A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis
B. Observe the color, consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature
A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client’s ability to swallow
D. Perform range of motion exercises
A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night?
B. Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position
D. Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation
A. Increase the daily intake of oral fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ? % proximal right coronary artery (RCA). The client later asks the nurse “what does all this mean for me?” What information should the nurse provide?
A. Blood supply to the heart is diminished by artherosclerotic lesions, which necessitate lifestyle changes.
B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid retention.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
0.6 ml
What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?
A. Sleep without pillows at night to maintain neck alignment.
B. Adjust food intake to three full meals per day and no snacks.
C. Minimize symptoms by wearing loose, comfortable clothing
D. Avoid participation in any aerobic exercise programs
C. Minimize symptoms by wearing loose, comfortable clothing
The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest
A. left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider.
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence
C. Yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness
C. Weakened cough effort
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?
A. Grafting increases the risk for bacterial infections
B. The xenograft is taken from nonhuman sources
C. Grafts are later removed by a debriding procedure
D. As the burn heals, the graft permanently attaches
B. The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next?
A. Bring additional sterile dressing supplies to the room
B. Prepare the client to return to the operating room
C. Obtain a sample of the drainage to send to the lab
D. Auscultate the abdomen for bowel sound activity
B. Prepare the client to return to the operating room
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client’s plan of care?
A. Altered urinary elimination
B. Impaired gas exchange
C. Fluid volume excess
D. Decreased cardiac output
C. Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement?
A. Begin preparing client for thyroidectomy procedure
B. Space the client’s care to provide periods of rest
C. Assess the client for hyperactive bowel sounds
D. Provide warm blankets to prevent heat loss
B. Space the client’s care to provide periods of rest
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?
A. Increase intake of high-fiber foods, such as bran cereal
B. Restrict protein intake by limiting meats and other high-protein foods
C. Limit oral fluid intake to 500 ml per day
D. Increase intake of potassium-rich foods such as bananas or cantaloupe
B. Restrict protein intake by limiting meats and other high-protein foods
An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
A client with Cushing’s syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
A. Irregular apical pulse
B. Purple marks on the skin of the abdomen
C. Quarter size blood spot on dressing
D. Pitting ankle edema
A. Irregular apical pulse
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?
A. Apply a cool compress to the affected fingers for 20 minutes
B. Secure a pulse oximeter to monitor the client’s oxygen saturation
C. Report the finding to the healthcare provider as soon as possible
D. Continue to monitor the fingers until color returns to normal
D. Continue to monitor the fingers until color returns to normal
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
A. Obtain oxygen saturation level
B. Encourage incentive spirometry
C. Assess lower extremity circulation
D. Administer PRN oral antipyretic
D. Administer PRN oral antipyretic
The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure?
A. Light yellow coloring of the client’s skin and eyes
B. The client’s blood pressure reading is 184/88 mm Hg.
C. The client vomits 20 ml of clear yellowish fluid
D. The IV insertion site is red, swollen, and leaking IV fluid
B. The client’s blood pressure reading is 184/88 mm Hg
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
A. Facial puffiness and periorbital edema
B. Hematocrit of 30%
C. Cold and dry skin
D. Further decline in level of consciousness
D. Further decline in level of consciousness
Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?
A. Avoid coiling the tubing and keep if free of kinks
B. Cleanse the perineal area with soap and water twice daily
C. Keep the drainage bag lower than the level of the bladder
D. Drink 1,000 ml of fluids daily to irrigate catheter
C. Keep the drainage bag lower than the level of the bladder
Which client has the highest risk for developing skin cancer?
A. A 16-year old dark-skinned female who tans in tanning beds once a week
B. A 65 year-old fair-skinned male who is a construction worker
C. A 25 year-old dark-skinned male whose mother had skin cancer
D. A 70 year-old fair-skinned female who works as a secretary
B. A 65 year-old fair-skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
A. Daily weight
B. Vital signs
C. Level of consciousness
D. Bowel sounds
A. Daily weight
A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.)
A. Offer ice chips and oral clear liquids
B. Verify pedal pulses using a doppler pulse device
C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg
E. Administer oral antispasmodics and narcotic analgesics
B. Verify pedal pulses using a doppler pulse device
C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg
A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem?
A. Pain
B. Nocturia
C. Dyspnea
D. Frequent cough
A. Pain
When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, “visual sensory/perceptual alterations.” This diagnosis is based on which etiology?
A. Limited eye movement
B. Decreased peripheral vision
C. Blurred distance vision
D. Photosensitivity
B. Decreased peripheral vision
A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?
A. Allow additional time to complete physical activities to reduce oxygen demand
B. Practice inhaling through the nose and exhaling slowly through pursed lips
C. Use a humidifier to increase home air quality humidity between 30-50%
D. Strengthen abdominal muscles by alternating leg raises during exhalation
B. Practice inhaling through the nose and exhaling slowly through pursed lips
A client with cancer is receiving chemotherapy with a known vesicant. The client’s IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation?
