent the development of tetanus.

Overview
Tetanus
Acute infectious disease of the CNS caused by exotoxin of Clostridium tetani. Causes painful muscle rigidity. Primary prevention occurs through immunization and boosters. Administer tetanus immune globulin (TIG) to child not immunized or inadequately immunized suffering a puncture wound contaminated with dirt, feces, soil, or saliva.

Essential Nursing Care
Tetanus is an acute toxic syndrome caused by a protein toxin produced during an infection with Clostridium tetani, a spore-forming anaerobic bacterium. While tetanus can be prevented by a vaccine, it can be fatal (1in 10 cases) if it goes untreated.

Signs and symptoms of Tetanus include
. Painful muscular rigidity and spasms
. Tightening of the jaw muscles (lockjaw) prohibiting breathing and swallowing
. Painful paraoxysmal seizures
. Irregular heartbeat and tachycardia
. High sensitivity to external stimuli
. Profuse sweating
. Low grade fever

Treatment of tetanus include
. Active immunization at age 2 months with Dtap vaccine
. Immunizations continue at ages 4, 6, and 15-18 months and 4-6 years (5 doses total)
. Vaccine should be given every 10 years thereafter or when a person presents with a potentially contaminated wound

Treatment
. Tetanus immune globulin (to neutralize tetanus toxin) and tetanus toxoid
. Penicillin G (IV)
. Metronidazole, erythromycin, or tetracycline for penicillin allergic patients
. Debridement of open wound through which contamination occurred
. Muscle relaxants and sedative, to treat and monitor cardiopulmonary status
. Antiseizure medications as needed

Nursing Care
. Maintain a patient airway in the child with tetanus and assure adequate ventilation
. Keep emergency airway equipment handy in case of respiratory failure
. Monitor vital signs frequently
. Maintain a quiet environment by reducing external stimuli from light, sound or touch
. While the child is very ill, mentation (mental activity) is unaffected so be sure to explain the disease, its treatment, or any procedures to allay any anxiety the child may be experiencing.
. Carefully monitor children with tetanus because they often must take potent muscle relaxants, and the resulting paralysis can make it impossible for the child to communicate clearly

Expected Outcomes
. Patient is treated successfully without untoward complications and recovery is complete

Background for Nursing Care
Background
. Tetanus is contracted by contamination with C. tetani, which is found in the soil and animal feces.
. C. tetani infects the body through a wound. The anaerobic tetanus bacilli reproduce when the oxygen supply is cut off because the wound is deep or forms a crust (e.g. as with burns)

Pathophysiology
. There is usually no obvious infection (e.g. pus, red area) at the wound site, which may give a false impression that no treatment is necessary.
. The tetanus bacilli produce protein toxins as they grow, which result in the clinical presentation of the disease.
. The protein toxins specifically bind to the motor neurons of the CNS. They are then transported to the brain stem and spinal cord, where the release of inhibitory neurotrasmitters (glycine, gamma-aminobutyric acid) is blocked.
. The blocking of these neurotransmitters results in increased firing rate of motor neurons and decreased activity of reflexes, producing rigidity and spasms

Causes/Risk Factors
Infection with C. tetani, which is transmitted through: Penetrating wounds, burns, open wounds of the skin, and contact with contaminated soil, dust, animal excreta, and surgical instruments

Diagnostic Tests
. History of significant for no tetanus immunization and with symptoms of muscle rigidity and breathing or swallowing difficulty
. Peripheral blood smear (to show increased leukocytes)

Complications
. Seizures
. Severe, sustained muscle contractions
. Respiratory muscle spasm, resulting in respiratory distress
. Asphyxia
. Death

What is the purpose of a drain in a wound?

It keeps the tissues close together so that healing can occur

It prevents infection by providing a way for bacteria to escape

It evaluates the effectiveness of hemostasis

It creates a space that facilitates reconstructive surgery at a later date

keep the tissues close together so that healing can occur- if blood or serous drainage collects underneath the skin edges, the tissues will not be able to heal properly

prevent infection by providing a means for bacteria to escape- aseptic technique used to prevent infection. The nurse should observe that drain is in place and note character of drainage and measure drainage volume

evaluate the effectiveness of hemostasis- achieved by sutures and dressings

create a space that will facilitate reconstructive surgery at a later date- keeps wound edges approximated

Overview
Drains
Drainage systems (open or closed) placed to provide exit route (gravity or vacuum) for air, blood and other material following surgery. Nursing considerations include: monitoring characteristics and volume of drainage, recording in output records, preventing skin contact, securing placement, and monitoring for infection.

In which situation should the nurse consider withholding morphine until further assessment is completed?

Client reports acute pain from deep partial thickness burn affecting lower extremities

Client’s blood pressure is 140/90, pulse 90, and respirations 28

Client’s level of consciousness fluctuates from alert to lethargic

Client exhibits restlessness, anxiety, and cold, clammy skin

Client’s level of consciousness fluctuates from alert to lethargic- morphine depresses the CNS (especially the respiratory center) and would cause a decrease or fluctuation of consciousness

Client reports acute pain from deep partial thickness burn affecting lower extremities- no contraindication for this client. During emergent post-burn phase, agents should be administered IV because of poor absorption from subcutaneous and intramuscular spaces

Client’s blood pressure is 140/90, pulse 90, and respirations 28- elevated vital signs indicate the client is in pain

Client exhibits restlessness, anxiety, and cold, clammy skin- pain causes peripheral vasoconstriction, which shifts blood supply to skeletal muscles and brain

Overview is on pain management

A client’s body mass index is 38kg/m2. What is the BEST description of the client’s body weight?

Obese- 30-39.9

Underweight- <18.5 Normal weight- 18.5-24.9 Over weight- 29.9 Overview Body Mass Index Body mass index estimates body fat. This allows the provider to counsel about risk factors for diabetes, heart disease, stroke, hypertension, and osteoarthritis. In addition to above values, morbid obesity is a BMI >40.
If a client is overweight with two or more risk factors for heart disease or obesity-related illnesses a weight loss program should be encouraged.

A client is admitted to the hospital with at temperature of 101 F (38.3 C) and a WBC count of 3,000/mm3. The nurse should institute which precaution?

Contact

Airborn

Droplet

Neutropenic

Neutropenic- Client is immunosuppressed so place them in a private room, use good handwashing before touching the client or any of their belongings, limit number of nurses caring for this patient, no fresh flowers or potted plants.

Contact- appropriate for wound infections, C. diff, infections caused by multidrug-resistant strains, or RSV

Airborne- appropriate for measles, m. tuberculosis, varicella, and disseminated zoster

Droplet- appropriate for diptheria, strep, pneumonia, and influenza

Overview
Neutropenic Precautions
Used for clients at increased risk of infection (immunosuppressed with a neutrophil count under 500 mm3). They require a private room that is scrupulously cleaned, meticulous handwashing and use of PPE by anyone entering the room, restriction of visitors is recommended, no fresh fruit/vegetables, avoidance of invasive procedures (catherization) unless essential.

A client is on droplet precautions. A nurse observes a staff member prepare to leave the client’s room. Based on something the nurse observes the nurse decides to intervene. What does the nurse observe?
The staff member removes the gloves by pulling off inside outThe staff member holds onto the outer surface of the facemask while pulling mask away from face

The staff member unties the gown and removes it without touching the outside of the gown

The nurse performs hand hygiene for 15 seconds

The staff member holds onto the outer surface of the facemask while pulling mask away from face- Do not touch outer surface of mask. Untie top mask string and then bottom string, pull the mask away from the face and drop into trash receptacle

The staff member removes the gloves by pulling off inside out- appropriate action (do not touch outside of glove

The staff member unties the gown and removes it without touching the outside of the gown- appropriate action

The nurse performs hand hygiene for 15 seconds- appropriate action

Overview
Droplet Precautions
Used with pathogens transmitted by infections droplets which happens during coughing, sneezing, talking, or during procedures (such as suctioning or bronchoscopy and involves contact of conjunctiva or mucous membranes of the nose or mouth. Patient should be in a private room or a room with a patient with the SAME infection, but no other infections. Maintain 3 feet of separation between infected patient and any visitors or other clients. The door may remain open, but the client must wear a mask if ambulating or being transported

A client is several days postoperative. The client reports pain, tenderness, and redness of the right calf. Which s/s are critical for the nurse to assess next?

Nausea and abd. distention

Back pain and hematuria

Chest pain and SOB

Similar findings in the right arm

Chest pain and SOB- calf pain suggests that the client may have a venous thromboembolism (VTE). Client should be placed on bedrest with leg elevated until anticoagulant therapy is started. To prevent VTE keep knee gatch flat, do not place pillows behind knees, perform leg exercises and apply anitembolic hose

Nausea and abd. distention- indicates small bowel obst.

Back pain and hematuria- indicates uninary tract calculi

Similar findings in the right arm- sx would not also be in the arm

Overview
Venous Thromboembolism (VTE)
Aggregate of platelets attached to a vein wall. Risk factors: pregnancy, immediate postpartum period, prolonged immobility, use of oral contraceptives, sepsis, smoking, dehydration, heart failure, and trauma (including surgery). Indications of VTE include: calf pain, localized edema of ONE extermity, possible warm skin over affected leg, possible fever, chills, and perspiration. Tx of VTE includes: bedrest, elevating extremity, anticoagulants, possible thrombolytic drugs, and possible surgery. Nursing care for VTE includes: maintain bedrest, raise extremity, compression stockings after acute stage, and administering prescribed analgesics.

The nurse instructs a client how to successfully start a regular exercise program. Based on something the client says, the nurse decides that the client needs more teaching. What does the client say?

“I should choose an exercise that suits my lifestyle.”

“I should incorporate exercise into my daily routine.”

“I should make a commitment to exercise regularly.”

“I should start by running 5 miles a day.”

“I should start by running 5 miles a day.”- should begin slowly

“I should choose an exercise that suits my lifestyle.”- exercise should be a combination of aerobic exdercise, stretching and flexibility exercise, resistance training

“I should incorporate exercise into my daily routine.”- should exercise 30 minutes or more a day for 3-4 hours per week

“I should make a commitment to exercise regularly.”- should commit ot daily exercise (does not have to be done at one time — can be broken down into 10 minute segments)

Overview
Exercise program
Programs of exercises designed to enhance rehabilitation. Specific exercises are designed for specific needs (cardiac, specific muscle, post surgery,or for specific medical conditions such as COPD, osteoarthritis, MS), and is designed to increase muscle strength and stamina.

A client is dx with a fractured humerus due to a fall in the home. A home care nurse provides care for the client. The nurse makes an observation that requires the nurse to intervene immediately. What observation does the nurse make?

The bathroom is equipped with grab bars

Throw rugs have been removed

The client ambulates wearing socks

The stairs are well lighted

The client ambulates wearing socks-should wear shoes or slippers with nonskid surfaces

The bathroom is equipped with grab bars- most injuries to older people involve falls. Bathrooms should shave grab bars near the toilet and the tub

Throw rugs have been removed- should be removed if they do not have nonskid backing. Make sure that the edges of carpets, mats, and tile are well secured

The stairs are well lighted- ensure adequate lighting on stairs as most falls occur at the top and bottom steps of the stairs

Overview
Elderly Adults
Provide additional lighting, grab bars on tub and toilet, monitor for side effects of drugs, teach client to take their time when getting out of bed and to bend from the waist or stoop slowly.
Essential Nursing Care
Purpose
. Eliminate risky events
.Prevent injury
. Education involves all parties about safety

Implementation
. Initiate a surveillance of environmental hazards within the healthcare facility and modify the environment as necessary
. Identify patients who are most at risk for injury or falls, especially those who: have a history of falls, suffer from confusion or disorientation, struggle with posture while seated, and have difficulty standing with support
. Ensure that pts wear ID bracelet
. Assess pts ability to follow instructions
. Orient pt. to hospital surroundings, safety features, and equipment in room (including call bell)
. Monitor for side effects of drugs, especially diuretics, tranquilizers, sedatives, hypnotics, or analgesics
. Practice good transfer techniques (Good body mechanics and lifting techniques, ensure pts body is in good alignment while being moved, use proper equipment i.e. gait belts for transfer and ambulation, lateral-assist devices have long handles to reduce reaching, mechanical lateral-assist device to eliminate the need to slide a pt. manually, powered stand-assist aide to mechanically assist pts to stand w/o assistance from nurse, powered full-body lifts for pts who cannot bear weigh, and transfer chairs which convert into a stretcher and eliminates need for lifting pt.
Expected Outcome
. Pt remains free of injury during hospital stay
. Pts family is aware of safety priorities within the home environment
. Pt can identify unsafe of hazardous situations in their environment

Background
Pt Teaching
. To take time when getting out of bed
. On how to bend from the waist or stoop slowly
. Wear comfortable and secure footwear
. Modify home environment by reducing clutter, removing throw rugs, provide additional lighting, installing safety bars, orienting pt. to surroundings and new equipment, or if moving to unfamiliar setting
. Discuss common causes of fires (smoking, faulty elect. Equip or heating devices) and educate about fire safety (no smoking in home, smoke detectors and check batteries, familiar with exits, how to use a fire extinguisher, know emergency numbers, ways to prevent accidental medication overdose by using calendars and daily pill dispensers, regular vision and hearing tests.

Special Considerations
. Pts with developmental disabilities, demented or delirious use same safety measures as with children
. Family members may participate in tx. by providing info. On pts episodes of weakness, confusion, or falls

A client requires a dressing change. The LPN assigned to care for the client reports to the registered nurse that the LPN once observed a similar dressing change while in nursing school, but has never performed the procedure. The RN will take which action?

Ask the LPN to review the hospital’s procedure manual regarding dressing changes

Review the steps of the dressing change with the LPN

Complete the dressing change while the LPN observes

Assign a more experienced LPN to the client

Complete the dressing change while the LPN observes- this accomplishes two goals, completing the dressing change and helping the LPN to learn how to do the procedure

Ask the LPN to review the hospital’s procedure manual regarding dressing changes- demonstration/return demonstration is more effective teaching tool than reading about a procedure

Review the steps of the dressing change with the LPN- important, but nurse should demonstrate

Assign a more experienced LPN to the client- nurse’s responsibility to instruct the staff about procedures and client care

Overview
Changing Dressings
To change a dressing, it is important to determine type of dressing, presence of drains, and frequency of dressing change, solutions or ointments used. Assess skin beneath tape, through hand washing before and after dressing change, do not touch would without wearing sterile gloves, change dressings when wet, and secure dressing with tape, ties, and bandages.

The nurse knows that aspirin, if given in high and prolonged doses, may precipitate which of the following physiological changes?

Urinary frequency

GI bleed

Hypoventilation

Hemoconcentration

GI bleed- salicylism result in gastric (GI bleed, blood dyscrasia, and acid-base disturbances, with fluid and electrolyte imbalances) that are directly associated with prolonged high doses of aspirin

Hypoventilation- respiratory depression caused by narcotics

Hemoconcentration- dehydration will cause hemoconcentration

Urinary frequency- not caused by aspirin

Overview
Aspirin (Acetylsalicylic Acid) (ASA)
Salicylate analgesic, antipyretic, anti-inflammatory, antirheumatic, antiplatelet. Side effects include: bleeding, hemorrhage, heartburn, nausea, salicylism including tinnitus, urticaria, bronchospasms, and anaphylactic shock. Nursing considerations include: observe for gum bleeding, bloody or black tarry stools, blood in urine, hemoptysis, and bruises. Give with milk, water, or food. Use enteric coated tablets to minimize gastric distress and monitor for tinnitus and fullness in ears.

