The nurse is teaching a client and her family about home care following a laryngectomy. Which statement by the client indicates a need for further teaching from the nurse?
Rationale:
C: I can resume water aerobics once my doctor says it is okay. This statement indicates a need for further teaching, as water activities could pose risks for individuals with a laryngectomy due to potential water aspiration and infection.
A: I will purchase a Medic-Alert bracelet. This shows awareness of the need for emergency identification, which is essential for communicating health conditions related to the laryngectomy.
B: I can wear loose-fitting turtlenecks to cover the stoma. This reflects an understanding of protecting the stoma from environmental elements, which is important for maintaining health and comfort post-surgery.
D: I have a lot of green houseplants year-round throughout my home. This suggests a lack of understanding regarding potential allergens and irritants that could affect respiratory function after a laryngectomy.
The nurse is assisting the health care provider to perform a renal biopsy. Which position should the nurse place the client in?
Rationale:
D: Prone with a pillow under the shoulders and abdomen. This position optimally exposes the kidney, stabilizes the area, and minimizes the risk of complications during the renal biopsy procedure, facilitating better access for the health care provider.
A: in the semi-Fowler's position. This position does not provide adequate access to the kidney and may hinder the procedure's effectiveness and safety during the biopsy.
B: on the same side of the kidney to be biopsied. This positioning could increase the risk of complications and impede the provider's ability to perform the biopsy effectively.
C: on the side opposite of the kidney to be biopsied. While this might provide some access, it does not offer the necessary exposure required for an efficient and safe renal biopsy.
The nurse is evaluating clients for risk of heparin-induced thrombocytopenia (HIT). Which client is at greatest risk for HIT, based on the nurse's assessment?
Rationale:
A: a male client who just completed a 1-week course of heparin. A short course of heparin typically poses a lower risk for HIT compared to longer-term use, leading to reduced susceptibility.
B: a male client taking enoxaparin for management of unstable angina. Enoxaparin, while related, does not carry the same risk profile for HIT as heparin, especially in acute management settings.
D: a female client taking enoxaparin to prevent clots following a mild myocardial infarction. Usage of enoxaparin generally presents less risk for HIT compared to heparin, making this client a lower-risk candidate.
The nurse is caring for a client who is undergoing a pharmacological stress test because she cannot use the treadmill. The nurse administers the prescribed dose of adenosine. Which physiological response indicates an adverse effect of the adenosine requiring intervention by the nurse? Select all that apply.
Rationale:
Chest pain indicates an adverse effect of adenosine that requires intervention by the nurse. This response can signal significant cardiac stress or ischemia during the pharmacological stress test, necessitating immediate evaluation.
A: nausea Nausea may occur during pharmacological interventions but does not typically signify a serious adverse reaction requiring urgent nursing action in this context.
B: RR of 18 A respiratory rate of 18 falls within normal limits for adults and does not indicate any adverse effect related to the administration of adenosine.
C: HR of 97 A heart rate of 97 beats per minute is considered acceptable and does not suggest a harmful reaction to adenosine during the stress test.
E: facial flushing Facial flushing can happen with adenosine administration; however, it is a common and benign side effect rather than an indication of a serious adverse event.
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Following the procedure, the nurse should be watching for which serious complications? Select all that apply.
Rationale:
B, C, E. After electroconvulsive therapy, monitoring for complications such as airway compromise, cardiac dysrhythmias, and neurological issues is crucial due to the potential impact of induced seizures on these systems.
A: skin burns. Skin burns are not commonly associated with ECT, as the procedure is designed to minimize physical harm during electrical stimulation.
D: loss of bladder control. While some patients may experience temporary side effects, loss of bladder control is not a typical serious complication following ECT.
The nurse is performing discharging instruction for a female client with cystitis. Which statement by the client indicates a need for further teaching?
Rationale:
C: I can continue using spermicide for birth control. Spermicide can irritate the vaginal mucosa, potentially exacerbating cystitis symptoms. Avoiding irritants is crucial for preventing recurrent urinary tract infections and promoting healing.
A: I should void before and after intercourse. Voiding before and after intercourse is a recommended practice to help reduce the risk of urinary tract infections, thus beneficial for cystitis management.
B: I should wear loose-fitting cotton underwear. Wearing loose-fitting cotton underwear helps maintain proper airflow and reduces moisture, minimizing the risk of irritation and infections, which is essential for someone with cystitis.