A. Impaired skin integrity
B. Fluid volume excess
C. Acute pain and anxiety
D. Peripheral neurovascular dysfunction
A. Impaired skin integrity
A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement?
A. Document the client’s report of pain in the electronic medical record
B. Determine which prescription will have the quickest onset of action
C. Compare the client’s pain scale rating with the prescribed dosing
D. Ask the client to choose which mediation is needed for pain
C. Compare the client’s pain scale rating with the prescribed dosing
While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
A. Document details of the seizure activity
B. Observe for lacerations to the tongue
C. Observe for prolonged periods of apnea
D. Evaluate for evidence of incontinence
C. Observe for prolonged periods of apnea
A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement.
A. Provide a warming pad (Aqua-pad or K-pad) to feet
B. Medicate the client with a prescribed sedative
C. Use a bed cradle to hold the covers off the feet
D. Place warm blankets next to the client’s feet
D. Place warm blankets next to the client’s feet
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
A. An old friend with eczema came for a visit
B. Recently received an influenza immunization
C. A grandson and his new dog recently visited
D. Corticosteroid cream was applied to eczema
C. A grandson and his new dog recently visited
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. what is the etiology of this problem?
A. Irritation of nerve endings
B. Diminished blood flow
C. Ischemic tissue changes
D. Compression of a nerve
D. Compression of a nerve
The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply)
A. Skin integrity
B. Functional ability
C. Heart sounds
D. Pain scale
E. Bowel sounds
A. Skin integrity
B. Functional ability
D. Pain scale
A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
A. Observe the perineal area for a chancroid-like lesion
B. Obtain a specimen of urethral drainage for culture
C. Assess for perineal itching, erythema and excoriation
D. Identify all sexual partners in the last four days
B. Obtain a specimen of urethral drainage for culture
A client with Addison’s disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
A. Osmolarity
B. Glucose
C. Albumin
D. Platelets
B. Glucose
A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
A. Elevated temperature
B. Generalized weakness
C. Diminished lung sounds
D. Pain when swallowing
D. Pain when swallowing
An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?
A. Collect a urine specimen for culture analysis
B. Review the client’s fluid intake prior to bedtime
C. Palpate the bladder above the symphysis pubis
D. Obtain a fingerstick blood glucose level
C. Palpate the bladder above the symphysis pubis
Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention should the nurse implement?
A. Remove all sources of liquids from the client’s room
B. Allow family to give client a measured amount of ice chips
C. Restrict family visiting until the client’s condition is stable
D. Provide the client with oral swabs to moisten his mouth
D. Provide the client with oral swabs to moisten his mouth
During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement?
A. Palpate for abdominal distention
B. Send fluid to the lab for analysis
C. Continue to monitor the fluid output
D. Clamp the drainage tube for 5 minutes
C. Continue to monitor the fluid output
While assessing a client with degenerative joint disease, the nurse observes Heberden’s nodes, large prominences on the client’s fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?
A. Review the client’s dietary intake of high-protein foods
B. Notify the healthcare provider of the finding immediately
C. Discuss approaches to the chronic pain control with the client
D. Assess the client’s radial pulses and capillary refill time
C. Discuss approaches to the chronic pain control with the client
A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider?
A. Weakness and fatigue
B. Intestinal cramping
C. Weight loss
D. Jaundiced sclera
D. Jaundiced sclera
Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion?
A. Stabilization of blood pressure ranges
B. Cessation of chest pain
C. Reduce heart rate
D. Decreased frequency of episodes of VT
D. Decreased frequency of episodes of VT
After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
A. Call respiratory therapy to give a breathing treatment
B. Send another nurse for an emergency tracheotomy set
C. Prepare a dose of epinephrine (Adrenalin)
D. Review the client’s complete list of allergies
C. Prepare a dose of epinephrine (Adrenalin)
The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
A. Nuchal rigidity
B. Carotid bruit
C. Jugular vein distention
D. Palpable cervical lymph node
B. Carotid bruit
The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.)
0.9 ml
The nurse is obtaining a client’s fingerstick glucose level. After gently milking the client’s finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
A. Collect the blood sample
B. Assess radial pulse volume
C. Apply pressure to the site
D. Select another finger
A. Collect the blood sample
A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?
A. Soak nasogastric tube in warm water
B. Insert tube with client’s head tilted back
C. Apply suction while inserting tube
D. Elevate head of bed 60 to 90 degrees
D. Elevate head of bed 60 to 90 degrees
A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?
A. Measure urine output hourly to assess for rental perfusion
B. Request a prescription for pain medication
C. Use an automated BP machine to monitor for hypotension
D. Provide a quiet environment with low lighting
C. Use an automated BP machine to monitor for hypotension
The wife of a client with Parkinson’s disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide?
A. Invite friends over regularly to share in meal times
B. Encourage the client to drink clear liquids between meals
C. Coach the client to make an intentional effort to swallow
D. Talk to the healthcare provider about prescribing an appetite stimulant
A. Invite friends over regularly to share in meal times
A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes,. Which assessment should the nurse implement first?