A client returns from abdominal surgery with an order for morphine sulfate IV q3 hours prn for pain. During the first 24-h after surgery what action by the nurse is best?
Offer pain medication every 4 hoursAdminister pain medication every 3 hours

Offer pain medication every 3 hours

Administer pain medication every 4 hours

Administer pain medication every 3 hours- pain is best controlled before it becomes sever and overwhelming. Reasonable expectation that a client will experience significant pain after abdominal surgery

Offer pain medication every 4 hours- preventive approach to medication administration is effective when pain is expected to occur during a 24-h period

Offer pain medication every 3 hours- give medication on a regular schedule – do not wait for the client to request the medication

Administer pain medication every 4 hours- imploring the client to use non pharmacological means to relieve pain while receiving medication

Overview is on pain management

The nurse performs discharge teaching for a client receiving warfarin. The nurse determines further teaching is required if the client makes which statement?
“I should look for yellow-tinged complexion.””I will wear a Medic-Alert bracelet.”

“I should tell the health care provider if I have black stools.”

“I should consult the health care provider before taking any medication.”

“I should look for yellow-tinged complexion.” – Yellow-tinged complexion or eyes are symptoms of hepatitis, which is not a side effect of warfarin.

“I will wear a Medic-Alert bracelet.” – appropriate action; instruct to watch for signs and symptoms of bleeding

“I should tell the health care provider if I have black stools.” – indicates bleeding; report to health care provider

“I should consult the health care provider before taking any medication.” – Over-the-counter medication may contain aspirin
Overview is on warfarin teaching

The nurse cares for a post op client with a NG tube. Which observation is the MOST reliable indication that the NG tube is correctly positioned?

Absence of respiratory distress

pH of aspirate is 3

The marking on the tube designating the correct length remains visible just outside the nares

The tube is securely taped

pH of aspirate is 3- aspirate for gastric contents and check pH which should be 4 or less

Absence of respiratory distress- if client is unable to talk then the tube has passed through the vocal cords

The marking on the tube designating the correct length remains visible just outside the nares- can mark the tube as a guide but more reliable to check pH of gastric aspirate

The tube is securely taped- does not indicate to the nurse that the tube is in the stomach

Overview
Nasogastric Tubes
Types include Levin (single-lumen stomach tube used to remove stomach contents to provide tube feeding), Salem stump (double-lumen stomach tube) that is most frequently used tube for decompression with suction, Sengtaken-Blakemore (triple-lumen gastric tube with inflatable esophagus balloon, stomach balloon, and gastric suction lumen) used for tx of bleeding esophageal varices. To verify placement, check pH of aspirated contents for acidic level and to irrigate Ng tube. Verify placement of tube by inserting 30-50mL syringe filled with normal saline into tube and inject slowly. If resistance is felt, check to see if tube is kinked and have pt. change position; pull back on the plunger or squeeze bulb to withdraw solution. If irrigation solution not removed, record as input and repeat as needed

The nurse notes an elderly pt. has a reddened area on the coccyx. Which action should the nurse take FIRST?

Continue assessment of the area

Reposition the pt. ever 1-2 hours

Massage the reddened area QID

Place the pt. in a semi reclining position

Reposition the pt. ever 1-2 hours- frequent change in position will relieve pressure on pts. Skin. Encourage the pt. to shift weight every 15 minutes. Use pillows to relieve pressure over bony prominences

Massage the reddened area QID- do not massage reddened areas as this causes damage to capillaries and deep tissues

Place the pt. in a semi reclining position- causes shearing force on sacral area

Continue assessment of the area- this situation does not require further assessment

Overview
Pressure Ulcer
Pressure ulcer is localized area of necrotic tissue that develops when soft tissue is compressed over a bony prominence. Risk factors include impaired sensory perception, impaired mobility, and altered level of consciousness, shear, friction, and moisture. Prevention includes frequent assessment of pressure areas for non-blanching reactive hyperemia, keeping moisture away from client’s skin, repositioning client using draw-sheet, implementing a turning schedule, providing adequate nutrition and fluids.

The nurse prepares four clients for surgery. The nurse is MOST concerned about the psychological adjustment of which pt.?

A 13 y.o. scheduled to have a wart removed from the nose

A 26 y.o. scheduled for the Whipple procedure due to cancer of the pancreas

A 42 y.o. scheduled to have a benign cyst removed from the left breast

An 80 y.o. scheduled for a colostomy due to severe diverticular disease

A 26 y.o. scheduled for the Whipple procedure due to cancer of the pancreas- life-threating illness with poor outcome. The nurse helps to deal with px changes due to surgery and the threat of dying

A 42 y.o. scheduled to have a benign cyst removed from the left breast- outcome of surgery is good

An 80 y.o. scheduled for a colostomy due to severe diverticular disease- nurse instructs client about changes to expect after surgery

A 13 y.o. scheduled to have a wart removed from the nose- expect resistance due to age, but involve in procedures and therapies, fears loss of independence and alterations in body image

Overview is on Preoperative Care

The nurse observes a staff member enter a pts room wearing a fit-tested respiratory device. The nurse determines care is appropriate if the staff member is caring for which client?

A pt. dx with varicella

A pt. dx with mumps

A pt. dx with vancomycin-resistant Enterococcus (VRE)

A pt. dx with pneumonia

A pt. dx with varicella- used with pathogens transmitted by airborne route. A private room with monitored negative pressure should be used and the door should be closed with the client in the room

A pt. dx with mumps- droplet precautions should be used with pathogens transmitted by infections droplets. A private room or with client with same infection. Maintain 3 feet between the pt. and any other pts or visitors. The door may be left open

A pt. dx with vancomycin-resistant Enterococcus (VRE) – contact precautions- place pt. in a private room or in a room with same infection. Wear clean, sterile gloves when entering room and change gloves after contact before washing hands

A pt. dx with pneumonia- droplet precautions should be used with pathogens transmitted by infections droplets. A private room or with client with same infection. Maintain 3 feet between the pt. and any other pts or visitors. The door may be left open
Overview
Airborne Precautions
Used with pathogens transmitted by airborne route. A private room with monitored negative pressure of 6-12 air changes per hour. Keep door closed and client in room. Can cohort or place client with another client with same organism. Place mask on client if being transported. Examples of disease in category include measles (rubella), M. tuberculosis, varicella (chickenpox), disseminated zoster (shingles)

The home care nurse visits an elderly pt. living alone on a limited income. The pts diet consists primarily of carbohydrates. Based on understanding of the nutritional needs of the elderly, which of these interpretations of the pts diet by the nurse is MOST justified?

The client is increase the intake of protein

The client should reduce the intake of fat

The client should increase the caloric intake

The client should decrease the fluid intake

The client is increase the intake of protein- ensuring the older client’s intake includes adequate protein is a challenge it is important for an elderly client to ingest protein organs functioning, and slow down the degeneration process

The client should reduce the intake of fat- does need to limit fat and cholesterol in the diet, but no indication that the client is ingesting too much fat

The client should increase the caloric intake- older adults usually require fewer calories and may require more calories if recovering from surgery

The client should decrease the fluid intake- should drink adequate amounts of water to maintain hydration

Overview
Elderly
Elderly are at risk for malnutrition because of the lack of transportation, poor food selection, loneliness, decreased sense of taste and smell, poor detention or poor fitting dentures, dry oral mucous membranes, and decreased appetite caused by medication side effects. Should eat a balanced diet as defined by the Dietary Guidelines for Americans (DGA) released by the United States Department of Health and Human Services. As metabolism decreases, calorie need decreases, calcium increases to 1200 mg because of decreased absorption of vitamin D increases to 15 micrograms, sodium intake decreases to 1200 mg or less, chloride decreases to 1800 mg.

The nurse identifies which finding is characteristic of chronic pain?

Weight loss or gain, fatigue

Obesity, restlessness, and thirst

Anxiety, insomnia, and memory loss

Quick response to analgesics

Weight loss or gain, fatigue- chronic pain is an episode of pain that lasts for 3 months or more and serves no useful function and becomes a problem of its own. Chronic pain often becomes a disability

Obesity, restlessness, and thirst- restlessness can indicate pain in nonverbal clients while acute pain acts as a warning signal, it is usually temporary and has a sudden onset and is easily localized

Anxiety, insomnia, and memory loss- chronic pain may cause the client to feel powerless, angry, anxious, and fearful. When assessing pain of a disoriented client, observe for nonverbal cues such as grimacing, crying, increased confusion, or combativeness.

Quick response to analgesics- types of pain include acute pain caused by injury, disease, or surgery. Chronic pain may be diffuse, not localized, and difficult to describe and is difficult to control.

Overview is on pain management

The nurse identifies which as a risk factor for a client to develop a pressure ulcer?

Decreased skin moisture

Ambulation with assistive device

Anemia

Alzheimer’s disease

Anemia- decreased O2 carrying capacity of the blood. Clients with low protein levels aren’t able to repair tissue

Decreased skin moisture- prolonged contact with increased moisture will contribute to skin breakdown. Ensure clients are not on wet linens or dressing

Ambulation with assistive device- prolonged sitting/lying w/o changing positions contributes to skin breakdown due to sensory loss

Alzheimer’s disease- does not predispose client to develop pressure ulcers
Overview
Pressure ulcer
Pressure ulcer is a localized area of necrotic tissue that develops when soft tissue is compressed over a bony prominence. Risk factors include impaired sensory perception, impaired mobility, altered LOC, shear, friction, and moisture. Prevention includes: frequent assessment of pressure areas for non-blanching reactive hyperemia, keeping moisture away from client’s skin, repositioning clients using a draw-sheet, implementing a turning schedule, and providing adequate nutrition and fluids

The nurse identifies which change in the pattern of urinary elimination as usually associated with aging?

Decreased frequency

Incontinence

Sphincter reflexes decreased

Formation of bladder stones

Sphincter reflexes decreased- decrease in sphincter reflexes is a physiological change that often occurs with advanced age

Decreased frequency- increased frequency due to decreased muscle tone and decreased bladder capacity

Incontinence- not a normal change associated with aging. Stress incontinence can be a problem due to decreased urinary sphincter tone and men may experience overflow incontinence due to BPH

Formation of bladder stones- kidney nephrons decrease in number and kidneys have more difficulty concentrating urine
Overview
Age related changes in the urinary system
Changes include decreased blood flow to the kidneys, decreased bladder tone and capacity, decreased filtration, males – benign prostatic hypertrophy, and incontinence related to bladder capacity is common.

After administering pain medication to a client, it is MOST important for the nurse to take which action?

Do not disturb the client

Keep the environment cool and quiet

Provide diversionary activities at short intervals

Determine whether the medication is effective

Determine whether the medication is effective- imperative that the client be assessed for the therapeutic, physiological, and psychological responses to pain medication and to learn to recognize evaluation answers

Do not disturb the client- important that the nurse determine if the medication is effective and if pain relief measure is ineffective the first time, try it one more time before abandoning the measure

Keep the environment cool and quiet- make the environment is comfortable for the client and frequently reassess

Provide diversionary activities at short intervals- determine activities that the client enjoys, works best for short, intense pain lasting a few minutes

Overview is pain management

The nurse knows which of the following statements describes an important consideration when spinal anesthesia is used?

Patients must be protected from injury since sensation is impaired

Partial paralysis is serious but frequent complication.

Patients should try to ambulate as soon as possible

Spinal headache may be prevented by restricting intake of oral and intravenous fluids.

Patients must be protected from injury since sensation is impaired- Frequently assess sensation and voluntary movement. Other side effects include hypotension and headache

Partial paralysis is serious but frequent complication. – Spinal anesthesia used to perform surgery on lower abdominal, pelvic, and lower extremities. Results in a loss of sensation of the area, does not cause paralysis.

Patients should try to ambulate as soon as possible- Lie flat for 12 hours until sensation has returned

Spinal headache may be prevented by restricting intake of oral and intravenous fluids. -Encourage oral fluids, monitor vital signs

Overview
Spinal Anesthesia
Local anesthetic injected into the lumbar intervertebral space beyond the dura mater into the subarachnoid space. Blocks pain sensations and movement. Causes anesthesia of lower extremities, perineum, and lower abdomen. Sympathetic nerve fibers blocked, hypotension caused by loss of vasoconstrictor ability, headache. Nursing considerations include monitoring vital signs, before regional anesthetic to assure adequate blood volume, if client becomes hypotensive increase rate of IV fluids, administer oxygen by mask, notify health care provider, encouraging oral fluids.

When witnessing the client’s signature during informed consent, it is most important for the nurse to make which assessment?

Does the client give consent voluntarily?

Does the client understand the procedure?

Does the client have any questions?

Is the client able to write the name?

Does the client give consent voluntarily? – Nurse’s signature indicates that the client voluntarily gave consent, the client’s signature is authentic, and the client is competent to give consent.

Does the client understand the procedure? – It is the health care provider’s responsibility to explain the procedure and the risks and benefits associated with the procedure

Does the client have any questions? – It is not the nurse’s responsibility belongs to the healthcare provider

Is the client able to write the name? – Client is legally able to place mark on consent form

Overview
Informed Consent
Informed consent is client’s agreement to have procedure performed after explanation of risks, benefits, and expectations, and alternatives to procedure, can be withdrawn at any time. Nurse ensures that consent form is signed and attached to the chart.

A client with ovarian cancer experiences sever pain. Which principle should the nurse remember when caring for this client?

Pain medication is more effective is given before pain becomes severe.

Caution must be used to prevent narcotic addition

Cancer pain is often psychological in origin

Pain medication should be given only with evidence of severe pain

Pain medication is more effective is given before pain becomes severe. – Pain medication given prior to the peak of severity is more effective in managing the pain

Caution must be used to prevent narcotic addition- Most important to treat the client’s pain. If pain continues, client feels anxiety and increased fear, which increases the pain

Cancer pain is often psychological in origin- All pain is real. Pain is “whatever the person experiencing the pain says it is”

Pain medication should be given only with evidence of severe pain-Preventive approach is preferable. Requires smaller doses of medication to relieve or prevent pain if medication is given regularly. Prevention allows the client to spend less time in pain and prevents addiction.

Overview
Pain Management
Pain is often referred to as the fifth vital sign and is defined as “whatever the person says it is, and it exists whenever the person says it does.” Can be acute or chronic. Culture and past experiences with pain are major factors influencing pain experiences. Indications include increased blood pressure and pulse, rapid irregular respirations, pupil dilation, increased perspiration, increased muscle tension, apprehension and irritability, grimacing, guarding, verbalizations of pain. Nursing interventions include establish a therapeutic relationship, establish a 24hr pain profile, teach patient about pain and its relief, reduce anxiety and fears, provide comfort measures, administer pain medications, refer for alternative methods of pain relief. With regard to pain medications, use preventive approach, which states that if pain is expected to occur throughout most of a 24hr period, a regular schedule is better than as needed, usually takes a smaller dose to alleviate mild pain or prevent occurrence of pain.

A nurse assesses an elderly pt. in the outpatient clinic. What does the nurse expect the client to say?

“I seem to get fewer upper respiratory infections than I did before.”

“I think that I am a little taller than I was before.”

“I do not enjoy eating anymore.”

“I sleep with fewer blankets now.”

“I do not enjoy eating anymore.”- Aging causes a diminished taste perception and a declining sense of smell, which contribute to a loss of appetite. Encourage meals that are economical and easy to prepare and the pt should eat when hungry – not according to a set meal schedule

“I seem to get fewer upper respiratory infections than I did before”- pts immune system is less effective due to the aging process.

“I think that I am a little taller than I was before.”- As part of the aging process, adults lose height due to bone loss. They also lose muscular strength and endurance

“I sleep with fewer blankets now.”- Older pts feel cold more easily and may require a warmer room and should be instructed to eat high-energy foods.