D: If I have burning when I urinate, I will contact my physician. This statement reflects appropriate behavior, as seeking medical advice for burning during urination indicates awareness of potential complications associated with cystitis.
A nurse is following the progress of a client being treated for hypothyroidism. Which findings indicate the client is experiencing side effects of the thyroid replacement therapy? Select all that apply.
Rationale:
Excessive sweating and leg cramps indicate the client is experiencing side effects of the thyroid replacement therapy. These symptoms suggest an overcorrection of hormone levels, leading to physiological imbalances.
B: Constipation This symptom typically signifies insufficient thyroid hormone levels rather than an excess, indicating that the therapy is not overly stimulating the metabolism.
C: Inability to tolerate cold This condition reflects low thyroid hormone levels, suggesting that the therapy is not adequately addressing the hypothyroidism rather than causing side effects.
The nurse is performing an admission assessment on a client with thrombocytopenia. Which signs and symptoms and lab findings would the nurse expect to see in this client? Select all that apply.
Rationale:
Epistaxis and petechiae are expected signs and symptoms in a client with thrombocytopenia, indicating low platelet levels which lead to bleeding tendencies. The lab findings would reflect these symptoms, confirming the diagnosis.
C: vomiting blood Reflects a severe condition but is not a primary symptom of thrombocytopenia; it may indicate other underlying issues.
D: elevated hematocrit Suggests dehydration or polycythemia, not thrombocytopenia, which typically presents with low platelet counts rather than elevated hematocrit levels.
E: increased platelet count Directly contradicts the definition of thrombocytopenia, where platelet counts are low, not increased, as the term specifically indicates a deficiency in platelets.
The nurse is reviewing arterial blood gases (ABGs) on a client. Which finding would prompt the nurse to notify the health care provider?
Rationale:
pH 7.67
A pH of 7.67 indicates alkalosis, which can lead to serious complications. This elevated level suggests a significant disturbance in the acid-base balance, warranting immediate notification of the health care provider for further assessment and intervention.
A: pH 7.42 A pH of 7.42 falls within the normal range, indicating no immediate concern regarding acid-base status. This value does not necessitate urgent action from the health care provider.
C: HCO3 24 mEq/L A bicarbonate level of 24 mEq/L is considered normal, suggesting that the metabolic component of the acid-base balance is stable. This does not prompt notification.
D: paCO2 41 mmHg A paCO2 level of 41 mmHg is within normal limits, reflecting adequate respiratory function. No abnormality is present that would require alerting the health care provider.
E: paCO2 44 mmHg While slightly elevated, a paCO2 of 44 mmHg remains close to normal. This value does not indicate a critical situation that requires immediate physician notification.
A nurse is preparing discharge instructions for a client with a below-the-knee amputation. Which instruction would be a priority?
Rationale:
B: elevation of residual limb. Elevating the residual limb is crucial to reduce swelling and promote proper healing after a below-the-knee amputation. This practice helps prevent complications and supports recovery.
A: sterile wound management. While important, sterile wound management is secondary to elevation, as managing swelling is essential for the healing process and overall recovery.
C: performing prescribed exercises. Although exercises are vital for rehabilitation, they come after ensuring the residual limb is properly elevated to prevent complications associated with swelling.
D: reporting occurrence of phantom limb pain immediately. While addressing phantom limb pain is necessary, it is not the immediate priority compared to managing elevation and reducing swelling for optimal healing.
The nurse is preparing to discharge a client with an ileal conduit done for treatment of bladder cancer. Which statement by the client indicates the need for further instruction?
Rationale:
I look forward to returning to my local health club to swim. Swimming in pools can pose risks of infection or irritation to the stoma, necessitating caution and additional guidance for safe activities post-surgery.
B: The local ostomy support group meets on Wednesday morning at 10 a.m. This statement reflects positive engagement and awareness of available support systems for managing life with an ileal conduit.
C: My stoma should be cleaned daily with soap and water. Proper stoma care does include cleaning, but specific products and methods may be advised, necessitating clarification on the best practices.
D: During the day I will wear a leg bag to collect my urine. Utilizing a leg bag is a standard practice for urine collection post-surgery, indicating the client understands their management plan effectively.
A client is admitted to the ED after complaining of acute chest pain radiating down the left arm. The client is diaphoretic and anxious, and has difficulty breathing. Which laboratory studies would the nurse anticipate?