A. Evaluate distal capillary refill for delayed perfusion
B. Check the extremities for bruising and petechiae
C. Examine the pretibial regions for pitting edema
D. Palpate the abdomen for tenderness and rigidity
D. Palpate the abdomen for tenderness and rigidity
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client’s postoperative discharge instructions?
A. Report when hematuria becomes pink tinged
B. Use incentive spirometer
C. Restrict physical activities
D. Monitor urinary stream for decrease in output
D. Monitor urinary stream for decrease in output
A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. I t is most important for the nurse to emphasize the need to observe for changes in which characteristic?
A. Elasticity of the skin
B. Appearance of any moles
C. Muscle aches and pains
D. Pigmentation of the skin
B. Appearance of any moles
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse’s assessment of the test after 62 hours indicates 5 mm of erythema without induration. What is the best initial nursing action?
Document negative results in the client’s medical record
The nurse is teaching the importance of an exercise regime that includes walking daily for a group of clients with asthma, chronic bronchitis, and emphysema at a pulmonary rehabilitation clinic. Which rationale should the nurse include when motivating the clients?
Daily exercise and walking enhances cardiovascular fitness
The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review?
A. Glucose
B. Platelet count
C. White blood cell count
D. Amylase
B. Platelet count
A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement?
Review most recent thyroid function test results
An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?
A. Teach a family member to administer eye drops
B. Encourage deep breathing and coughing exercises
C. Provide an eye shield to be worn while sleeping
D. Obtain vital signs every 2 hours during hospitalization
C. Provide an eye shield to be worn while sleeping
A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse
implement?
Protect cornea with lubricant and eye shields
An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take?
A. Assist the lien tot a high Fowler’s position in bed
B. Observe the client for the presence of a barrel chest
C. Prepare to transfer the client to a critical care unit
D. Instruct the client to pursed lip breathing techniques
D. Instruct the client in pursed lip breathing techniques
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client’s plan of care?
Teach the client techniques for performing intermittent catheterization
When providing care for a client following bronchoscopy, which assessment finding should he nurse immediately report to the healthcare provider?
A. Slight blood-tinged sputum
B. Dyspnea and dysphagia
C. Sore throat and hoarseness
D. No gag reflex after thirty minutes
D. No gag reflex after thirty minutes
The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best medication that the client is adhering to the prescribed diabetic regimen?
Hemoglobin A1C of 6.2%
A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement?
Provide an overhead trapeze to the bed for the client to use
An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate the left pedal pulses. Which action is most important for the nurse to implement?
Use a doppler to assess bilateral pedal pulses
A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with a severe dehydration. Which assessment finding warrants immediate intervention by the nurse.
A. Strong foul-smelling flatus
B. Gastroccult positive emesis
C. Complaint of poor night vision
D. Loose bowel movements
B. Gastroccult positive emesis
A female client who was involved in a motor vehicle collision with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? Select all that apply
Monitor left leg for pain, pallor, paresthesia, paralysis, pressure. Verify pedal pulses using a doppler pulse device. Evaluate the application of the splint to the left leg
A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants
immediate intervention by the nurse?
A. True urinary output of 50ml/hr
B. Lower abdominal tenderness
C. Blood urine output with clots
D. Urine leaking around the meatus
D. Urine leaking around the meatus
A client tells the nurse that her biopsy results indicate that the cancer cells are
well-differentiated. How should the nurse respond?
Ask the client if the healthcare provider has given her any information about the classification of her cancer
The nurse is assessing a client who has tinea pedis. Which question will allow the nurse to gather further information about this condition?
Do you see any improvement when using tolnaftate?
A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first?
A. Notify the healthcare provider
B. Assure the client that such feelings occur with wound infections
C. Visualize the abdominal incision
D. Obtain sterile towels soaked in saline
C. Visualize the abdominal incision
A male client with pernicious anemia takes supplemental folate and self-administers monthly Vitamin B12 injections. He reports feeling increasingly fatigued. Which laboratory value should the nurse review?
Complete blood count
A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation
A. Low-sodium soups.
B. Over all fluid intake
C. Tea and hot chocolate
D. Citrus fruit juices
C. Tea and hot chocolate
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
Tell the client to remain in bed
An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family’s concern?
A. Encourage the family to offer to feed the client when she does not eat her entire meal.
B. Suggest that the family bring foods from home that the client enjoys
C. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
D. Demonstrate the use of visual scanning during meals to the client and family.
D. Demonstrate the use of visual scanning during meals to the client and family
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement?
Administer opioid and non-opioid medication simultaneously
A female client who received partial-thickness and full-thickness burns over 40% of her body in a house fire is admitted to the inpatient burn unit. What fluid should the nurse prepare to
administer during the acute phase of the client’s burn recovery?
Ringer’s Lactate
A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement?
A. Schedule an appointment or the client to see the healthcare provider
B. Advise the client to apply plastic wrap over the ointment to promote healing
C. Instruct the client to continue the ointment until all erythema is relieved
D. Explain the client need to complete all prescribed dose of the medication
A. Schedule an appointment for the client to see the healthcare provider.
A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?