Overview
Growth and Development: Older Adult
Late adulthood. Erikson’s stage of integrity vs despair. Physiologic systems decline in efficiency and overall function, butt chronological age by itself is not predictor of when or how much this will occur. They may have decreased stamina and strength, GI tone, temperature adaptability (sub-q fat, circulation to the skin, lower core body temperature), cardiac output, oxygen to muscles, less effective breathing, slower healing, decreased sensory acuity, slowed nerve impulses, decreased bladder tone and urinary function, degeneration of connective tissue, cartilage and bone. Psychosocially cope with loss of significant others, chance in social roles and sometimes have slowed speed of cognition.

A 5 y.o. is scheduled for a tonsillectomy and adenoidectomy. The child is given midazolam preoperatively. For which purpose is the nurse administering this medication?

Decrease the gag reflex

Provides sedation and anxiety reduction

Enhance wound healing

Promote vasoconstriction of the mucous membranes

Provides sedation and anxiety reduction- benzodiazepine, provides anxiety reduction, amnesia, sedation, side effects include agitation, hiccups, nausea, vomiting; preoperative medication given to reduce anxiety, sedate, reduce secretions, antiemetic

Enhance wound healing- diet high in protein and vitamin C will enhance wound healing

Promote vasoconstriction of the mucous membranes- does not promote vasoconstriction

Decrease the gag reflex- does not decrease the gag reflex

Overview
Preoperative medication
Medications given before surgery to relax the client and reduce moisture in mucous membranes. Some medications reduce the amount of anesthesia needed (barbiturates, tranquilizers, opioids, and anticholinergics). May become drowsy and/or dizzy, have a dry mouth – ensure safety measures are met to prevent falls

The nurse understands which describes psoriasis?

A chronic autoimmune reaction

An acute infectious disease

A viral disease

A cystic disease that is self-limiting

A chronic autoimmune reaction- lifelong scaling skin disorder with underlying inflammation, characterized by exacerbations and remissions, there is usually a family hx

An acute infectious disease- not an infectious process as the cause is unknown, but symptoms improve in warmer climates

A viral disease- not a viral disease. Tx includes topical steroids, tar preparation, and ultraviolet light therapy

A cystic disease that is self-limiting- is a lifelong disorder
Overview
Psoriasis
Chronic noninfectious inflammatory disease of the skin. Indications include chronic recurrent thick, itchy, erythematous papules/plaques covered with silvery white scales with symmetrical distribution and are commonly found on the scalp, knees, sacrum, elbows, and behind ears. Nursing considerations include soak in bath with oil or coal tar preparation added, use soft brush to gently scrub plaques, topical steroids followed by warm (moist) dressing with occlusive outer wrapping, administer antimetabolites, ultraviolet light, counseling to support/enhance self-image/self-esteem, important for nurse to touch client to demonstrate acceptance

Wet-to-dry dressing changes are ordered for a client. After the first dry dressing is removed, the client yells at the nurse, “Ouch that really hurts. Are you sure you’re doing it right?” Which statement is the BEST response by the nurse?

“I know it hurts and I am really sorry to have to do it, but sometimes things have to hurt before they get better.”

“I am peeling away the dead tissue. It hurts more the first time. Next time it will not hurt as much, I promise.”

“Yes, I am doing it right. The dead tissue is supposed to stick to the dry dressing, but if I wet it a little bit, it won’t hurt so much.”

“This type of dressing cleans the wound so that it can heal. I’ll bring you some pain medication.”

“This type of dressing cleans the wound so that it can heal. I’ll bring you some pain medication.”- This response explains what the nurse is doing to the client, and offers relief for the pain that the client is experiencing. The next time the dressing is changed pain medication could be offered before the procedure. Apply moist gauze onto wound surface and cover with a dry dressing using sterile procedure.

“I know it hurts and I am really sorry to have to do it, but sometimes things have to hurt before they get better.”- does not respond to the client’s feeling or explain why the nurse is performing the dressing change.

“I am peeling away the dead tissue. It hurts more the first time. Next time it will not hurt as much, I promise.”- All parts of the answer have to be correct in order for the answer to be correct. The nurse cannot promise that a procedure will not be uncomfortable the next time

“Yes, I am doing it right. The dead tissue is supposed to stick to the dry dressing, but if I wet it a little bit, it won’t hurt so much.”- If dressing is moistened prior to removing, it will not remove exudate and wound debris

Overview
Therapeutic Communication
Listening to and understanding the client while promoting clarification and insight. The goal is to understand the client’s message, to facilitate the client’s verbalization of feelings, to communicate the nurse’s understanding and acceptance, and to identify problems, goals and objectives.

An elderly pt. is admitted to the hospital to undergo abdominal surgery. Admitting orders include activity as desired, standard bowel prep, and intravenous infusion of 5% dextrose in water to infuse at 75mL per hour starting at 1800 on the evening before surgery. The nurse understands the primary purpose of administering intravenous fluids to a client prior to surgery includes which reason?

To establish a route for the nurse to give medications quickly

To avoid the nurse having to insert the IV on the morning of the surgery

To decrease the client’s desire to have fluids by mouth before surgery

To make sure the client is sufficiently hydrated during surgery.

To make sure the client is sufficiently hydrated during surgery. – Bowel prep prior to surgery, especially in elderly can cause dehydration so starting fluids in the evening will ensure the client maintains hydration

To establish a route for the nurse to give medications quickly- not the reason for IV fluids

To avoid the nurse having to insert the IV on the morning of the surgery- IV can be started the morning of the surgery

To decrease the client’s desire to have fluids by mouth before surgery- will be NPO

Overview is on preoperative care

The nurse knows that serum albumin is used as an indicator of malnutrition for which reason?

Eggs are commonly eaten in the American diet, so the nurse can assume that albumin from eggs is consistently found in the American diet.

Albumin is the first result on a protein electrophoresis, and the result is often included on the hospital record.

Serum albumin is easy to measure and can indicate a protein deficiency that is not detected on a physical examination.

Serum albumin has a short half-life, so it is an easy protein to measure.

Serum albumin is easy to measure and can indicate a protein deficiency that is not detected on a physical examination. – Albumin is easy to measure in the serum, and has been shown to be quite accurate in identifying hospitalized clients who are malnourished and is an important part of nutrition assessment

Eggs are commonly eaten in the American diet, so the nurse can assume that albumin from eggs is consistently found in the American diet.- most abundant form of protein in the blood and helps to maintain oncotic pressure and transportation of other nutrients, medications, and hormones through the blood

Albumin is the first result on a protein electrophoresis, and the result is often included on the hospital record. – Malnutrition reflected in low serum albumin concentrations

Serum albumin has a short half-life, so it is an easy protein to measure. – has a long half-life and a large body pool, serum albumin is slow to respond to nutritional deficits
Overview
Albumin, serum
Protein formed in the liver. 60% is total protein. Contributes to colloid osmotic pressure, transports enzymes, drugs, and hormones. Indicates liver and nutritional status. Body supply not depleted until malnutrition severe. Decreased in malnutrition, severe burns liver disease, overhydrating, 3rd trimester pregnancy, protein losing nephropathies and increased with dehydration

A pt. has a left modified radical mastectomy. Upon transfer from the recovery room to the surgical unit, the nurse notices the Hemovac drain is half filled with blood. Which action should the nurse take FIRST?

Contact the provider about the pt.

Increase the rate of the IV fluids for the pt.

Look at the recovery room record for the pt.

Measure the pts Hemovac output

Look at the recovery room record for the pt- necessary to look at the recovery room record. Interpretation of the drainage of the Hemovac can be made only if the nurse knows how much drainage was there before the client’s arrival in the room. For example, the recovery room nurse has just emptied the drain and charted 50mL, the fact that it is already half full might be a problem that would require further evaluation. If the drain has not been emptied in the recovery room the amount of drainage in the Hemovac drain would not indicate a problem.

Measure the pts Hemovac output- need to determine the amount of drainage

Contact the provider about the pt. – need more information to determine if the pt. is hemorrhaging

Increase the rate of the IV fluids for the pt. – nurse should determine if quantity of drainage is excessive before implementing, purpose is to collect drainage from wound to promote wound healing. And evaluate character and amount of drainage

On the morning before surgery, a pt. signs an operative consent form. Soon afterward, the client tells the nurse that they do not want the surgery. Which action will the nurse take FIRST?

Encourage the pt. to discuss reasons for canceling the surgery

Tell the provider about the pts decision

Tell the pt. that the decision has caused a delay in the operating room schedule

Ask the pts family to encourage the pt. to have the surgery

Encourage the pt. to discuss reasons for canceling the surgery- Nurse should assess pt. reasons to withdraw consent. Inform pt. of the outcome of decision

Tell the provider about the pts decision- Pt has the right to withdraw consent. Notify health care provider after first assessing the pts reasons

Tell the pt. that the decision has caused a delay in the operating room schedule- Pt has the right to withdraw consent

Ask the pts family to encourage the pt. to have the surgery-Do not try to talk pt. into changing mind. Pt must be informed about outcome of decision
Overview is on informed consent

The nurse understands that which of these common foods are the most likely cause of eczema and should be eliminated from the diet?

Milk, wheat, egg whites

Fish, nuts, chocolate

Strawberries, tomato, apples

Soybeans, orange juice, egg yolks

Milk, wheat, egg whites- Are all common allergens associated with eczema

Fish, nuts, chocolate- Eczema is an inflammatory rash caused by allergic immune response. Nuts commonly cause anaphylactic reaction. Other foods do not

Strawberries, tomato, apples- Berries commonly cause allergic reaction. Other foods do not.

Soybeans, orange juice, egg yolks- Some legumes can cause allergic reaction

Overview
Eczema
Itchy red skin rash commonly seen in young children. May ooze serum and form a crust. Often associated with allergic reaction to allergen, chemical, or drug. Treatment is avoidance of allergen, application of astringent solution, corticosteroid cream, or antihistamines. Keep pt. from scratching.

Which nursing action is most important when caring for a client in pain?

Establish a trusting relationship with the pt.

Teach the pt. about the pain

Determine how various relaxation techniques affect the pain

Administer pharmacological agents

Determine how various relaxation techniques affect the pain- Important to convey to the client in pain that the nurse believes that pts pain is real and that the nurse is appropriate action, but nurse first establishes a trusting relationship

Establish a trusting relationship with the pt.- To effectively develop a plan of care for relieving a pts pain, trust is essential. Pt may not have documented physiological responses to pain and nurse must rely on pts report. If pt. mistrusts the nurse the pt. will not be as likely to report pain.

Teach the pt. about the pain- determines the effectiveness of the intervention for pain based on the pts response.

Administer pharmacological agents -Common pharmacological agents include aspirin, acetaminophen, NSAIDS, and opiates.

Overview is on pain management

The nurse cares for a pt beginning intermittent heparin therapy. The nurse knows which laboratory test I used to monitor the effectiveness of heparin?

Prothrombin time

Partial thromboplastin time

Bleeding time

Protein electrophoresis

Partial thromboplastin time- PTT must be measured at least once a week. Anticoagulation is effective when the ptt is 1.5 to 2 times the control. Antidote is protamine sulfate

Prothrombin time- Used to measure therapeutic level of warfarin. Antidote is vitamin K. apply prolonged pressure to venipuncture site.

Bleeding time- Measures duration of bleeding after standardized skin incision. Prolonged in thrombocytopenic purpura, platelet abnormality, leukemia, and sever liver disease

Protein electrophoresis-Differentiates between protein fractions.

Overview
Heparin
Anticoagulant. Used for short term therapy, given IV or subcutaneous. Action: inactivates thrombin and prevents conversion of fibrinogen to fibrin. Dosage is adjusted according to partial thromboplastin time PTT, therapeutic range is 1.5-2 times normal value. Nursing considerations: leave needle in place for 10 seconds after injection, don’t massage. Side effects: hemorrhage with excessive dosage, thrombocytopenia, and hypersensitivity reactions. Antagonist: protamine sulfate.

The nurse cares for a pt with an abdominal wound. The nurse notes there is purulent drainage from the wound. Which action should the nurse take first?

Contact the health care provider

Place the pt on contact precautions

Irrigate the wound

Ask the client to identify the level of pain on a numeric scale.

Place the pt. on contact precautions- Place pt. in private room or in a room with same infection but no other infections. Wear clean, sterile gloves when entering the pts room. Change gloves after pt. contact. Wash hands

Contact the health care provider- Place pt. on contact precautions to prevent spread of infection to other pt.

Irrigate the wound- Used to cleanse wound. Use sterile technique

Ask the client to identify the level of pain on a numeric scale.-Appropriate to assess pain but priority is to place pt. on contact precautions. Manifestations of infection include redness and swelling. Infected drainage may be yellow, green, or brown. Systemic infections cause fever, fatigue, and malaise. WBCs will be elevated. Normal range is 5000-10000/mm3
Overview
Contact-Based Precautions
Required with pt. care activities that require physical skin to skin contact or those that occur between two clients or occur by contact with contaminated inanimate objects in pts environment. Private room or with client with same infection but no other infection. Clean, nonsterile gloves when entering room, change gloves after client contact with fecal material or wound drainage, remove gloves before leaving the pts environment and wash hands with antimicrobial agent, wear gown when entering room if clothing has contact with pt., environmental surfaces, or if pt. is incontinent, has diarrhea, an ileostomy, colostomy, or wound drainage.

When teaching correct body mechanics to a nurse’s aide, which of the following suggestions by the nurse is MOST appropriate?

“Lift objects with your arms extended.”

“Lean forward when lifting objects.”

“Bend Knees when lifting objects.”

“Bend at the waist when lifting objects.”

“Bend Knees when lifting objects.”- Maintains center of gravity and allows the legs muscles to do the lifting

“Bend at the waist when lifting objects.”- Using back to lift. Should use arms and legs

“Lift objects with your arms extended.”¬- Keep weight close to the lifter’s body

“Lean forward when lifting objects.”-Keep trunk erect, and do not twist.

Overview
Body Mechanics

Principles of good body mechanics include a wide base of support, low center of gravity, alignment of line of gravity with its base of support, bending at the knees, using the stronger muscle groups (legs), holding the lifted object close to the body, facing the direction of movement rather than twisting, avoiding lifting when possible, pushing rather than pulling, alternating periods of rest and activity.

The nurse expects which physiological change to occur to a client during episodes of acute pain?

Decreased blood pressure

Decreased heart rate

Decreased respiration

Decreased skin temperature

Decreased skin temperature- Increased perspiration occurs during acute pain episodes, thereby cooling off the skin

Decreased blood pressure- Blood pressure and heart rate increase, which increases blood flow to the brain and muscles.

Decreased heart rate- Blood pressure and heart rate increase, which increases blood flow to brain and muscles

Decreased respiration-Rapid, irregular respirations lead to increased oxygen supply to brain and muscles

Overview is on pain management

The clinic nurse interviews a middle-aged adult who comes to the clinic reporting difficulty sleeping and ongoing fatigue. The nurse learns the pt. works as a security guard and frequently works nights. Which is the best initial response by the registered nurse?

“You probably sleep when you can during your night tour”

“This is normal for your age group”

“Tell me about your sleeping habits.”

“Working the night shift is known to disrupt sleep patterns”

“Tell me about your sleeping habits.”- Nurse must assess prior to implementing. Important to find out pts usual sleep patterns

“You probably sleep when you can during your night tour”- Nurse is making an assumption

“This is normal for your age group”- Most middle aged adults do not have trouble sleeping

“Working the night shift is known to disrupt sleep patterns”-This is the second best answer. The best initial response is to assess

At discharge, the nurse advises a pt. about a calorie-restricted diet. Which is an ideal rate of weight loss

One-half pound per day

One-half pound per week

1lb per day

1lb per week

1lb per week- Losing 1-2 lbs. per week is safe and effective. Adult women should not fall below 1200 calories per day. Adult men should consume a minimum of 1500 calories per day

One-half pound per day- Weight loss is too rapid

One-half pound per week- Ideal weight loss for overweight to mildly obese pt. is 1-2 lbs. per week

1lb per day-Weight loss is too rapid.