Rationale:
D: myoglobin. In cases of acute chest pain with potential myocardial infarction, myoglobin levels are crucial as they indicate muscle damage. Elevated myoglobin can signal heart injury early, guiding immediate intervention.
A: blood urea nitrogen (BUN) Measures kidney function and hydration status, which are not directly related to acute chest pain symptoms and the immediate concern of cardiac events.
B: white blood cell count Reflects infection or inflammation levels rather than acute cardiac distress, making it less relevant in an emergency scenario focused on potential myocardial injury.
C: LDH Indicates tissue damage but is less specific for acute myocardial infarction compared to myoglobin, which provides more timely information regarding heart muscle injury.
The nurse is preparing the client for a liver biopsy. Which statement by the client indicates a need for further instruction regarding the procedure?
Rationale:
I can resume strenuous activity in 2 to 3 days.
The statement suggests a misunderstanding of post-procedure recovery time. Typically, patients are advised to avoid strenuous activities for at least a week to allow proper healing and prevent complications following a liver biopsy.
B: I will have to lay on my right side after the procedure.
Laying on the right side is often recommended to minimize bleeding and promote comfort, indicating a correct understanding of post-procedure care.
C: I will have a small bandage instead of stitches afterward.
A small bandage is standard for liver biopsies, as stitches are often unnecessary due to the small incision, demonstrating a proper grasp of the procedure’s aftermath.
D: My right shoulder may begin to hurt as the anesthesia wears off.
Referred pain to the right shoulder can occur due to diaphragm irritation during the biopsy, showing the client has accurate awareness of potential side effects.
E: I may have a small amount of pain or discomfort during the procedure.
Experiencing some pain or discomfort during a liver biopsy is expected, indicating the client has realistic expectations regarding the procedure's nature and associated sensations.
The nurse is teaching a newly admitted client about fall prevention. The nurse understands that which of the following interventions can help prevent client falls? Select all that apply.
Rationale:
Keeping personal articles within reach, explaining the call light system, and reminding the client to call for assistance when getting out of bed are effective interventions for preventing falls.
A: Keeping personal articles within reach minimizes the risk of clients stretching or overexerting themselves to access items, ensuring they remain stable and safe during their movements.
B: Explaining the use of the call light system empowers clients to seek assistance quickly, but it does not directly address their immediate physical safety or environmental conditions.
C: Keeping the bed in the lowest position with all side rails up may create a false sense of security, as it can impede the client's ability to get in and out safely.
D: Dimming the room lights can lead to increased fall risk due to inadequate visibility, counteracting the need for a well-lit environment to promote safe ambulation and orientation.
The nurse is caring for a client in the cardiac unit and notices the client's rhythm changes from normal sinus rhythm to coarse ventricular fibrillation. Which is the priority nursing action?
Rationale:
Initiate CPR while waiting on help to arrive. This action is critical as coarse ventricular fibrillation indicates a life-threatening arrhythmia requiring immediate intervention to maintain circulation and oxygenation until advanced care is available.
A: Call a code blue. While necessary, this action does not address the immediate need for resuscitation, which can only be achieved through CPR during the waiting period.
B: Check the client and check the leads. Although assessing the situation is important, it wastes precious time that should be spent performing CPR to restore normal cardiac function swiftly.
D: Prepare to start the client on a diltiazem (Cardizem) drip. Administering medication is inappropriate in this urgent scenario, as the primary focus must be on immediate life-saving measures like CPR.
E: Clear the room of unnecessary items to allow room for the crash cart and team. This task, while helpful for logistics, diverts attention from the immediate need for resuscitation efforts.
The nurse is assessing a client with Addison's disease. The nurse expects to note which of the following?
Rationale:
Clients with Addison's disease often experience a craving for salty foods due to the loss of sodium and adrenal insufficiency. This craving is a compensatory mechanism to address electrolyte imbalances caused by the disease.
B: Weight gain is typically not associated with Addison's disease, as the condition can lead to weight loss due to decreased appetite and metabolism issues.
C: Craving of sweet foods does not correlate with Addison's disease; instead, patients often seek salt to compensate for low levels of sodium due to adrenal dysfunction.
D: Hyperactivity is not characteristic of Addison's disease; patients usually experience fatigue and weakness related to hormonal imbalances, which contrasts sharply with increased energy levels.
The nurse is reviewing labs of a newly admitted client. Which lab result would prompt the nurse to contact the health care provider?