A. Serum sodium of 185 mEq/L
B. Dry skin with inelastic turgor
C. Apical rate of 110 beats/minute
D. Polyuria and excessive thirst
A. Serum sodium of 185 mEq/L
A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet; swelling, redness, and restricted joint motion; and reports feeling fatigued. Which nursing diagnosis has the highest priority for this client?
Pain related to joint inflammation
When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?
Restrict sodium intake
A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose of Humulin N insulin at 0800. At 1600, the client
complains of diaphoresis, rapid heartbeat, and feeling shaky. What should the nurse do first?
Determine the client’s current glucose level
The nurse determines that a client who arrives in the preoperative holding area before surgery is allergic to bananas. Which action should the nurse implement prior to taking the client into the operative area?
Replace latex-containing devices in the OR with alternate synthetic materials
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
A. Black ulcers and dependent rubor
B. Irregular ulcer shapes and sever edema
C. Absent pedal pulses and shiny skin
D. Hairless lower extremities and cool feet
B. Irregular ulcer shapes and severe edema
A 70-year-old male client with type 2 diabetes mellitus (DM) is hospitalized with an infected ulcer on his great right toe. Which instruction should the nurse emphasize during discharge teaching?
Check the insides and linings of all enclosed shoes before putting the shoes on
The nurse is providing discharge instructions to a client who is receiving prednisone (Deltasone) 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?
Rapid weight gain
The family suspects that AIDS dementia is occurring in their son who is HIV positive. Which symptom confirms their suspicions?
A change has recently occurred in his handwriting.
A woman who works as a data entry clerk is concerned as to how recent diagnosis of Raynaud’s syndrome is going to affect her job performance. Which instruction should the nurse provide this client?
Use a space heater to keep the workspace warm
An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply)
A. Monitor dryness of mucous membranes
B. Check for changes in mentation
C. Observe color of skin and nailbeds
D. Note appearance of jugular veins
E. Assess breathing patterns
B. Check for changes in mentation.
C. Observe color of skin and mucous.
E. Assess breathing patterns
An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?
A. Auscultate for presence of bowl sounds.
B. Monitor hemoglobin and hematocrit
C. Encourage turning and deep breathing
D. Administer IV antibiotics as prescribed.
D. Administer IV antibiotics as prescribed
A client’s telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client’s rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse?
A. Prepare for transcutaneous pacing
B. Deliver another defibrillator shock
C. Administer IV Epinephrine per ACLS protocol
D. Give IV dose of adenosine rapidly over 1-2 seconds.
D. Give IV dose of adenosine rapidly over 1-2 seconds
Two days following abdominal surgery a client begins to report camping abdominal pain, and the nurse’s inspection the abdomen indicates slight distention. Which action should the nurse implement first?
A. Encourage the client to ambulate
B. Offer ice ships or warm liquids
C. Auscultate the client’s abdomen
D. Assess the client’s temperature
C. Auscultate the client’s abdomen
A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which laboratory value is most important for the nurse to monitor following the procedure?
A. Serum creatinine
B. Blood urea nitrogen (BUN)
C. White blood cell count
D. Serum glucose
C. White blood cell count
A client with draining skin lesions of the lower extremity is admitted with possible
Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan on care? (Select all that apply.)
Institute contact precautions for staff and visitors.
Send wound drainage for culture and sensitivity.
Monitor the client’s white blood cell count.
During preoperative teaching for a male client schedule for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understand the need to perform coughing and deep breathing exercise after surgery. How should the nurse respond?
A. Ask for a demonstration of these exercises
B. Explain that coughing should be avoided
C. Review the client previous surgical history
D. Document the clients understanding of teaching
A. Ask for a demonstration of these exercises
An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client’s plan of care?
A. Assist with ambulation in the hallway
B. Encourage active range of motion exercises
C. Provide a bedside commode for toileting
D. Teach to sleep in a slide-laying position
C. Provide a bedside commode for toileting
Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?
A. Teach the client to elevate the head of the bed on blocks
B. Remind the client to avoid high-fiber foods
C. Encourage the client to lie down and rest after meals.
D. Instruct the client to use antacids only as a last resort
A. Teach the client to elevate the head of the bed on blocks
A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next?
Blood pressure
The healthcare provider prescribes epoetin alfa (Procrit) 8,200 units subcutaneously for a client with chronic kidney disease (CKD). The 2 ml multidose vial is labeled, “Each 1 ml of solution contains 10,000 units of epoetin alfa.” How many ml should the nurse administer?
0.8
A nurse assists a male client with Parkinson’s disease (PD) to ambulate in the hallway. The client appears to “freeze” and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond?
A. Re-orient the client to his present location and circumstances
B. Confirm that this is an effective technique to help with ambulation
C. Assist the client to a carpeted area where he can walk more easily.
D. Plan to assess the client’s cognition after returning to his room.
B. Confirm that this is an effective technique to help with ambulation
Which food is most important for the nurse to encourage a male client with osteomalacia to include in his daily diet?