Overview
Weight Reduction
Using a balanced food intake to lose weight. Reduction of calories. Decrease fat intake below 30 percent of total intake. Decrease saturated fats to less than 10 percent of daily intake. Increase fresh fruit and vegetable intake. Reduce processed foods. Decrease intake of empty calories. Increase whole grain intake. Lose no more than 1-2 lbs. per week.

A 53-year old pt. is admitted to the hospital for hematuria. The pt has no previous history of illness, is married, and has 3 high school children. Which task of middle adulthood would most likely be disturbed by a physical disability?

Assisting the children to grow to adulthood

Coping with a role transition

Renewing earlier relationships

Developing adult leisure time activities

Assisting the children to grow to adulthood- According to Erikson, middle adulthood is the time of guiding the next generation. This occurs not only in family life but also in one’s professional career, if this developmental task is not achieved, client becomes self-absorbed

Coping with a role transition- Middle age is called the sandwich generation. Are still involved with children, but are also involved in caring for aging parents or other realities

Renewing earlier relationships- Middle-aged adults are leaders in their professions and communities

Developing adult leisure time activities- Middle-aged adults find that they have more financial resources and more leisure time. Nurse should instruct pt. about the importance of engaging in daily leisure activity.

Overview
Erikson’s stages of psychosocial development
Theory of psychosocial development throughout the life span. Divided into 8 stages that define particular tasks that individuals need to accomplish before moving to next stage. Each stage has a positive and negative outcome.
Infancy (Birth to 12 months) Trust vs Mistrust.- infant learns to trust self and others
Toddler (12months – 3 yrs) Autonomy vs Shame- toddler learns to exercise self control and influences the environment directly
Preschool (3-6 years) – Initiative vs guilt- child begins to evaluate own behavior; learns limits on influence in the environment
School age (6-12 years)- Industry vs Inferiority Child develops a sense of confidence. Uses creative energies to influence the environment.
Adolesence (12-20 years)- Identify vs role confusion – adolescent develops a coherent sense of self. Plans for a future of work/education
Young Adult- (35-65 years) Generativity vs Stagnation- Involved with established family. Expands personal creativity and productivity focus is supporting future generation
Late adulthood- (65+ years) Integrity vs despair- identifies that life was meaningful

Following surgery, the nurse becomes concerned because the pt has not voided since before surgery which was 10 hours ago. Which nursing action is most appropriate?

Inform the health care provider immediately

Palpate for bladder distention

Insert a catheter into the bladder

Encourage client to take sips of water

Palpate for bladder distention-Preform assessment before implementing

Insert a catheter into the bladder -Assess before implementing

Encourage client to take sips of water-Assumes client is dehydrated. Assess the status of the bladder

Inform the health care provider immediately-Perform assessment of pt before contacting health care provider

Overview is post-op care

The nurse identifies a staff member is using standard precautions appropriately if which action is observed?

The staff member irrigates an abdominal wound wearing a gown and gloves

The nurse removes gloves after bathing a client and puts on clean pair of gloves to bathe another.

The staff member places contaminated linens in a leak proof bag

The nurse wears gloves when taking the blood pressure of a client diagnosed with AIDS

The staff member places contaminated linens in a leak proof bag-prevent contact with skin and mucous membranes

The nurse wears gloves when taking the blood pressure of a client diagnosed with AIDS -Wear gloves when touching blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes. Not necessary to wear gloves when taking blood pressure

The staff member irrigates an abdominal wound wearing a gown and gloves -Should also wear mask or eye protection if splashes or sprays of blood or body fluid might occur

The nurse removes gloves after bathing a client and puts on clean pair of gloves to bathe another -Always wash hands between contacts with pts. Wash hands immediately after removing gloves.
Overview
Standard Precautions

Used with all clients to prevent health care associated infections. Apply to blood, all body fluids, and secretions. Wash hands immediately on contact with blood or body fluids. As soon as gloves are removed, between pt contact, between procedures or tasks with the same pt, wear gloves when touching blood, body fluids, or before touch mucous membranes or nonintact skin, wear mask, face shield, and gown if splashes and sprays likely.

The nurse cares for a pt with a body mass index (BMI) 17.0 kg/m2. What is the best description of the clients body weight?

Underweight

Normal weight

Overweight

Obese

Underweight-BMI of less than 18.5 is underweight

Normal weight- Normal BMI is 18.5-24.9

Overweight- Overweight BMI is 25.0-29.9

Obese- Obese BMI is 30.0-30.9

Overview
BMI
BMI estimates body fat. Allows health care provider to counsel about risk factors for diabetes, heart disease, stroke, hypertension, osteoarthritis.

Which of the following fears is most important to consider when planning care for a 4 year old about to have surgery?

Fear of mutilation

Fear of losing independence

Fear of losing control

Fear of separation

Fear of mutilation- Preschool children are frightened of invasive procedures because they fear mutilation. Allow child to play with models of equipment. Encourage expression of feelings

Fear of losing independence-Fear of adolescent. Involve adolescent in procedures and therapies. Express understanding of concerns

Fear of losing control- Fear of school age child. Explain procedures in simple terms allow choices when possible

Fear of separation-Fear of toddle. Teach parents to expect regression.
Overview
Age-Appropriate preparation -Preschool
Preschooler runs well, jumps rope, dresses without help. Has a 2100 word vocabulary, ties shoes, imitates adult patterns and roles. Offer playground material. Housekeeping toys. Coloring books. Use bicycle helmet. Safety restraints in car. Teach to look both ways before crossing street.

A liver scan is ordered for a client prior to surgery. The nurse understands which description best describes the procedure?

The client will be asked to lie still while a scanning probe is passed back and forth over the body

The client will be strapped to a table and irradiated by a cobalt scanner

The client will stand in front of a large machine that takes x-ray pictures of liver

The clients skin will be lubricated with oil and ultrasound pictures will be taken

The client will be asked to lie still while a scanning probe is passed back and forth over the body- Client will be placed in many different positions, but must lie still during scan, no follow up care is necessary

The client will be strapped to a table and irradiated by a cobalt scanner- Client will receive IV injection of radioactive colloid, which is taken up by the liver and spleen. Liver and spleen are scanned

The client will stand in front of a large machine that takes x-ray pictures of liver- Scan is nuclear medicine technique

The clients skin will be lubricated with oil and ultrasound pictures will be taken-Ultrasound used to image soft tissues such as liver spleen pancreas and gall bladder.

While a pt. is being treated for a wound infection, it is most important for the nurse to routinely preform which action?

Check and record the clients temp

Send samples of wound drainage for culture

Assess the perfusion in the area

Evaluating the results of the blood culture.

Evaluating the results of the blood culture.-A client with a wound infection is at risk for bacteremia or other complications such as glomerulonephritis. Nurse should evaluate for temp elevation.

Send samples of wound drainage for culture-Would be done initially

Assess the perfusion in the area-Assess for indication of inflammation

Evaluating the results of the blood culture.-Health care provider will order appropriate antibiotics. Place client on contact precautions.

A client is given a lab test. Which finding from the lab test indicates the client has an infection?

Serum creatinine level of 2.4 mg/dL

AST (SGOT) 15u/L

White blood cell count of 16,000/mm3

White blood cell count of 4,000/mm3

White blood cell count of 16,000/mm3 – normal range is 5,000-10,000/mm3; elevation indicates infection

Serum creatinine level of 2.4 mg/dL – measures renal function; normal is 0.5-1.5 mg/dL; elevated in acute kidney injury and chronic kidney disease

AST (SGOT) 15u/L – measures damage to liver and heart; normal is 10-40 u/L

White blood cell count of 4,000/mm3 – indicates patient becoming immunosuppressed

Overview
Infection
Presence and growth of a microorganism that causes tissue damage; chain of infection includes an infectious agent, reservoir where pathogen can live, portal of exit that allows the organism to exit one host, mode of transmission, portal of entry into the new host, and susceptible host. If an infection is localized, indications include pain, tenderness and redness at the wound site. If infection is systemic, indications include fever, fatigue, nausea/vomiting, malaise, enlarged, tender lymph nodes. Treatment: obtain culture and sensitivity of wound, antibiotics/antifungal agents specific to organism(s). While waiting for the culture and sensitivity, broad-based antibiotic/antifungal might be used until the results are obtained and then switched to the antibiotic/antifungal appropriate for the organism(s).
Nursing considerations: obtain culture and sent to laboratory before starting medication. Client education: take medication as ordered and entire course of medication, return for follow-up.

A client has multiple wounds. Which diet best meets the needs of this client?

High-protein, low-fat, high-iron diet

High-vitamin C, high-protein, high-carbohydrate diet

High-vitamin A, high-calcium, high-fat diet

High-vitamin B, high-protein, low-carbohydrate diet

High-vitamin C, high-protein, high-carbohydrate diet- increased vitamin C is essential to wound healing, and high protein is necessary for tissue growth; carbohydrate is needed or energy so the protein is properly utilized for repair of tissue
Explanation
High-protein, low-fat, high-iron diet – increased iron appropriate for client with iron deficiency anemiaHigh-vitamin A, high-calcium, high-fat diet – vitamin A contributes to night vision and growth of bones and teeth; vitamin A found in liver, fish, liver oils, and fortified dairy products

High-vitamin B, high-protein, low-carbohydrate diet – high carbohydrates needed for energy

Overview
Wound Healing Diet
Diet to support wound healing should be high in protein, fat, carbohydrates, vitamins (especially A, C, E), and minerals (including zinc).

Essential Nursing Care
Proper nutrition is one of the most important factors to effect wound healing, and can be assessed by monitoring urinary and bowel elimination patterns.
Purpose
. Promotes wound healing
. Prevents infection
. Influences balanced diet
Sample Associated Nursing Dx
. Imbalanced Nutrition
. Risk for Imbalanced Nutrition
. Anxiety
. Risk for Impaired Fluid Volume
. Delay in Wound Healing
. Deficient Knowledge
. Disturbed Body Image
. Impaired Skin Integrity
. Impaired Tissue Integrity
. Risk for Infection
Implementation
. Postoperative Assessment and Interventions
. Assess wound drainage and maintain prescribed IV fluid infusion rates
. Assess skin turgor and mucous membranes for dehydration
. Monitor weight and postoperative dietary progression (i.e., from clear to full liquids, and soft to regular foods)
. Identify nutritional needs and monitor for nutritional risks. Encourage food and fluid intake according to dietary progression or as prescribed.
. Double the patient’s recommended dietary allowance of protein (from 0.8/kg/day) before tissue even begins to heal
. Supply fruit juices and high-fiber foods
. Adjust the patient’s general intake of carbohydrates, fats, vitamins (especially A, C, and E), and minerals (including zinc) according to needs
. Ensure that patient’s environment is clean, neat, and free of odors to promote appetite
. Encourage patient to sit up in bed or chair for meals, and encourage family participation in meals
. Provide privacy when patient is using the bedpan, urinal, commode, or bathroom
. Monitor patterns of intake and output and assess patient’s ability to pass flatus and stool
. Palpate above the symphis pubis if:
. Patient has not voided within 8 hours after surger
. Patient has been voiding frequently in amounts of less than 50mL
. Notify physician of abnormalities
. Auscultate bowel sounds every 4 hours when the patient is awake to assess for return of peristalsis
. If bowel sounds not audible, or high-pitches, assess abdominal distention
. Administer suppositories, enemas, or medications, and encourage oral fluid intake as prescribed
Expected Outcomes
. Patent successfully makes transition from fluids to solid foods and maintains normal elimination pattern
. Patient’s wound(s) heal without complication
. Patient adheres to dietary needs following release from the hospital
(Adapted from Fundamentals of Nursing Made Incredibly Easy, pp. 410-411; Fundamentals of Nursing, Sixth edition, by Taylor et al., pp. 903-904)
Background for Nursing Care
Proper nutrition is one of the most important factors to effect wound healing, and can be assessed by monitoring urinary and bowel elimination patterns
Patient Teaching
. Encourage patient to actively participate in nutrition intake preoperatively
. Manage fluid balance; adjust fluid/food intak
. Avoid alcohol and certain medication; can alter body;s use of nutrients
. Discuss with patient postoperative complications as direct relation to nutrition
. Inform that severity of complications as direct relation to nutrition
. Delayed wound healing, wound infection and disruption in integrity of wound
. Fluid imbalances (from fluid loss during surgery, wound drainage, or surgical stress response)
. Provide patient with pamphlets/other educational resources
. Discuss ways that a standard diet needs to be adjusted to influence wound healing
Special Considerations
. General Considerations
. An obese patient has less resistance to infection; poor blood supply; increased risk for respiratory, cardiovascular, and gastrointestinal problems
. Pediatric Considerations
. Discuss with parents or guardians ways to implement a healthy diet into a pediatric patient’s meal plan
. Pediatric patient are especially at risk for imbalances in fluid volume (deficits or excess) following surgery
. Geriatric Considerations
. Older patients are especially at risk for fluid imbalances (deficits or excess) and malnutrition following surgery
(Adapted from Fundamentals of Nursing, Sixth edition, by Taylor et al.; pp. 883, 886-891, 897-905; 1189, 1192-1193, 1428-1433; Fundamentals of Nursing Made Incredibly Easy, pp. 410-411

A client just had surgery. The nurse helps the client to cough and breathe deeply. What position does the nurse help the client to take?

Side-lying

Prone

Supine with one pillow

High Fowler’s

High Fowler’s- high Fowler’s is the best position to deep breathe and cough.
Explanation
Side-lying impedes expansion of lungs; ask client to take two slow, deep breaths, inhaling through nose and exhaling through mouth; inhale deeply third time and cough.Prone lying on abdomen; would not be able to expand lungs; lying prone will prevent hip flexion.

Supine with one pillow ask client to splint abdominal wound with pillow; administer analgesic prior to asking client to cough and deep breath

Overview
Cough and Deep Breathe (CDB)- After surgery or immobility for any period of time, client develops pulmonary disorders; coughing and deep breathing (CDB) will alleviate these problems; client might use an incentive spirometer or just take several deep breathes and cough – deep cough; once mucus is disturbed the client will cough it up; CDB is an independent nursing activity; each cycle of CDB includes at least 3 deep breaths and a deep cough; at least 10 cycles every 1-2 hours.

A client is immobilized and in bed. The nurse wants to help the client rest and sleep in the evening. What is the most important for the nurse to provide?

Privacy at night

Back rubs at night

Baths every day

Activities during the day

Daytime activities – particularly important for the immobilized and bedridden client. It causes them to nap less during the day, and provides relief from tension. It enables the client to relax and sleep at night

Privacy – more important that clients maintain daytime activity

Back rubs – will help the client relax, but daytime activity is more important

Daily baths – bathing and skin care are part of hygiene of the client

Overview
Rest and Sleep
Rest is a basic physiological need that allows the body to repair damaged cells, enhances removal of waste products from the body, restores tissue to maximum functional ability before another activity is begun. Sleep restores balance among different parts of the CNS, mediates stress, anxiety and tension, and helps a person cope with daily activities. Disturbances in rest and sleep are caused by stress, medication (hypnotics, antidepressants, stimulants, caffeine, beta-adrenergic blockers, barbiturates, diuretics, and alcohol), unfamiliar and/or noisy and/or bright environments, daytime sleeping, working shifts, and overeating. Nursing care includes establishing a database about the client’s pattern or rest and sleep, give care in blocks to allow for uninterrupted periods of rest and sleep, avoid unnecessary lights and noises, comfortable room temperature, non-stimulating beverages, promote bedtime routine, encourage daytime activity, limit daytime naps, reposition client, straighten and replace wrinkled or soiled linens, administer pain mediation, provide diversionary and occupational activities during the day to relieve boredom and utilize nighttime for sleep.