Rationale:
BNP 760 pg/mL would prompt the nurse to contact the health care provider. Elevated BNP levels indicate potential heart failure or fluid overload, requiring immediate clinical assessment and possible intervention to prevent complications.
A: ALT 33 units/L indicates normal liver function, with typical ranges suggesting no immediate concern for the client’s health status or need for urgent physician contact.
C: WBC 10,450 mcL falls within a generally acceptable range, suggesting no acute infection or inflammatory process requiring immediate intervention or provider notification at this time.
D: Direct bilirubin 0.2 mg/dL is within normal limits, indicating healthy liver function and normal bilirubin metabolism, thus not necessitating urgent communication with the healthcare provider.
The nurse is educating a client newly diagnosed with gout regarding dietary choices. The nurse understands that further teaching is needed if the client orders which foods for lunch?
Rationale:
Ordering a tuna fish sandwich with green peas indicates that further dietary education is necessary for the client newly diagnosed with gout. Tuna and certain legumes can elevate uric acid levels, exacerbating gout symptoms.
A: fruit cup with corn bread and tea. This option contains low-purine items, promoting healthy choices suitable for managing gout, making it a safe lunch selection.
C: a peanut butter sandwich with 1 percent milk. Peanut butter is relatively low in purines and provides a nutritious option, which aligns with dietary recommendations for gout management.
D: low-fat cheese and crackers with blueberries. This choice includes low-fat dairy and fruit, both of which are generally acceptable for someone managing gout symptoms, promoting overall well-being.
The nurse is caring for a client who just had an arteriovenous (AV) fistula placed for dialysis. The nurse is providing home care instructions to the client. Which statement by the client indicates a need for further teaching by the nurse?
Rationale:
D: I should wear tight sleeves to protect and support the fistula so I don't bend it. Wearing tight sleeves can restrict blood flow and create complications for the fistula, which requires a free flow of blood for effective dialysis access and function.
A: I should avoid wearing a watch on my arm with the fistula. This statement reflects proper understanding, as wearing tight accessories could impede circulation and damage the fistula.
B: It may take several weeks before the fistula is ready to use. This indicates awareness of the maturation process necessary for the fistula to function effectively for dialysis.
C: I should not have my blood pressure taken in my access arm. This demonstrates knowledge of protecting the fistula from unnecessary pressure, which could compromise its integrity and function.
The nurse is caring for a client who just returned from a total hip arthroplasty. A student nurse is helping provide care for this client. Which action by the student nurse requires intervention by the nurse?
Rationale:
The student nurse positions the client with the legs adducted.
Positioning the legs adducted after a total hip arthroplasty can lead to complications such as hip dislocation. Proper positioning should involve maintaining abduction to ensure stability and promote healing post-surgery.
A: The student nurse floats the client's heels with a pillow. This action helps prevent pressure ulcers and promotes comfort, aligning with best practices for post-operative care.
C: The student nurse applies the sequential compression device (SCD) per orders. Utilizing SCDs is essential for preventing deep vein thrombosis, adhering to standard post-operative protocols effectively.
D: The student nurse encourages deep breathing and incentive spirometer use every 2 hours. Promoting respiratory exercises is vital for preventing pulmonary complications, demonstrating appropriate post-surgical care measures.
The nurse is caring for an adult client with a total bilirubin of 2.1 mg/dL. Which signs and symptoms would the nurse expect to find? Select all that apply.
Rationale:
Itchy skin and pale stools are expected signs and symptoms associated with elevated bilirubin levels. A total bilirubin of 2.1 mg/dL suggests possible liver dysfunction or hemolysis, leading to these manifestations.
B: Nausea typically correlates with various gastrointestinal issues, not specifically with bilirubin levels. While it can occur in liver disease, it is not a direct indicator of elevated bilirubin.
D: Colorless urine, often indicating bilirubinuria, occurs when bilirubin levels are significantly high, and this value does not suggest a standard presentation associated with the given bilirubin level.
E: A total bilirubin of 2.1 mg/dL is elevated, not within the normal range, hence symptoms like itchy skin and pale stools can manifest, contrary to the option's claim.
The nurse is caring for a client with hypoparathyroidism. The nurse understands that this client is at risk for which problem?
Rationale:
The client is at risk for low parathyroid hormone levels. Hypoparathyroidism results in insufficient parathyroid hormone production, leading to decreased calcium levels and related complications, making monitoring critical for this condition.