Fortified milk and cereals
A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client’s bowel movements?
A. Hard pellets of stool
B. Clay-colored stool
C. Stool with fatty streaks
D. Blood in the stool
C. Stool with fatty streaks
The healthcare provider prescribes an IV solution of regular insulin (Hummulin-R) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hour?
30
A client with chronic kidney disease (CDK) arrives at the clinic reporting shortness of breath on exertion and extreme weakness. Vital signs are temperature 100.4 F (38 C), heart rate 110
beats/minute, respirations 28 breaths/minute, and blood pressure 175/98 mmHg. The client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens are sent to the laboratory for analysis. Which laboratory results should the nurse report to the healthcare provider immediately?
Potassium 6.5 mEq/L (mmol/L)
A client with unstable asthma had an emergent cardiac catheterization. Which complication should the nurse monitor for in the initial 24 hours after the procedure?
Thrombus formation
A male client with a history of asthma reports having episodes of bronchoconstriction and
increased mucous production while exercising. Which action should the nurse implement?
Determine if the client is using an inhaler before exercising
After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter’s patency. Which action should the nurse implement?
Clamp the catheter for 30 minutes prior to irrigating with saline
A male client with chronic kidney disease (CKD) is beginning his first hemodialysis 3 times per week. Which short-term goal is most important for the nurse to include in the plan of care for this client as he begins the series?
A. Reports subjective symptom’s during hemodialysis
B. Documents his oral intake during dialysis treatments
C. Demonstrates self-care of the arteriovenous (AV) Shunt
D. Verbalizes understanding of the reasoning for dialysis
D. Verbalizes understanding of the reasoning for dialysis
The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
A. Eating patterns and dietary intake
B. Level and amount of physical activity
C. Color and consistency of feces
D. Presence and activity of bowel sounds
A. Eating patterns and dietary intake
Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement?
A. Patch one eye and then the other every few hours
B. Encourage bedrest until the diplopia is resolved
C. Instruct the client to limit intake of oral fluids
D. Administer artificial tear drops to both eyes
A. Patch one eye and then the other every few hours
The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete?
A. Manual dexterity and visual acuity
B. Capillary refill time and radial pulse volume
C. Deep tendon reflexes and skin color
D. Skin elasticity and hand grip strength.
A. Manual dexterity and visual acuity
A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first?
A. Teach the client about the importance of hydration
B. Report the volume of emesis t the healthcare provider
C. Administer ondansetron hydrochloride (Zofran)
D. Encourage the client to limit the amount of movement
C. Administer ondansetron hydrochloride (Zofran)
The nurse calculates the body mass index (BMI) for an obese adult. Which additional assessment finding places the client at high risk for cardiac disease?
A. Large waist circumference with central fat
B. High serum insulin level
C. Hyperpigmentation on neck skin folds
D. Poor muscle tone
A. Large waist circumference with central fat
An adult male client is admitted for Pneumocystis carinal pneumonia (PCP) secondary to AIDSs. While hospitalized, he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain?
A. IV pentamidine may offer protection to other AIDS-related conditions, such as Kaposi’s sarcoma
B. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month
C. IV pentamidine will be given until oral pentamidine can be tolerated
D. AZT (Azidothymidine) therapy must be stopped when IV or aerosol pentamidine is being used.
B. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month
A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide?
A. Elevate the hands on two pillows at night
B. Notify the healthcare provider as soon as possible
C. Wear braces as both writs during the night
D. Apply cold compresses for 30 min before bedtime
C. Wear braces as both writs during the night
An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should the nurse monitor?
A. Serum electrolytes
B. Neutrophils and eosinophils
C. Serum iron and ferritin
D. Platelet count and hematocrit
C. Serum iron and ferritin
The nurse is evaluating a male client understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?
A. Uses only lactose-free dairy products.
B. Enjoys fat free yogurt as an occasional snack food
C. No longer includes grains in his daily diet
D. Carefully cleans and peels all fresh fruit and vegetables
D. Carefully cleans and peels all fresh fruit and vegetables
An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse?
A. Glucose of 350 mg/dl
B. White blood cell count of 15, 000 mm3
C. Blood PH of 7.30
D. Potassium of 2.5 mEq/L
D. Potassium of 2.5 mEq/L
A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/l) is admitted to the hospital. Which prescribed medication should the nurse administer first
A. Sevelamer (RenaGel) one tablet PO.
B. Epoetin alfa, recombinant (Epogen) 2, 500 units SUBQ
C. Sodium polystyrene (Kayexalate) 15 grams PO
D. Calcium acetate (Phos-Lo) one tablet PO
C. Sodium polystyrene (Kayexalate) 15 grams PO
Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement?
A. Palpate the abdomen
B. Measure hourly urine output
C. Ambulate client in hallway
D. Auscultate bowels sounds.
D. Auscultate bowels sounds.
An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (select all that apply)
A. Serum creatinine and blood urea nitrogen (BUN)
B. Sensation in feet and legs
C. Skin condition of lower extremities
D. Visual acuity
E Signs of respiratory tract infection
A. Serum creatinine and blood urea nitrogen (BUN)
B. Sensation in feet and legs
C. Skin condition of lower extremities
D. Visual acuity
A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action?