A client has acute pain. The healthcare provider prescribed meperidine 50 mg IV every 3-4 hours prn for pain. The client asks the nurse to give medication at bedtime. Before the nurse gives the client the pain medication, what does the nurse do?

The nurse assumes that the client’s pain is psychological

The nurse tries several other ways to relieve the pain instead of giving the pain medication

The nurse assesses the location, character, and intensity of the client’s pain

The nurse checks to see if the client has a history of drug addiction

Assess location, character, and intensity of pain – Determine onset, duration, and sequence of pain as well as location and intensity

Assume the pain is psychological – pain is “whatever the person says it is, and it exists whenever the person says it does”. Assume the client’s pain is real.

Check to see if the client has a history of addiction – assessment answer, the nurse should assess the characteristic of the client’s pain

Try several other pain relief measures -appropriate to use a variety of relief measures, such as relaxation, guided imagery, listening to music, biofeedback. Prior to implementing any measures for pain relief the nurse must assess the client.

Overview
Pain Management
Pain is often referred to as the fifth vital sign and is defines as, “Whatever the person says it is, and it exists whenever the person says it does.” Pain can be acute or chronic. Culture and past experiences with pain are major factors influencing pain experiences. Indications include increased blood pressure and pulse, rapid irregular respiration, pupil dilation, increased perspiration, increased muscle tension, apprehension and irritability, grimacing, guarding, and verbalization of pain. Nursing interventions include establishing a therapeutic relationship, establishing a 24-h pain profile, teach the patient about pain and it’s relief, reduce anxiety an fears, provide comfort measures, administer pain medications, and refer for alternative methods of pain relief. With regard to pain medication, use the preventive approach (if pain is expected to occur throughout most of a 24-h period a regular schedule is better than prn because it usually takes smaller doses to alleviate mild pain or to prevent occurrence of pain.

A nurse gives a preoperative medication to a client. Which action is essential for the nurse to do next?

Make sure the client has signed the operative permit

Tell the client what to expect in the operating room

Discuss the client’s feelings about surgery

Raise the side rails of the client’s bed

Raise the side rails of the bed – this will prevent injury to the client

Ensure the operative permit is signed – cannot be signed once preoperative medication is administered

Discuss the client’s feelings about surgery – safety takes priority over psychosocial needs

Tell the client what to expect in the operating room – this is part of the preoperative teaching and occurs prior to administering preoperative medication

Overview
Preoperative Checklist
Preoperative checklist includes ensuring that informed consent is signed and attached to the chart, all lab tests, chest x-ray, and EKG have all been completed, performing skin and bowel prep, NPO, administering preoperative medications (sedation, antibiotics), removing dentures, jewelry, and nail polish.

The nurse counsels a client about how to maintain an adequate intake of protein. The nurse determines further teaching is required if the client chooses which foods?

Peanut butter on whole wheat bread

Rice and red beans

Orange juice and white toast

Spaghetti and meat sauce

Orange juice and white toast- juice contains little protein, most of it is in the pulp. Bread is made from white flour and is also limited in protein content

Peanut butter on whole wheat bread- both peanut butter and whole wheat bread contain protein

Rice and red beans- red beans contain some protein

Spaghetti and meat sauce- meat sauce contains some protein

Overview
Increased Protein Diet
Diet in which protein is increased from the normal expected amounts. Protein is used during tissue repair and rebuilding. This diet is used after surgery, fractures, stress to the body, cancers, and other times when increase repair is required. Foods which are high in protein include: meat, fish, nuts, cheese, protein powder, and peanut butter.

On the first postoperative day, a client develops a fever. The nurse auscultates crackles bilaterally in the lower lobes. Which complication from surgery does the nurse recognize the client is probably developing?

Pulmonary embolism

Thrombophlebitis

Heart failure

Atelectasis

Atelectasis- the most probable cause for crackles because secretions block the bronchioles and the alveoli collapse, causing hypoventilation

Heart failure- failure of the cardiac muscle to pump sufficient blood to meet the body’s metabolic needs. Manifestations include dyspnea, orthopnea (the sensation of breathlessness when in the recumbent position), pleural effusion, dependent edema, and bounding pulses.

Thrombophlebitis- manifestations include unilateral edema, warmth and tenderness of lower extremity, swelling tenderness, and localized redness over a vein with an intravenous catheter. Thrombophlebitis (throm-boe-fluh-BY-tis) occurs when a blood clot blocks one or more of your veins, typically in your legs. Rarely, thrombophlebitis (sometimes called phlebitis) can affect veins in your arms or neck. The affected vein may be near the surface of your skin, causing superficial thrombophlebitis, or deep within a muscle, causing deep vein thrombosis (DVT). Thrombophlebitis can be caused by trauma, surgery or prolonged inactivity. Superficial thrombophlebitis may occur in people with varicose veins. A clot in a deep vein increases your risk of serious health problems, including the possibility of a dislodged clot (embolus) traveling to your lungs and blocking an artery there (pulmonary embolism). Deep vein thrombosis is usually treated with blood-thinning medications. Superficial thrombophlebitis is sometimes treated with blood-thinning medications, too.

Pulmonary embolism – Manifestations include: dyspnea, tachypnea, and pleuritic chest pain

Overview
Postoperative (Post Op) Care
Full system assessment required because anesthesia, immobility, and surgery can affect any system in the body. Neuropsychosicial (stimulates client post anesthesia) monitor level of consciousness. Cardiovascular (monitor vital signs every 15 minutes x4 (1 hour), every 30 minutes x2 (1 hour), every hour x2 (2 hours), then every hour or prn) check potassium level, monitor central venous pressure. Respiratory (check airway and breath sounds) turn, cough, and deep breathe (unless containdicated i.e. brain, spinal, or eye injury), splint wound, offer pain medication, teach how to use incentive spirometer (hold mouthpiece in mouth, exhale normally, seal lips and inhale slowly and deeply, keep balls or cylinder elevated, exhale and repeat). Gastrointestinal (check bowel sounds in all four quadrants for 5 minutes each if nothing is heard and keep NPO until bowel sounds are present) provide good mouth care while NPO, provide antiemetics for nausea and vomiting, check abdomen for distention, check for passage of flatus and stool. Genitourinary (monitor intake and output, encourage to void, check for bladder distention, notify healthcare provider if unable to void within 8 hours, catheterize if needed), monitor for complications (hemorrhage, paralytic ileus, atelectasis, pneumonia, embolism, infection of wound, dehiscence, evisceration, venous thromboembolism (VTE), psychosis). Musculoskeltal get out of bed as soon as possible and ambulate as much as possible.

A client steps on a dirty, rusty nail. After puncturing her foot with the nail, the client goes to the emergency room. The client states that she received her last Td immunization 6 years ago. What does the nurse do FIRST?

Give the client tetanus toxoid

Give the client tetanus immune globulin (TIG)

Find out how many Td immunizations the client has received

Monitor for lockjaw

Determine how many Td immunizations that client has received- if the client received at least 3 doses of Td, administer tetanus toxoid booster to prevent development of tetanus. If less than 3 doses has been received administer Td AND tetanus immune globulin (TIG)

Administer tetanus toxioid- should first determine immunization history because tetanus is a fatal disease caused by a bacterium that can live for a long time in soil and dirt. It can enter the blood via wounds and can affect the CNS. After a dirty wound, a tetanus toxoid booster (TIG) is given to ensure protection against tetanus

Administer tetanus immune globulin (TIG)- appropriate action if client received less than 3 doses of Td or has developed tetanus

Monitor for lockjaw- Lockjaw is the first sign of generalized tetanus. Other manifestations include opisthotonus, muscle rigidity, cramps, and muscle spasms. Give tetanus toxoid to prevent the development of tetanus.

Overview
Tetanus
Acute infectious disease of the CNS caused by exotoxin of Clostridium tetani. Causes painful muscle rigidity. Primary prevention occurs through immunization and boosters. Administer tetanus immune globulin (TIG) to child not immunized or inadequately immunized suffering a puncture wound contaminated with dirt, feces, soil, or saliva.

Essential Nursing Care
Tetanus is an acute toxic syndrome caused by a protein toxin produced during an infection with Clostridium tetani, a spore-forming anaerobic bacterium. While tetanus can be prevented by a vaccine, it can be fatal (1in 10 cases) if it goes untreated.

Signs and symptoms of Tetanus include
. Painful muscular rigidity and spasms
. Tightening of the jaw muscles (lockjaw) prohibiting breathing and swallowing
. Painful paraoxysmal seizures
. Irregular heartbeat and tachycardia
. High sensitivity to external stimuli
. Profuse sweating
. Low grade fever

Treatment of tetanus include
. Active immunization at age 2 months with Dtap vaccine
. Immunizations continue at ages 4, 6, and 15-18 months and 4-6 years (5 doses total)
. Vaccine should be given every 10 years thereafter or when a person presents with a potentially contaminated wound

Treatment
. Tetanus immune globulin (to neutralize tetanus toxin) and tetanus toxoid
. Penicillin G (IV)
. Metronidazole, erythromycin, or tetracycline for penicillin allergic patients
. Debridement of open wound through which contamination occurred
. Muscle relaxants and sedative, to treat and monitor cardiopulmonary status
. Antiseizure medications as needed

Nursing Care
. Maintain a patient airway in the child with tetanus and assure adequate ventilation
. Keep emergency airway equipment handy in case of respiratory failure
. Monitor vital signs frequently
. Maintain a quiet environment by reducing external stimuli from light, sound or touch
. While the child is very ill, mentation (mental activity) is unaffected so be sure to explain the disease, its treatment, or any procedures to allay any anxiety the child may be experiencing.
. Carefully monitor children with tetanus because they often must take potent muscle relaxants, and the resulting paralysis can make it impossible for the child to communicate clearly

Expected Outcomes
. Patient is treated successfully without untoward complications and recovery is complete

Background for Nursing Care
Background
. Tetanus is contracted by contamination with C. tetani, which is found in the soil and animal feces.
. C. tetani infects the body through a wound. The anaerobic tetanus bacilli reproduce when the oxygen supply is cut off because the wound is deep or forms a crust (e.g. as with burns)

Pathophysiology
. There is usually no obvious infection (e.g. pus, red area) at the wound site, which may give a false impression that no treatment is necessary.
. The tetanus bacilli produce protein toxins as they grow, which result in the clinical presentation of the disease.
. The protein toxins specifically bind to the motor neurons of the CNS. They are then transported to the brain stem and spinal cord, where the release of inhibitory neurotrasmitters (glycine, gamma-aminobutyric acid) is blocked.
. The blocking of these neurotransmitters results in increased firing rate of motor neurons and decreased activity of reflexes, producing rigidity and spasms

Causes/Risk Factors
Infection with C. tetani, which is transmitted through: Penetrating wounds, burns, open wounds of the skin, and contact with contaminated soil, dust, animal excreta, and surgical instruments

Diagnostic Tests
. History of significant for no tetanus immunization and with symptoms of muscle rigidity and breathing or swallowing difficulty
. Peripheral blood smear (to show increased leukocytes)

Complications
. Seizures
. Severe, sustained muscle contractions
. Respiratory muscle spasm, resulting in respiratory distress
. Asphyxia
. Death

The nurse understands the purpose of a drain in the wound is to

keep the tissues close together so that healing can occur

prevent infection by providing a means for bacteria to escape

evaluate the effectiveness of hemostasis

create a space that will facilitate reconstructive surgery at a later date

keep the tissues close together so that healing can occur- if blood or serous drainage collects underneath the skin edges, the tissues will not be able to heal properly

prevent infection by providing a means for bacteria to escape- aseptic technique used to prevent infection. The nurse should observe that drain is in place and note character of drainage and measure drainage volume

evaluate the effectiveness of hemostasis- achieved by sutures and dressings

create a space that will facilitate reconstructive surgery at a later date- keeps wound edges approximated

Overview
Drains
Drainage systems (open or closed) placed to provide exit route (gravity or vacuum) for air, blood and other material following surgery. Nursing considerations include: monitoring characteristics and volume of drainage, recording in output records, preventing skin contact, securing placement, and monitoring for infection.

A client is prescribed morphine. Because of the client’s situation, the nurse decides to wait to give the morphine until there is further assessment. What is the client’s situation?
Client reports acute pain from deep partial thickness burn affecting lower extremitiesClient’s blood pressure is 140/90, pulse 90, and respirations 28

Client’s level of consciousness fluctuates from alert to lethargic

Client exhibits restlessness, anxiety, and cold, clammy skin

Client’s level of consciousness fluctuates from alert to lethargic- morphine depresses the CNS (especially the respiratory center) and would cause a decrease or fluctuation of consciousness

Client reports acute pain from deep partial thickness burn affecting lower extremities- no contraindication for this client. During emergent post-burn phase, agents should be administered IV because of poor absorption from subcutaneous and intramuscular spaces

Client’s blood pressure is 140/90, pulse 90, and respirations 28- elevated vital signs indicate the client is in pain

Client exhibits restlessness, anxiety, and cold, clammy skin- pain causes peripheral vasoconstriction, which shifts blood supply to skeletal muscles and brain

Overview is on pain management

The nurse cares for a client with a body mass indes (BMI) of 38kg/m2. What is the BEST description of the client’s body weight?

Underweight

Normal weight

Over weight

Obese

Obese- 30-39.9

Underweight- <18.5 Normal weight- 18.5-24.9 Over weight- 29.9 Overview Body Mass Index Body mass index estimates body fat. This allows the provider to counsel about risk factors for diabetes, heart disease, stroke, hypertension, and osteoarthritis. In addition to above values, morbid obesity is a BMI >40.
If a client is overweight with two or more risk factors for heart disease or obesity-related illnesses a weight loss program should be encouraged.

The nurse observes a staff member prepare to leave the room of a client on droplet precautions. The nurse should intervene if which action is observed?

The staff member removes the gloves by pulling off inside out

The staff member holds onto the outer surface of the facemask while pulling mask away from face

The staff member unties the gown and removes it without touching the outside of the gown

The nurse performs hand hygiene for 15 seconds

The staff member removes the gloves by pulling off inside out
The staff member holds onto the outer surface of the facemask while pulling mask away from face- Do not touch outer surface of mask. Untie top mask string and then bottom string, pull the mask away from the face and drop into trash receptacleThe staff member removes the gloves by pulling off inside out- appropriate action (do not touch outside of glove

The staff member unties the gown and removes it without touching the outside of the gown- appropriate action

The nurse performs hand hygiene for 15 seconds- appropriate action

Overview
Droplet Precautions
Used with pathogens transmitted by infections droplets which happens during coughing, sneezing, talking, or during procedures (such as suctioning or bronchoscopy and involves contact of conjunctiva or mucous membranes of the nose or mouth. Patient should be in a private room or a room with a patient with the SAME infection, but no other infections. Maintain 3 feet of separation between infected patient and any visitors or other clients. The door may remain open, but the client must wear a mask if ambulating or being transported

Several days postoperatively, a client reports pain, tenderness, and redness of the right calf. Which s/s are critical for the nurse to assess for next?

Nausea and abd. distention

Back pain and hematuria

Chest pain and SOB

Similar findings in the right arm

Chest pain and SOB- calf pain suggests that the client may have a venous thromboembolism (VTE). Client should be placed on bedrest with leg elevated until anticoagulant therapy is started. To prevent VTE keep knee gatch flat, do not place pillows behind knees, perform leg exercises and apply anitembolic hose

Nausea and abd. distention- indicates small bowel obst.