A: hypercalcemia Excess calcium levels are typically associated with hyperparathyroidism, not hypoparathyroidism, where calcium levels are likely to be low due to insufficient parathyroid hormone.
B: hypermagnesemia Elevated magnesium levels do not directly correlate with hypoparathyroidism. The primary concern lies with calcium and phosphorus balance rather than magnesium imbalances in this condition.
C: decreased phosphorus levels Hypoparathyroidism often leads to increased phosphorus levels due to reduced excretion, not decreased levels, which directly contradicts the expected metabolic changes associated with this disorder.
The nurse has received shift report on the assigned client. Which client would the nurse anticipate to be at highest risk for skin breakdown?
Rationale:
A: an elderly client who is up to the chair for meals with assistance. While elderly clients are at risk, this client has assistance for mobility, reducing skin breakdown risk.
B: a 24-year-old client with diabetes whose hemoglobin A1C is 6.4%. This A1C level indicates good diabetes control, lowering the risk of skin issues typically associated with poor glucose management.
C: a client who is legally blind and lives independently, except for driving. Independence in daily activities suggests the client maintains adequate mobility and care, minimizing risk for skin breakdown.
E: a client who had a right pneumothorax and has a chest tube and can reposition independently. The ability to reposition independently helps prevent skin breakdown, indicating a lower risk compared to others.
The nurse is caring for a client who was admitted with an upper respiratory infection. The client's temperature is 102.4°F, and he is confused. In the last 2 hours, systolic blood pressure has dropped from 138 to 90. The nurse should perform which intervention? Select all that apply.
Rationale:
Obtain blood cultures, administer supplemental oxygen, administer antipyretics as ordered, and encourage rest and limit physical activity are essential interventions for managing the client's upper respiratory infection and associated symptoms. These actions will help identify the infection, improve oxygenation, reduce fever, and prevent further complications related to confusion and hypotension.
B: Place the client on NPO status. While fasting might be considered in certain situations, it is not immediately necessary here and could hinder overall recovery and hydration.
F: Provide a warming blanket to alleviate chills. Although this may seem helpful, it does not address the underlying infection and could raise body temperature further, complicating the client's condition.
A nurse in intensive coronary care is caring for a client with an endotracheal tube who underwent coronary bypass surgery. The client awakens and attempts to communicate. Which nursing interventions should the nurse perform? Select all that apply.
Rationale:
Offering a communication board and asking simple yes/no questions are essential interventions for a client with an endotracheal tube, facilitating effective communication while ensuring the client's comfort and safety during recovery.
A: offer a communication board Providing a communication board allows the client to express needs and feelings visually, enhancing understanding and reducing frustration.
B: ask simple yes/no questions Simple yes/no questions limit the client's ability to express more complex thoughts and emotions, which could lead to miscommunication or misunderstandings in their care.
C: ask open-ended questions Open-ended questions require verbal responses that are not possible with an endotracheal tube, making them ineffective for communication in this situation.
D: offer an electrolarynx An electrolarynx is not suitable for clients with an endotracheal tube, as it requires the ability to breathe through the mouth, which is not feasible in this context.
The nurse is caring for a client with seizure disorder. Which statement regarding seizure precautions is correct?
Rationale:
Oxygen and suctioning should be at the bedside. These tools are essential during a seizure to maintain airway patency and ensure adequate oxygenation, as complications may arise during an episode.
A: Padded tongue blades should be at the bedside. Using tongue blades poses risks of dental injury or airway obstruction, making them an unsuitable option for seizure management.
C: Padding bed rails with blankets can help prevent injury. While this option enhances safety, it does not replace the crucial need for oxygen and suctioning during a seizure.
D: Restraint mitts will help keep the client from removing tubes or IVs. Restraints can pose ethical concerns and may lead to further injury, contradicting best practices for seizure care.
A young child with a rash that's raised and has circumscribed areas filled with fluid comes to the school nurse. What type of rash should the nurse document?
Rationale:
A vesicular rash should be documented. This type of rash is characterized by raised lesions containing fluid-filled blisters, which aligns with the description of the child's rash presented to the nurse.
A: maculopapular rash This option refers to flat and raised spots without fluid, which does not match the fluid-filled characteristics described.
B: heat rash Heat rash typically appears as small red bumps due to sweat blockage, lacking the fluid-filled vesicles present in the child's condition.
D: pustular rash A pustular rash consists of pus-filled lesions, differing from the clear fluid found in a vesicular rash, making it an inappropriate choice for this case.