A. Encourage frequent mouth care
B. Cleanse the tongue and mouth with glycerin swabs
C. Obtain a soft diet for the client
D. Administer a topical analgesic per PRN protocol.
D. Administer a topical analgesic per PRN protocol.
The nurse is preparing a client for discharge who recently diagnosed with Addison’s disease. Which instruction is most important for the nurse to include in the client’s discharge teaching plan?
A. Use a walker when weakness occurs
B. Avoid extreme environmental temperatures
C. Increase daily intake of sodium in diet
D. Take prescribed cortisone accurately
C. Increase daily intake of sodium in diet
To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (Select all that apply)
A. Initiate passive range of motion exercises
B. Establish a regular bladder routine
C. Teach the client breathing exercises
D. Perform chest physiotherapy
E. Encourage use of incentive spirometer
C. Teach the client breathing exercises
D. Perform chest physiotherapy
E. Encourage use of incentive spirometer
A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client?
A. Cheese pasta and a lettuce and tomato salad
B. Beef steak with steamed broccoli and orange slices
C. Broiled white fish with a baked sweet potato
D. Grilled shrimp and season rice with asparagus salad
B. Beef steak with steamed broccoli and orange slices
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?
A. Continuous cardiac monitoring
B. Perform passive range of motion
C. Evaluate level of consciousness
D. Assess lung sounds q4 hours.
A. Continuous cardiac monitoring
An adult female with multiple sclerosis (MS) fells while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
A. Determine clients last dose of corticosteroids
B. Determine neurological baseline prior to the fall
C. Administer a PRN IV antiemetic as prescribed
D. Complete head to toe neurological assessment.
D. Complete head to toe neurological assessment.
A client who has a history of long-standing back pain treated with methadone (Dolophines), is admitted to the surgical unit following urological surgery. Which modifications in the plan of care should the nurse make for this client’s pain management during the postoperative period?
A. Consult with surgeon about increasing methadone in lieu of parenteral opioids.
B. Use minimal parenteral opioids for surgical pain, in addition to oral methadone
C. Maintain client’s methadone, and medicate surgical pain based on pain rating
D. Make no changes in the standard pain management for the surgery and hold methadone.
C. Maintain client’s methadone, and medicate surgical pain based on pain rating
When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care?
A. Provide assistive devices to empower client independence
B. Implement measures to manage chronic pain
C. Teach coping skills for living with a chronic illness
D. Schedule rest periods between activates to minimize fatigue.
C. Teach coping skills for living with a chronic illness
Burns
Tissue injury or necrosis caused by transfer of energy from a heat source to the body
Categories of Burns
Thermal
radiation
electrical
chemical
Tissue destruction results from
Coagulation
protein denaturation ionization of cellular contents
Critical systems affected include
Respiratory integumentary cardiovascular
renal
G.I.
neurologic
Severity is determined by
Burn depth
1st° burn
Superficial partial thickness, injury to the epidermis, leaves skin pink or red but no blisters, dry, painful, slight edema, no scarring or skin graft required
2nd° burn
Deep partial thickness destruction of epidermis and upper layers of dermis, injury to deeper portions of the dermis, painful, appears red or white, weeps fluid, blisters present, hair follicles intact, very edematous, blanching followed by capillary refill, heals without surgical intervention
3rd° burn
Full thickness and deep full thickness involves total destruction of dermis and epidermis, skin cannot regenerate, require skin grafting, underlying tissue may be involved, wound appears dry and leathery as eschar develops, painless
Severity is determined by:
Rule of nines, Lund and browder method
Rules of Nines: head/neck
9%
Rule of Nines: upper extremities
9% each
4.5% anterior&posterior
Rule of Nines: lower extremities
18% each
9% anterior/posterior
Rule of Nines:
Front trunk
18%
Rule of Nines: back trunk
18%
Rule of Nines: perineal area
1% for adults
Three stages of burn care
Resuscitative/emergent
acute
rehabilitation
Resuscitative/emergent stage: 48-72 hrs
Begins at time of injury and concludes with the restoration of capillary permeability. Characterized by fluid shift from intravascular to interstitial and shock.dnsjd Candid Expect to administer large volumes of fluid. Fluid replacement formulas calculated from time of injury.
Acute phase: 48-72 hrs after injury
Occurs from beginning of diuresis to near completion of wound closure. Characterized by fluid shift from interstitial to intravascular. Focus on infection control wound care & closure, pain management, nutritional support, physical therapy
Rehabilitation phase
Occurs from Major wound closure to return to optimal level of physical and psychosocial adjustment. Characterized by grafting and rehabilitation specific to the client.