Back pain and hematuria- indicates uninary tract calculi

Similar findings in the right arm- sx would not also be in the arm

Overview
Venous Thromboembolism (VTE)
Aggregate of platelets attached to a vein wall. Risk factors: pregnancy, immediate postpartum period, prolonged immobility, use of oral contraceptives, sepsis, smoking, dehydration, heart failure, and trauma (including surgery). Indications of VTE include: calf pain, localized edema of ONE extermity, possible warm skin over affected leg, possible fever, chills, and perspiration. Tx of VTE includes: bedrest, elevating extremity, anticoagulants, possible thrombolytic drugs, and possible surgery. Nursing care for VTE includes: maintain bedrest, raise extremity, compression stockings after acute stage, and administering prescribed analgesics.

The nurse instructs a client how to successfully establish a regular exercise program. The nurse determines further teaching is needed if the client makes which statement?

“I should choose an exercise that suits my lifestyle.”

“I should incorporate exercise into my daily routine.”

“I should make a commitment to exercise regularly.”

“I should start by running 5 miles a day.”

“I should start by running 5 miles a day.”- should begin slowly

“I should choose an exercise that suits my lifestyle.”- exercise should be a combination of aerobic exdercise, stretching and flexibility exercise, resistance training

“I should incorporate exercise into my daily routine.”- should exercise 30 minutes or more a day for 3-4 hours per week

“I should make a commitment to exercise regularly.”- should commit ot daily exercise (does not have to be done at one time — can be broken down into 10 minute segments)

Overview
Exercise program
Programs of exercises designed to enhance rehabilitation. Specific exercises are designed for specific needs (cardiac, specific muscle, post surgery,or for specific medical conditions such as COPD, osteoarthritis, MS), and is designed to increase muscle strength and stamina.

The home care nurse cares for a client diagnosed with a fractured humerus due to a fall in the home. Which of the following observations made by the nurse, requires immediate intervention?

The bathroom is equipped with grab bars

Throw rugs have been removed

The client ambulates wearing socks

The stairs are well lighted

The client ambulates wearing socks-should wear shoes or slippers with nonskid surfaces

The bathroom is equipped with grab bars- most injuries to older people involve falls. Bathrooms should shave grab bars near the toilet and the tub

Throw rugs have been removed- should be removed if they do not have nonskid backing. Make sure that the edges of carpets, mats, and tile are well secured

The stairs are well lighted- ensure adequate lighting on stairs as most falls occur at the top and bottom steps of the stairs

Overview
Elderly Adults
Provide additional lighting, grab bars on tub and toilet, monitor for side effects of drugs, teach client to take their time when getting out of bed and to bend from the waist or stoop slowly.
Essential Nursing Care
Purpose
. Eliminate risky events
.Prevent injury
. Education involves all parties about safety

Implementation
. Initiate a surveillance of environmental hazards within the healthcare facility and modify the environment as necessary
. Identify patients who are most at risk for injury or falls, especially those who: have a history of falls, suffer from confusion or disorientation, struggle with posture while seated, and have difficulty standing with support
. Ensure that pts wear ID bracelet
. Assess pts ability to follow instructions
. Orient pt. to hospital surroundings, safety features, and equipment in room (including call bell)
. Monitor for side effects of drugs, especially diuretics, tranquilizers, sedatives, hypnotics, or analgesics
. Practice good transfer techniques (Good body mechanics and lifting techniques, ensure pts body is in good alignment while being moved, use proper equipment i.e. gait belts for transfer and ambulation, lateral-assist devices have long handles to reduce reaching, mechanical lateral-assist device to eliminate the need to slide a pt. manually, powered stand-assist aide to mechanically assist pts to stand w/o assistance from nurse, powered full-body lifts for pts who cannot bear weigh, and transfer chairs which convert into a stretcher and eliminates need for lifting pt.
Expected Outcome
. Pt remains free of injury during hospital stay
. Pts family is aware of safety priorities within the home environment
. Pt can identify unsafe of hazardous situations in their environment

Background
Pt Teaching
. To take time when getting out of bed
. On how to bend from the waist or stoop slowly
. Wear comfortable and secure footwear
. Modify home environment by reducing clutter, removing throw rugs, provide additional lighting, installing safety bars, orienting pt. to surroundings and new equipment, or if moving to unfamiliar setting
. Discuss common causes of fires (smoking, faulty elect. Equip or heating devices) and educate about fire safety (no smoking in home, smoke detectors and check batteries, familiar with exits, how to use a fire extinguisher, know emergency numbers, ways to prevent accidental medication overdose by using calendars and daily pill dispensers, regular vision and hearing tests.

Special Considerations
. Pts. with developmental disabilities, demented or delirious use same safety measures as with children
. Family members may participate in tx. by providing info. On pts. episodes of weakness, confusion, or falls

A client needs a dressing change. A LPN is assigned to care for the client, but reports to the RN that a similar dressing change was once observed while in school and the LPN has not done a dressing change before. What does the RN do?

Ask the LPN to review the hospital’s procedure manual regarding dressing changes

Review the steps of the dressing change with the LPN

Complete the dressing change while the LPN observes

Assign a more experienced LPN to the client

Complete the dressing change while the LPN observes- this accomplishes two goals, completing the dressing change and helping the LPN to learn how to do the procedure

Ask the LPN to review the hospital’s procedure manual regarding dressing changes- demonstration/return demonstration is more effective teaching tool than reading about a procedure

Review the steps of the dressing change with the LPN- important, but nurse should demonstrate

Assign a more experienced LPN to the client- nurse’s responsibility to instruct the staff about procedures and client care

Overview
Changing Dressings
To change a dressing, it is important to determine type of dressing, presence of drains, and frequency of dressing change, solutions or ointments used. Assess skin beneath tape, through handwashing before and after dressing change, do not touch would without wearing sterile gloves, change dressings when wet, and secure dressing with tape, ties, and bandages.

When aspirin is given in high and prolonged doses, it can cause physiological changes. Which of the following physiological changes can it cause?

Urinary frequency

GI bleed

Hypoventilation

Hemoconcentration

GI bleed- salicylism result in gastric (GI bleed, blood dyscrasia, and acid-base disturbances, with fluid and electrolyte imbalances) that are directly associated with prolonged high doses of aspirin

Hypoventilation- respiratory depression caused by narcotics

Hemoconcentration- dehydration will cause hemoconcentration

Urinary frequency- not caused by aspirin

Overview
Aspirin (Acetylsalicylic Acid) (ASA)
Salicylate analgesic, antipyretic, anti-inflammatory, antirheumatic, antiplatelet. Side effects include: bleeding, hemorrhage, heartburn, nausea, salicylism including tinnitus, urticaria, bronchospasms, and anaphylactic shock. Nursing considerations include: observe for gum bleeding, bloody or black tarry stools, blood in urine, hemoptysis, and bruises. Give with milk, water, or food. Use enteric coated tablets to minimize gastric distress and monitor for tinnitus and fullness in ears.

Following abdominal surgery, a client is prescribed morphine sulfate IV q3 hours prn for pain. During the first 24 hours after surgery, which action by the nurse is BEST?

Offer pain medication every 4 hours

Administer pain medication every 3 hours

Offer pain medication every 3 hours

Administer pain medication every 4 hours

Administer pain medication every 3 hours- pain is best controlled before it becomes sever and overwhelming. Reasonable expectation that a client will experience significant pain after abdominal surgery

Offer pain medication every 4 hours- preventive approach to medication administration is effective when pain is expected to occur during a 24-h period

Offer pain medication every 3 hours- give medication on a regular schedule – do not wait for the client to request the medication

Administer pain medication every 4 hours- imploring the client to use nonpharmacological means to relieve pain while receiving medication

Overview is on pain management

The client is taking warfarin. A nurse provides discharge teaching for the pt. the pt. makes one of the following statements. Based on this statement, the nurse determines that the pt. needs more teaching. What does the pt. say?

“I should look for yellow-tinged complexion.”

“I will wear a Medic-Alert bracelet.”

“I should tell the health care provider if I have black stools.”

“I should consult the health care provider before taking any medication.”

“I should look for yellow-tinged complexion.” – Yellow-tinged complexion or eyes are symptoms of hepatitis, which is not a side effect of warfarin.

“I will wear a Medic-Alert bracelet.” – appropriate action; instruct to watch for signs and symptoms of bleeding

“I should tell the health care provider if I have black stools.” – indicates bleeding; report to health care provider

“I should consult the health care provider before taking any medication.” – Over-the-counter medication may contain aspirin

A nurse cares for a postop pt. with a NG tube. The nurse checks to make sure the NG tube is correctly positioned. Which observation is the MOST reliable indication that the NV tube is correctly position?

Absence of respiratory distress

pH of aspirate is 3

The marking on the tube designating the correct length remains visible just outside the nares

The tube is securely taped

pH of aspirate is 3- aspirate for gastric contents and check pH which should be 4 or less

Absence of respiratory distress- if client is unable to talk then the tube has passed through the vocal cords

The marking on the tube designating the correct length remains visible just outside the nares- can mark the tube as a guide but more reliable to check pH of gastric aspirate

The tube is securely taped- does not indicate to the nurse that the tube is in the stomach

Overview
Nasogastric Tubes
Types include Levin (single-lumen stomach tube used to remove stomach contents to provide tube feeding), Salem stump (double-lumen stomach tube) that is most frequently used tube for decompression with suction, Sengtaken-Blakemore (triple-lumen gastric tube with inflatable esophagus balloon, stomach balloon, and gastric suction lumen) used for tx of bleeding esophageal varices. To verify placement, check pH of aspirated contents for acidic level and to irrigate Ng tube. Verify placement of tube by inserting 30-50mL syringe filled with normal saline into tube and inject slowly. If resistance is felt, check to see if tube is kinked and have pt. change position; pull back on the plunger or squeeze bulb to withdraw solution. If irrigation solution not removed, record as input and repeat as needed

A 5 y.o. is scheduled for a tonsillectomy and adenoidectomy. The child is given midazolam preoperatively. What does the nurse understand is the purpose for giving this medication?

Decrease the gag reflex

Provides sedation and anxiety reduction

Enhance wound healing

Promote vasoconstriction of the mucous membranes

Provides sedation and anxiety reduction- benzodiazepine, provides anxiety reduction, amnesia, sedation, side effects include agitation, hiccups, nausea, vomiting; preoperative medication given to reduce anxiety, sedate, reduce secretions, antiemetic

Enhance wound healing- diet high in protein and vitamin C will enhance wound healing

Promote vasoconstriction of the mucous membranes- does not promote vasoconstriction

Decrease the gag reflex- does not decrease the gag reflex

Overview
Preoperative medication
Medications given before surgery to relax the client and reduce moisture in mucous membranes. Some medications reduce the amount of anesthesia needed (barbiturates, tranquilizers, opioids, and anticholinergics). May become drowsy and/or dizzy, have a dry mouth – ensure safety measures are met to prevent falls

A client is at risk to develop a pressure ulcer. Which does the nurse identify is a risk factor for the client?

Decreased skin moisture

Ambulation with assistive device

Anemia

Alzheimer’s disease

Anemia- decreased O2 carrying capacity of the blood. Clients with low protein levels aren’t able to repair tissue

Decreased skin moisture- prolonged contact with increased moisture will contribute to skin breakdown. Ensure clients are not on wet linens or dressing

Ambulation with assistive device- prolonged sitting/lying w/o changing positions contributes to skin breakdown due to sensory loss

Alzheimer’s disease- does not predispose client to develop pressure ulcers

Overview
Pressure ulcer
Pressure ulcer is a localized area of necrotic tissue that develops when soft tissue is compressed over a bony prominence. Risk factors include impaired sensory perception, impaired mobility, altered LOC, shear, friction, and moisture. Prevention includes: frequent assessment of pressure areas for non-blanching reactive hyperemia, keeping moisture away from client’s skin, repositioning clients using a draw-sheet, implementing a turning schedule, and providing adequate nutrition and fluids

An elderly client lives alone on a limited income. The client’s diet consists primarily of carbohydrates. A home care nurse visits the client. Based on the nurse’s understanding of the nutrition needs of the elderly, which interpretation about the client’s diet is MOST appropriate?

The client is increase the intake of protein

The client should reduce the intake of fat

The client should increase the caloric intake

The client should decrease the fluid intake

The client is increase the intake of protein- ensuring the older client’s intake includes adequate protein is a challenge it is important for an elderly client to ingest protein organs functioning, and slow down the degeneration process

The client should reduce the intake of fat- does need to limit fat and cholesterol in the diet, but no indication that the client is ingesting too much fat

The client should increase the caloric intake- older adults usually require fewer calories and may require more calories if recovering from surgery

The client should decrease the fluid intake- should drink adequate amounts of water to maintain hydration

Overview
Elderly
Elderly are at risk for malnutrition because of the lack of transportation, poor food selection, loneliness, decreased sense of taste and smell, poor detention or poor fitting dentures, dry oral mucos membranes, and decreased appetite caused by medication side effects. Should eat a balanced diet as defined by the Dietary Guidelines for Americans (DGA) released by the United States Department of Health and Human Services. As metabolism decreases, calorie need decreases, calcium increases to 1200 mg because of decreased absorption of vitamin D increases to 15 micrograms, sodium intake decreases to 1200 mg or less, chloride decreases to 1800 mg.

The nurse prepares four pts for surgery. The nurse considers how each is likely to adjust psychologically to surgery. Which pt is the nurse MOST concerned about?

A 13 y.o. scheduled to have a wart removed from the nose

A 26 y.o. scheduled for the Whipple procedure due to cancer of the pancreas

A 42 y.o. scheduled to have a benign cyst removed from the left breast

An 80 y.o. scheduled for a colostomy due to severe diverticular disease

A 26 y.o. scheduled for the Whipple procedure due to cancer of the pancreas- life-threating illness with poor outcome. The nurse helps to deal with px changes due to surgery and the threat of dying

A 42 y.o. scheduled to have a benign cyst removed from the left breast- outcome of surgery is good

An 80 y.o. scheduled for a colostomy due to severe diverticular disease- nurse instructs client about changes to expect after surgery

A 13 y.o. scheduled to have a wart removed from the nose- expect resistance due to age, but involve in procedures and therapies, fears loss of independence and alterations in body image

Overview is on Preoperative Care

The nurse notices a reddened area on the coccyx of an elderly client. What does the nurse do first?

Continue assessment of the area

Reposition the pt. ever 1-2 hours

Massage the reddened area QID

Place the pt. in a semi reclining position

Reposition the pt. ever 1-2 hours- frequent change in position will relieve pressure on pts. Skin. Encourage the pt to shift weight every 15 minutes. Use pillows to relieve pressure over bony prominences

Massage the reddened area QID- do not massage reddened areas as this causes damage to capillaries and deep tissues

Place the pt. in a semi reclining position- causes shearing force on sacral area

Continue assessment of the area- this situation does not require further assessment

Overview
Pressure Ulcer
Pressure ulcer is localized area of necrotic tissue that develops when soft tissue is compressed over a bony prominence. Risk factors include impaired sensory perception, impaired mobility, and altered level of consciousness, shear, friction, and moisture. Prevention includes frequent assessment of pressure areas for non-blanching reactive hyperemia, keeping moisture away from client’s skin, repositioning client using draw-sheet, implementing a turning schedule, providing adequate nutrition and fluids.

A staff member wears a fit-tested respiratory device. A nurse observes the staff member enter a client’s room. Based on the client’s dx, the nurse determines this protective device is appropriate. What is the client’s dx?

A pt. dx with varicella

A pt. dx with mumps

A pt. dx with vancomycin-resistant Enterococcus (VRE)

A pt. dx with pneumonia

A pt. dx with varicella- used with pathogens transmitted by airborne route. A private room with monitored negative pressure should be used and the door should be closed with the client in the room

A pt. dx with mumps- droplet precautions should be used with pathogens transmitted by infections droplets.

A private room or with client with same infection. Maintain 3 feet between the pt. and any other pts or visitors. The door may be left open

A pt. dx with vancomycin-resistant Enterococcus (VRE) – contact precautions- place pt. in a private room or in a room with same infection. Wear clean, sterile gloves when entering room and change gloves after contact before washing hands

A pt. dx with pneumonia- droplet precautions should be used with pathogens transmitted by infections droplets. A private room or with client with same infection. Maintain 3 feet between the pt. and any other pts or visitors. The door may be left open
Overview
Airborne Precautions
Used with pathogens transmitted by airborne route. A private room with monitored negative pressure of 6-12 air changes per hour. Keep door closed and client in room. Can cohort or place client with another client with same organism. Place mask on client if being transported. Examples of disease in category include measles (rubella), M. tuberculosis, varicella (chickenpox), disseminated zoster (shingles)

A nurse assesses a client with chronic pain. Which findings are characteristic of chronic pain?

Weight loss or gain, fatigue

Obesity, restlessness, and thirst

Anxiety, insomnia, and memory loss

Quick response to analgesics

Weight loss or gain, fatigue- chronic pain is an episode of pain that lasts for 3 months or more and serves no useful function and becomes a problem of its own. Chronic pain often becomes a disability

Obesity, restlessness, and thirst- restlessness can indicate pain in nonverbal clients while acute pain acts as a warning signal, it is usually temporary and has a sudden onset and is easily localized

Anxiety, insomnia, and memory loss- chronic pain may cause the client to feel powerless, angry, anxious, and fearful. When assessing pain of a disoriented client, observe for nonverbal cues such as grimacing, crying, increased confusion, or combativeness.

Quick response to analgesics- types of pain include acute pain caused by injury, disease, or surgery. Chronic pain may be diffuse, not localized, and difficult to describe and is difficult to control.

Overview is on pain management

The pattern of urinary elimination changes as a person gets older. Which change is associated with aging?

Decreased frequency

Incontinence

Sphincter reflexes decreased

Formation of bladder stones

Sphincter reflexes decreased- decrease in sphincter reflexes is a physiological change that often occurs with advanced age

Decreased frequency- increased frequency due to decreased muscle tone and decreased bladder capacity

Incontinence- not a normal change associated with aging. Stress incontinence can be a problem due to decreased urinary sphincter tone and men may experience overflow incontinence due to BPH

Formation of bladder stones- kidney nephrons decrease in number and kidneys have more difficulty concentrating urine
Overview
Age related changes in the urinary system
Changes include decreased blood flow to the kidneys, decreased bladder tone and capacity, decreased filtration, males – benign prostatic hypertrophy, and incontinence related to bladder capacity is common.

A nurse gives pain medication to a client. After the nurse gives the medication, what is MOST important for the nurse to do?

Do not disturb the client

Keep the environment cool and quiet

Provide diversionary activities at short intervals

Determine whether the medication is effective

Do not disturb the client- Determine whether the medication is effective- imperative that the client be assessed for the therapeutic, physiological, and psychological responses to pain medication and to learn to recognize evaluation answers

Keep the environment cool and quiet- Do not disturb the client- important that the nurse determine if the medication is effective and if pain relief measure is ineffective the first time, try it one more time before abandoning the measure

Provide diversionary activities at short intervals- Keep the environment cool and quiet- make the environment is comfortable for the client and frequently reassess

Determine whether the medication is effective-Provide diversionary activities at short intervals- determine activities that the client enjoys, works best for short, intense pain lasting a few minutes

Overview is pain management

Spinal anesthesia requires important considerations. Which statement describes an important consideration for the nurse?

Patients must be protected from injury since sensation is impaired

Partial paralysis is serious but frequent complication.

Patients should try to ambulate as soon as possible

Spinal headache may be prevented by restricting intake of oral and intravenous fluids.

Patients must be protected from injury since sensation is impaired- Frequently assess sensation and voluntary movement. Other side effects include hypotension and headache

Partial paralysis is serious but frequent complication. – Spinal anesthesia used to perform surgery on lower abdominal, pelvic, and lower extremities. Results in a loss of sensation of the area, does not cause paralysis.

Patients should try to ambulate as soon as possible- Lie flat for 12 hours until sensation has returned

Spinal headache may be prevented by restricting intake of oral and intravenous fluids. -Encourage oral fluids, monitor vital signs

Overview
Spinal Anesthesia
Local anesthetic injected into the lumbar intervertebral space beyond the dura mater into the subarachnoid space. Blocks pain sensations and movement. Causes anesthesia of lower extremities, perineum, and lower abdomen. Sympathetic nerve fibers blocked, hypotension caused by loss of vasoconstrictor ability, headache. Nursing considerations include monitoring vital signs, before regional anesthetic to assure adequate blood volume, if client becomes hypotensive increase rate of IV fluids, administer oxygen by mask, notify health care provider, encouraging oral fluids

A nurse watches a client sign the name on a document of informed consent for a procedure. What question is most important for the nurse to assess for?

Does the client give consent voluntarily?

Does the client understand the procedure?

Does the client have any questions?

Is the client able to write the name?

Does the client give consent voluntarily? – Nurse’s signature indicates that the client voluntarily gave consent, the client’s signature is authentic, and the client is competent to give consent.

Does the client understand the procedure? – It is the health care provider’s responsibility to explain the procedure and the risks and benefits associated with the procedure

Does the client have any questions? – It is not the nurse’s responsibility belongs to the healthcare provider

Is the client able to write the name? – Client is legally able to place mark on consent form

Overview
Informed Consent
Informed consent is client’s agreement to have procedure performed after explanation of risks, benefits, and expectations, and alternatives to procedure, can be withdrawn at any time. Nurse ensures that consent form is signed and attached to the chart.

A client with ovarian cancer experiences sever pain. A nurse provides care for the client. Which principle regarding pain medication does the nurse remember?
Pain medication is more effective is given before pain becomes severe.Caution must be used to prevent narcotic addition

Cancer pain is often psychological in origin

Pain medication should be given only with evidence of severe pain

Pain medication is more effective is given before pain becomes severe. – Pain medication given prior to the peak of severity is more effective in managing the pain

Caution must be used to prevent narcotic addition- Most important to treat the client’s pain. If pain continues, client feels anxiety and increased fear, which increases the pain

Cancer pain is often psychological in origin- All pain is real. Pain is “whatever the person experiencing the pain says it is”

Pain medication should be given only with evidence of severe pain-Preventive approach is preferable. Requires smaller doses of medication to relieve or prevent pain if medication is given regularly. Prevention allows the client to spend less time in pain and prevents addiction.

Overview
Pain Management
Pain is often referred to as the fifth vital sign and is defined as “whatever the person says it is, and it exists whenever the person says it does.” Can be acute or chronic. Culture and past experiences with pain are major factors influencing pain experiences. Indications include increased blood pressure and pulse, rapid irregular respirations, pupil dilation, increased perspiration, increased muscle tension, apprehension and irritability, grimacing, guarding, verbalizations of pain. Nursing interventions include establish a therapeutic relationship, establish a 24hr pain profile, teach patient about pain and its relief, reduce anxiety and fears, provide comfort measures, administer pain medications, refer for alternative methods of pain relief. With regard to pain medications, use preventive approach, which states that if pain is expected to occur throughout most of a 24hr period, a regular schedule is better than as needed, usually takes a smaller dose to alleviate mild pain or prevent occurrence of pain.

The nurse assesses an elderly pt. in the outpatient clinic. Which statement does the nurse expect the client to make?

“I seem to get fewer upper respiratory infections than I did before.”

“I think that I am a little taller than I was before.”

“I do not enjoy eating anymore.”

“I sleep with fewer blankets now.”

“I do not enjoy eating anymore.”- Aging causes a diminished taste perception and a declining sense of smell, which contribute to a loss of appetite. Encourage meals that are economical and easy to prepare and the pt should eat when hungry – not according to a set meal schedule

“I seem to get fewer upper respiratory infections than I did before”- pts immune system is less effective due to the aging process.

“I think that I am a little taller than I was before.”- As part of the aging process, adults lose height due to bone loss. They also lose muscular strength and endurance

“I sleep with fewer blankets now.”- Older pts feel cold more easily and may require a warmer room and should be instructed to eat high-energy foods.

Overview
Growth and Development: Older Adult
Late adulthood. Erikson’s stage of integrity vs despair. Physiologic systems decline in efficiency and overall function, butt chronological age by itself is not predictor of when or how much this will occur. They may have decreased stamina and strength, GI tone, temperature adaptability (sub-q fat, circulation to the skin, lower core body temperature), cardiac output, oxygen to muscles, less effective breathing, slower healing, decreased sensory acuity, slowed nerve impulses, decreased bladder tone and urinary function, degeneration of connective tissue, cartilage and bone. Psychosocially cope with loss of significant others, chance in social roles and sometimes have slowed speed of cognition.

What is psoriasis?

A chronic autoimmune reaction

An acute infectious disease

A viral disease

A cystic disease that is self-limiting

A chronic autoimmune reaction- lifelong scaling skin disorder with underlying inflammation, characterized by exacerbations and remissions, there is usually a family hx

An acute infectious disease- not an infectious process as the cause is unknown, but symptoms improve in warmer climates

A viral disease- not a viral disease. Tx includes topical steroids, tar preparation, and ultraviolet light therapy

A cystic disease that is self-limiting- is a lifelong disorder
Overview
Psoriasis
Chronic noninfectious inflammatory disease of the skin. Indications include chronic recurrent thick, itchy, erythematous papules/plaques covered with silvery white scales with symmetrical distribution and are commonly found on the scalp, knees, sacrum, elbows, and behind ears. Nursing considerations include soak in bath with oil or coal tar preparation added, use soft brush to gently scrub plaques, topical steroids followed by warm (moist) dressing with occlusive outer wrapping, administer antimetabolites, ultraviolet light, counseling to support/enhance self-image/self-esteem, important for nurse to touch client to demonstrate acceptance

A client is given wet-to-dry dressing changes. After the first dry dressing is removed, the client yells at the nurse, “Ouch that really hurts. Are you sure you’re doing it right?” Which statement is the BEST response by the nurse?

“I know it hurts and I am really sorry to have to do it, but sometimes things have to hurt before they get better.”

“I am peeling away the dead tissue. It hurts more the first time. Next time it will not hurt as much, I promise.”

“Yes, I am doing it right. The dead tissue is supposed to stick to the dry dressing, but if I wet it a little bit, it won’t hurt so much.”

“This type of dressing cleans the wound so that it can heal. I’ll bring you some pain medication.”

“This type of dressing cleans the wound so that it can heal. I’ll bring you some pain medication.”- This response explains what the nurse is doing to the client, and offers relief for the pain that the client is experiencing. The next time the dressing is changed pain medication could be offered before the procedure. Apply moist gauze onto wound surface and cover with a dry dressing using sterile procedure.

“I know it hurts and I am really sorry to have to do it, but sometimes things have to hurt before they get better.”- does not respond to the client’s feeling or explain why the nurse is performing the dressing change.

“I am peeling away the dead tissue. It hurts more the first time. Next time it will not hurt as much, I promise.”- All parts of the answer have to be correct in order for the answer to be correct. The nurse cannot promise that a procedure will not be uncomfortable the next time

“Yes, I am doing it right. The dead tissue is supposed to stick to the dry dressing, but if I wet it a little bit, it won’t hurt so much.”- If dressing is moistened prior to removing, it will not remove exudate and wound debris

Overview
Therapeutic Communication
Listening to and understanding the client while promoting clarification and insight. The goal is to understand the client’s message, to facilitate the client’s verbalization of feelings, to communicate the nurse’s understanding and acceptance, and to identify problems, goals and objectives.

An elderly pt. is admitted to the hospital to undergo abdominal surgery. Admitting orders include activity as desired, standard bowel prep, and intravenous infusion of 5% dextrose in water to infuse at 75mL per hour starting at 1800 on the evening before surgery. What is the PRIMARY purpose of giving IV fluids to the client before surgery?

To establish a route for the nurse to give medications quickly

To avoid the nurse having to insert the IV on the morning of the surgery

To decrease the client’s desire to have fluids by mouth before surgery

To make sure the client is sufficiently hydrated during surgery.

To make sure the client is sufficiently hydrated during surgery. – Bowel prep prior to surgery, especially in elderly can cause dehydration so starting fluids in the evening will ensure the client maintains hydration

To establish a route for the nurse to give medications quickly- not the reason for IV fluids

To avoid the nurse having to insert the IV on the morning of the surgery- IV can be started the morning of the surgery

To decrease the client’s desire to have fluids by mouth before surgery- will be NPO

Overview is on preoperative care

Why is serum albumin used to identify malnutrition?

Eggs are commonly eaten in the American diet, so the nurse can assume that albumin from eggs is consistently found in the American diet.

Albumin is the first result on a protein electrophoresis, and the result is often included on the hospital record.

Serum albumin is easy to measure and can indicate a protein deficiency that is not detected on a physical examination.

Serum albumin has a short half-life, so it is an easy protein to measure.

Serum albumin is easy to measure and can indicate a protein deficiency that is not detected on a physical examination. – Albumin is easy to measure in the serum, and has been shown to be quite accurate in identifying hospitalized clients who are malnourished and is an important part of nutrition assessment

Eggs are commonly eaten in the American diet, so the nurse can assume that albumin from eggs is consistently found in the American diet.- most abundant form of protein in the blood and helps to maintain oncotic pressure and transportation of other nutrients, medications, and hormones through the blood

Albumin is the first result on a protein electrophoresis, and the result is often included on the hospital record. – Malnutrition reflected in low serum albumin concentrations

Serum albumin has a short half-life, so it is an easy protein to measure. – has a long half-life and a large body pool, serum albumin is slow to respond to nutritional deficits
Overview
Albumin, serum
Protein formed in the liver. 60% is total protein. Contributes to colloid osmotic pressure, transports enzymes, drugs, and hormones. Indicates liver and nutritional status. Body supply not depleted until malnutrition severe. Decreased in malnutrition, severe burns liver disease, overhydrating, 3rd trimester pregnancy, protein losing nephropathies and increased with dehydration

A pt. had a left modified radical mastectomy. The client is transferred from the recovery room to the surgical unit. The nurse notices the Hemovac drain is half filled with blood. What does the nurse do FIRST?

Contact the provider about the pt.

Increase the rate of the IV fluids for the pt.

Look at the recovery room record for the pt.

Measure the pts Hemovac output

Look at the recovery room record for the pt- necessary to look at the recovery room record. Interpretation of the drainage of the Hemovac can be made only if the nurse knows how much drainage was there before the client’s arrival in the room. For example, the recovery room nurse has just emptied the drain and charted 50mL, the fact that it is already half full might be a problem that would require further evaluation. If the drain has not been emptied in the recovery room the amount of drainage in the Hemovac drain would not indicate a problem.