Absence of bowel sounds indicate
Paralytic ileus
Urine output in first 72 hours after injury
Radically decreased with increased specific gravity
Urine output 72 hours to two weeks after injury
Radically increased
Signs of inhalation burn
Red or burned face, cinched facial and nasal hairs, conjunctivitis, sooty nasal mucosal or bloody sputum, hoarseness, rails or wheezing denoting smoke inhalation
Nursing plans for emergent phase
admission care, monitor hydration status, monitor respiratory functioning, asses for paralytic ileus, wound care, pain management, asses for circulatory compromise, proper nutrition.
Nursing plans for acute phase
Provide infection control, no live plants or flowers in room, perform ROM, prevent contractures, provide fluid therapy, provide adequate nutrition ( up to 5000 calories per day)
Pain management
Provide pain medication before dressing change
Dietary interventions with burn clients
High calorie, high protein, high carb, no free water, tube feeding at night, weigh daily
Hyperthyroidism
Excessive activity of thyroid gland.
graves disease or goiter.
Treatment for hyperthyroidism
Thyroid ablation by medication, radiation, thyroidectomy, adenectomy of portion of anterior pituitary where TSH producing tumor is located = hormone replacement
Signs and symptoms for hyperthyroidism
Weight-loss
increased appetite diarrhea
heat intolerance tachycardia diaphoresis nervousness
Exophthalmos
T3 elevated above 220
T4 elevated above 12
Thyroid storm
Life threatening symptoms include fever, tachycardia, agitation, anxiety and hypertension. Maintain an airway.
Drugs for thyroid storm
PTU (propylthiouracil)
Tapazole (methimazole)
Diet for hyperthyroidism
High calorie
High protein
low caffeine
Low Fiber
Treatment of hyperthyroidism
Thyroid ablation, radiation, thyroidectomy, adenectomy
Normal calcium level
9.0-10.5
Tests for hypocalcemia
Trousseau sign
Chvostek sign
Hypothyroidism
Hashimoto, myxedema. Hypofunction of the thyroid gland resulting in insufficiency of thyroid hormone
Signs & symptoms of hypothyroidism
Thin, dry hair
Thick, brittle nails
constipation
bradycardia
Goiter
PeriOrbital edema
cold intolerance
weight gain
Diagnosis of hypothyroidism
Low T3 below 70
Low T4 below 5
Presence of T4 antibody
Signs and symptoms of myxedema coma
Hypotension
Hypothermia
Hyponatremia
Hypoglycemia
Respiratory failure
Corticosteroids
Hydrocortisone
Prednisone
Dexamethasone
Medrol
Addison disease
Hypo function of the adrenal cortex. Sudden withdrawal from corticosteroids. characterized by lack of cortisol, aldosterone.
Diagnosis of Addison disease
ACTH stimulation test
Signs and symptoms of Addison disease
Fatigue
weight-loss
anorexia
postural hypotension hypoglycemia hyponatremia hyperkalemia hyperpigmentation loss of body hair
hypovolemia
Diet requirements for Addison’s disease
High sodium
low potassium
high carb
Addison crisis
Vascular collapse hypoglycemia
Essential to reversing the crisis
aldosterone replacement
Cushing syndrome
Excess adrenocorticoid activity. Also caused by adrenal, pituitary or hypothalamus tumors
Signs and symptoms of Cushing’s
Moon face
truncal obesity
Buffalo hump
abdominal striae thinning of skin hyperpigmentation Hirsutism in females bruises easily hypertension
Lab data for Cushing’s
Hyperglycemia hypernatremia hypokalemia increased plasma cortisol
Decreased eosinophils and lymphocytes
Diet for Cushing’s
Low-sodium, encourage consumption of foods that contain vitamin D and calcium
Diabetes mellitus
High levels of glucose resulting from defects in insulin secretion, insulin action or both
Diabetes mellitus is characterized by
Hyper glycemia
Ways to diagnose DM
Fasting plasma glucose greater than 126
HBA1c greater than 6.5%
random blood glucose greater than 200
OGTT greater than 200
Type 1 DM
Results from B cell destruction
Type 2 DM
Results from progressive secretory insulin deficit and or defect in insulin uptake
Characteristics of type 1 DM
Can become hyper glycemic and ketosis prone relatively easily. Can develop DKA from under management of glucose
Characteristics of diabetic ketoacidosis
Serum glucose of 250 ketonurea in large amounts
arterial pH of less than 7.30
nausea/vomiting dehydration abdominal pain Kushmaul reparations
Type 2 DM
Rare development of ketoacidosis
with extreme hyperglycemia HHNKS develops
Hyperosmolar hyperglycemia nonketotic syndrome characteristics
Hyperglycemia greater than 600, plasma hyperosmolarity,
dehydration, changed mental status, absent ketone bodies
OA’s: sulfonylureas
1st gen =Tolbutamide (orinase), chlorpropamide (diabinese).