Measure the pts Hemovac output- need to determine the amount of drainage

Contact the provider about the pt. – need more information to determine if the pt. is hemorrhaging

Increase the rate of the IV fluids for the pt. – nurse should determine if quantity of drainage is excessive before implementing, purpose is to collect drainage from wound to promote wound healing. And evaluate character and amount of drainage

On the morning before surgery, a pt. signs an operative consent form. Soon afterward, the client tells the nurse that they do not want the surgery. What does the nurse do FIRST?
Encourage the pt. to discuss reasons for canceling the surgeryTell the provider about the pts decision

Tell the pt. that the decision has caused a delay in the operating room schedule

Ask the pts family to encourage the pt. to have the surgery

Encourage the pt. to discuss reasons for canceling the surgery- Nurse should assess pt. reasons to withdraw consent. Inform pt. of the outcome of decision

Tell the provider about the pts decision- Pt has the right to withdraw consent. Notify health care provider after first assessing the pts reasons

Tell the pt. that the decision has caused a delay in the operating room schedule- Pt has the right to withdraw consent

Ask the pts family to encourage the pt. to have the surgery-Do not try to talk pt. into changing mind. Pt must be informed about outcome of decision
Overview is on informed consent

Some common foods cause eczema and should be removed from a person’s diet. Which of these foods does the nurse understand to be the most likely cause of eczema?

Soybeans, orange juice, egg yolks

Milk, wheat, egg whites

Fish, nuts, chocolate

Strawberries, tomato, apples

Milk, wheat, egg whites- Are all common allergens associated with eczema

Fish, nuts, chocolate- Eczema is an inflammatory rash caused by allergic immune response. Nuts commonly cause anaphylactic reaction. Other foods do not

Strawberries, tomato, apples- Berries commonly cause allergic reaction. Other foods do not.

Soybeans, orange juice, egg yolks- Some legumes can cause allergic reaction

Overview
Eczema
Itchy red skin rash commonly seen in young children. May ooze serum and form a crust. Often associated with allergic reaction to allergen, chemical, or drug. Treatment is avoidance of allergen, application of astringent solution, corticosteroid cream, or antihistamines. Keep pt. from scratching.

A nurse cares for a pt. in pain. What is most important for the nurse to do?

Establish a trusting relationship with the pt.

Teach the pt. about the pain

Determine how various relaxation techniques affect the pain

Administer pharmacological agents

Determine how various relaxation techniques affect the pain- Important to convey to the client in pain that the nurse believes that pts pain is real and that the nurse is appropriate action, but nurse first establishes a trusting relationship

Establish a trusting relationship with the pt.- To effectively develop a plan of care for relieving a pts pain, trust is essential. Pt may not have documented physiological responses to pain and nurse must rely on pts report. If pt. mistrusts the nurse the pt. will not be as likely to report pain.

Teach the pt. about the pain- determines the effectiveness of the intervention for pain based on the pts response.

Administer pharmacological agents -Common pharmacological agents include aspirin, acetaminophen, NSAIDS, and opiates.

Overview is on pain management

A pt. begins intermittent heparin therapy. A nurse cares for the pt. which laboratory test does the nurse recognize is used to monitor the effectiveness of heparin?

Bleeding time

Protein electrophoresis

Partial thromboplastin time

Prothrombin time

Partial thromboplastin time- PTT must be measured at least once a week. Anticoagulation is effective when the ptt is 1.5 to 2 times the control. Antidote is protamine sulfate

Prothrombin time- Used to measure therapeutic level of warfarin. Antidote is vitamin K. apply prolonged pressure to venipuncture site.

Bleeding time- Measures duration of bleeding after standardized skin incision. Prolonged in thrombocytopenic purpura, platelet abnormality, leukemia, and sever liver disease

Protein electrophoresis-Differentiates between protein fractions.

Overview
Heparin
Anticoagulant. Used for short term therapy, given IV or subcutaneous. Action: inactivates thrombin and prevents conversion of fibrinogen to fibrin. Dosage is adjusted according to partial thromboplastin time PTT, therapeutic range is 1.5-2 times normal value. Nursing considerations: leave needle in place for 10 seconds after injection, don’t massage. Side effects: hemorrhage with excessive dosage, thrombocytopenia, and hypersensitivity reactions. Antagonist: protamine sulfate.

A nurse cares for a pt. with abdominal wound. The nurse notices purulent drainage from the wound. What does the nurse do first?

Ask the client to identify the level of pain on a numeric scale.

Place the pt. on contact precautions

Contact the health care provider

Irrigate the wound

Place the pt. on contact precautions- Place pt. in private room or in a room with same infection but no other infections. Wear clean, sterile gloves when entering the pts room. Change gloves after pt. contact. Wash hands
Contact the health care provider- Place pt. on contact precautions to prevent spread of infection to other pt.
Irrigate the wound- Used to cleanse wound. Use sterile technique
Ask the client to identify the level of pain on a numeric scale.-Appropriate to assess pain but priority is to place pt. on contact precautions. Manifestations of infection include redness and swelling. Infected drainage may be yellow, green, or brown. Systemic infections cause fever, fatigue, and malaise. WBCs will be elevated. Normal range is 5000-10000/mm3
Overview
Contact-Based Precautions
Required with pt. care activities that require physical skin to skin contact or those that occur between two clients or occur by contact with contaminated inanimate objects in pts environment. Private room or with client with same infection but no other infection. Clean, nonsterile gloves when entering room, change gloves after client contact with fecal material or wound drainage, remove gloves before leaving the pts environment and wash hands with antimicrobial agent, wear gown when entering room if clothing has contact with pt., environmental surfaces, or if pt. is incontinent, has diarrhea, an ileostomy, colostomy, or wound drainage.

The nurse teaches correct body mechanics to a nurse aide. Which of the following suggestions by the nurse is most appropriate?

“Bend at the waist when lifting objects.”

“Lift objects with your arms extended.”

“Lean forward when lifting objects.”

“Bend Knees when lifting objects.”

“Bend Knees when lifting objects.”- Maintains center of gravity and allows the legs muscles to do the lifting

“Bend at the waist when lifting objects.”- Using back to lift. Should use arms and legs

“Lift objects with your arms extended.”¬- Keep weight close to the lifter’s body

“Lean forward when lifting objects.”-Keep trunk erect, and do not twist.

Overview
Body Mechanics

Principles of good body mechanics include a wide base of support, low center of gravity, alignment of line of gravity with its base of support, bending at the knees, using the stronger muscle groups (legs), holding the lifted object close to the body, facing the direction of movement rather than twisting, avoiding lifting when possible, pushing rather than pulling, alternating periods of rest and activity.

A pt. experiences episodes of acute pain. Which physiological change occurs during acute pain?

Decreased blood pressure

Decreased heart rate

Decreased skin temperature

Decreased respiration

Decreased skin temperature- Increased perspiration occurs during acute pain episodes, thereby cooling off the skin

Decreased blood pressure- Blood pressure and heart rate increase, which increases blood flow to the brain and muscles.

Decreased heart rate- Blood pressure and heart rate increase, which increases blood flow to brain and muscles

Decreased respiration-Rapid, irregular respirations lead to increased oxygen supply to brain and muscles

Overview is on pain management

A middle aged adult comes to the clinic. The pt. reports having difficulty sleeping and being constantly tired. The clinic nurse interviews the pt. the nurse learns the pt. works as a security guard and frequently works nights. Which is the best response for the nurse to say first.

“Working the night shift is known to disrupt sleep patterns”

“Tell me about your sleeping habits.”

“You probably sleep when you can during your night tour”

“This is normal for your age group”

“Tell me about your sleeping habits.”- Nurse must assess prior to implementing. Important to find out pts usual sleep patterns

“You probably sleep when you can during your night tour”- Nurse is making an assumption

“This is normal for your age group”- Most middle aged adults do not have trouble sleeping

“Working the night shift is known to disrupt sleep patterns”-This is the second best answer. The best initial response is to assess

At discharge, the nurse tells a pt how to follow a low-calorie diet to lose weight. What is the ideal rate for a person to lose weight?

1lb per day

1lb per week

One-half pound per day

One-half pound per week

1lb per week- Losing 1-2 lbs. per week is safe and effective. Adult women should not fall below 1200 calories per day. Adult men should consume a minimum of 1500 calories per day

One-half pound per day- Weight loss is too rapid

One-half pound per week- Ideal weight loss for overweight to mildly obese pt. is 1-2 lbs. per week

1lb per day-Weight loss is too rapid.

Overview
Weight Reduction
Using a balanced food intake to lose weight. Reduction of calories. Decrease fat intake below 30 percent of total intake. Decrease saturated fats to less than 10 percent of daily intake. Increase fresh fruit and vegetable intake. Reduce processed foods. Decrease intake of empty calories. Increase whole grain intake. Lose no more than 1-2 lbs. per week.

A 53 year old pt. is admitted to the hospital for hematuria. The pt. has no previous history of illness. The pt. is married with 3 children in high school. Which task of middle adult hood is most likely to be disturbed by a physical disability?

Renewing earlier relationships

Developing adult leisure time activities

Assisting the children to grow to adulthood

Coping with a role transition

Assisting the children to grow to adulthood- According to Erikson, middle adulthood is the time of guiding the next generation. This occurs not only in family life but also in one’s professional career, if this developmental task is not achieved, client becomes self-absorbed

Coping with a role transition- Middle age is called the sandwich generation. Are still involved with children, but are also involved in caring for aging parents or other realities

Renewing earlier relationships- Middle-aged adults are leaders in their professions and communities

Developing adult leisure time activities- Middle-aged adults find that they have more financial resources and more leisure time. Nurse should instruct pt. about the importance of engaging in daily leisure activity.

Overview
Erikson’s stages of psychosocial development

Theory of psychosocial development throughout the life span. Divided into 8 stages that define particular tasks that individuals need to accomplish before moving to next stage. Each stage has a positive and negative outcome.

Infancy (Birth to 12 months) Trust vs Mistrust.- infant learns to trust self and others

Toddler (12months – 3 yrs.) Autonomy vs Shame- toddler learns to exercise self-control and influences the environment directly

Preschool (3-6 years) – Initiative vs guilt- child begins to evaluate own behavior; learns limits on influence in the environment

School age (6-12 years) – Industry vs Inferiority Child develops a sense of confidence. Uses creative energies to influence the environment.

Adolescence (12-20 years) – Identify vs role confusion – adolescent develops a coherent sense of self. Plans for a future of work/education

Young Adult- (35-65 years) Generativity vs Stagnation- Involved with established family. Expands personal creativity and productivity focus is supporting future generation
Late adulthood- (65+ years) Integrity vs despair- identifies that life was meaningful.

Ten hours after surgery, the nurse becomes concerned because the pt has not voided. Which action by the nurse is most appropriate?

Insert a catheter into the bladder

Encourage client to take sips of water

Inform the health care provider immediately

Palpate for bladder distention

Palpate for bladder distention-Preform assessment before implementing

Insert a catheter into the bladder -Assess before implementing

Encourage client to take sips of water-Assumes client is dehydrated. Assess the status of the bladder

Inform the health care provider immediately-Perform assessment of pt before contacting health care provider
Overview is post op care

A nurse observes a staff member. The nurse recognizes that the staff member uses standard precautions appropriately. What does the nurse observe?

The staff member places contaminated linens in a leak proof bag

The nurse wears gloves when taking the blood pressure of a client diagnosed with AIDS

The staff member irrigates an abdominal wound wearing a gown and gloves

The nurse removes gloves after bathing a client and puts on clean pair of gloves to bathe another.

The staff member places contaminated linens in a leak proof bag-prevent contact with skin and mucous membranes

The nurse wears gloves when taking the blood pressure of a client diagnosed with AIDS -Wear gloves when touching blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes. Not necessary to wear gloves when taking blood pressure

The staff member irrigates an abdominal wound wearing a gown and gloves -Should also wear mask or eye protection if splashes or sprays of blood or body fluid might occur

The nurse removes gloves after bathing a client and puts on clean pair of gloves to bathe another -Always wash hands between contacts with pts. Wash hands immediately after removing gloves.

Overview
Standard Precautions

Used with all clients to prevent health care associated infections. Apply to blood, all body fluids, and secretions. Wash hands immediately on contact with blood or body fluids. As soon as gloves are removed, between pt contact, between procedures or tasks with the same pt, wear gloves when touching blood, body fluids, or before touch mucous membranes or non-intact skin, wear mask, face shield, and gown if splashes and sprays likely.

A pt. has a BMI of 17kg/m2. What is the best description of the pts body weight?

Underweight

Normal weight

Overweight

Obese

Underweight-BMI of less than 18.5 is underweight

Normal weight- Normal BMI is 18.5-24.9

Overweight- Overweight BMI is 25.0-29.9

Obese- Obese BMI is 30.0-30.9

Overview
BMI
BMI estimates body fat. Allows health care provider to counsel about risk factors for diabetes, heart disease, stroke, hypertension, osteoarthritis

A 4 year old is about to have surgery. A nurse plans to care for the child. Which of the following fears most important for the nurse to consider?

Fear of separation

Fear of mutilation

Fear of losing independence

Fear of losing control

Fear of mutilation- Preschool children are frightened of invasive procedures because they fear mutilation. Allow child to play with models of equipment. Encourage expression of feelings

Fear of losing independence-Fear of adolescent. Involve adolescent in procedures and therapies. Express understanding of concerns

Fear of losing control- Fear of school age child. Explain procedures in simple terms allow choices when possible

Fear of separation-Fear of toddle. Teach parents to expect regression.

Overview
Age-Appropriate preparation -Preschool
Preschooler runs well, jumps rope, dresses without help. Has a 2100 word vocabulary, ties shoes, imitates adult patterns and roles. Offer playground material. Housekeeping toys. Coloring books. Use bicycle helmet. Safety restraints in car. Teach to look both ways before crossing street.

Before surgery, a client will receive a liver scan. Which statement best describes a liver scan?

The client will stand in front of a large machine that takes x-ray pictures of liver

The clients skin will be lubricated with oil and ultrasound pictures will be taken

The client will be asked to lie still while a scanning probe is passed back and forth over the body

The client will be strapped to a table and irradiated by a cobalt scanner

The client will be asked to lie still while a scanning probe is passed back and forth over the body- Client will be placed in many different positions, but must lie still during scan, no follow up care is necessary

The client will be strapped to a table and irradiated by a cobalt scanner- Client will receive IV injection of radioactive colloid, which is taken up by the liver and spleen. Liver and spleen are scanned

The client will stand in front of a large machine that takes x-ray pictures of liver- Scan is nuclear medicine technique

The clients skin will be lubricated with oil and ultrasound pictures will be taken-Ultrasound used to image soft tissues such as liver spleen pancreas and gall bladder.

A pt. is treated for a wound infection. A nurse provides routine care. What is the most important for the nurse to do?

Send samples of wound drainage for culture

Assess the perfusion in the area

Evaluating the results of the blood culture.

Check and record the clients temp

Evaluating the results of the blood culture.-A client with a wound infection is at risk for bacteremia or other complications such as glomerulonephritis. Nurse should evaluate for temp elevation.

Send samples of wound drainage for culture-Would be done initially

Assess the perfusion in the area-Assess for indication of inflammation

Evaluating the results of the blood culture.-Health care provider will order appropriate antibiotics. Place client on contact precautions.

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? Glucose level After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion …

1) A nurse is caring for a client with hyperparathyroidism and notes that the client’s serum calcium level is 13 mg/dL. Which medication should the nurse prepare to administer as prescribed to the client? 1. Calcium chloride 2. Calcium gluconate …

1. When formulating a definition of “health,” the nurse should consider that health, within its current definition, is: 1. The absence of disease 2. A function of the physiological state 3. The ability to pursue activities of daily living 4. …

Respiratory Diagnostic and Therapeutic Procedures: Overview Respiratory diagnostic procedures are used to evaluate a client’s respiratory status by checking indicators such as the oxygenation of the blood, lung functioning, and the integrity of the airway. Respiratory Diagnostic and Therapeutic Procedures: …

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