2nd gen = Glipizide (glucotrol), glimepiride (amaryl)
Action of sulfonylureas
Lowers blood sugar by stimulating the release of insulin by the beta cells of the pancreas and causes tissues to take up and store glucose more easily
OA’s: biguanides
Metformin (glucophage)
Action of biguanides
Lowers serum glucose levels by inhibiting hepatic glucose production and increasing sensitivity of peripheral tissue to insulin
OA’s: alpha-glucose inhibitors
Acarbose (precose)
Miglitol (glyset)
Action of alpha glucose inhibitors
Lowers blood glucose by blunting sugar levels after meals
Diet for DM
45% to 50% carbs
15% to 20% protein 30% or less fat
Foods high in complex carbs, high in fiber, low in fat
Rapid acting insulin
HumaLog
NovoLog
Apidra
Rapid acting: onset
15 mins
Rapid acting: peak
30-90 mins
Rapid acting: duration
3 – 5 hrs
Short acting insulin
Regular insulin
Short acting: onset
30-60 min
Short acting: peak
2-4 hrs
Short acting: duration
5-8 hrs
Intermediate acting insulin
Isophane insulin
Intermediate: onset
1-3 hr
Intermediate: peak
8 hr
Intermediate: duration
12-16 hr
Long acting insulin
Glargine (Lantus)
Detemir (Levemir)
Long acting: onset
1 hr
Long acting: peak
Peak less
Long acting: duration
20-26 hr
Hyperglycemia
High blood glucose happens when the body has too little insulin or when the body can’t use insulin properly.
Signs and symptoms of hyper glycemia
Polydipsia
polyuria
polyphagia
blurred vision weakness
weight-loss
Hypoglycemia
deficiency of glucose in the bloodstream
Signs and symptoms of hypoglycemia
Headache
nausea
sweating
Tremors
lethargy
hunger
confusion
slurred speech tingling around mouth
Hiatal hernia
Herniation of the esophagogastric junction and a portion of the stomach into the chest through the esophageal hiatus of the diaphragm
GERD
Result of an incompetent lower esophageal sphincter that allows regurgitation of acidic gastric contents into the esophagus
diagnostic test for hernia and gerd
Fluoroscopy
barium swallow
Gastroscopy
Antacids
aluminum hydroxide & magnesium hydroxide
Action of antacids
Treatment of peptic ulcer’s. Work by neutralizing or reducing acidity of stomach contents. differences in absorption rate
Histamine 2 antagonists
Ranitidine (Zantac)
Cimetidine (Tagamet)
Famotidine (Pepcid)
Action of histamine 2 antagonists
Treatment of peptic ulcer’s. prophylactic treatment for client at risk for developing ulcers.
Mucosal healing agent
Sucralfate (carafate)
Action of mucosal healing agent
Treatment of peptic ulcer’s
PPI’s
Lansolrazole (Prevacid)
Pantoprazole (protonix)
Omeprazole (Prilosec)
Action of PPI’s
Treatment of erosive esophagitis associated with GERD
Peptic ulcer disease
Ulceration that penetrates the mucosal wall of the G.I. tract
Location of gastric ulcers
Lesser curvature of the stomach
Location of duodenal ulcers
Occur in the duodenum. Most common location of peptic ulcer disease
Symptoms of peptic ulcer disease
Belching
bloating
epigastric pain radiating to the back and relieved by antacids (not associated with food eaten)
How to determine presence and location of peptic ulcer’s
EGD
barium swallow
gastric analysis indicating increased levels of stomach acid
Diet for peptic ulcers
Small frequent meals
high-protein
high fat
Low carb
Medications to avoid with peptic ulcer’s
Salicylates
NSAID’s
Corticosteroids
Anticoagulants
Symptoms of G.I. bleeding
Dark tarry stool’s
coffee ground emesis
bright red rectal bleeding
fatigue
Pallor
Severe abdominal pain
Decreased BP
rapid pulse
Inflammatory bowel diseases
Crohn’s disease and ulcerative colitis
Crohn’s disease
Severe, acute chronic inflammation extending throughout all layers of intestinal mucosal. Periods of remission interspersed with periods of exacerbation
Diagnostic testing for Crohn’s disease
Capsule endoscopy has shown greater sensitivity than radiography
Symptoms of Crohn’s disease
Abdominal pain right LOWER quadrant
fatty diarrheal stools constant fluid loss low-grade fever weight-loss
Diet for Crohn’s disease
Low residue
Low fat
High protein
high calorie diet with no dairy products
Medication for Crohn’s disease
Aminosalicylates
Antimicrobials
Corticosteroids
Immunosuppressants
Ulcerative colitis
Affects superficial mucosa of the large intestines and rectum causing the bowel to eventually narrow shorten and thicken do to muscular hypertrophy
Diagnostic test for ulcerative colitis
Sigmoidoscopy and colonoscopy
Signs and symptoms of ulcerative colitis
Diarrhea
abdominal pain intermittent tenesmus
rectal bleeding
liquid stools: may pass 10 to 20 liquid stools per day
weakness
fatigue
Diet for ulcerative colitis
Low residue
low-fat
high-protein
high calorie
no dairy products
Medications for ulcerative colitis
Corticosteroids
Antidiarrheals
Sulfasalazine (azulfidine)
Mesalamine
Infliximab (remicade)
Opiate drugs
Depress gastric motility given with caution. Assess for abdominal distention, pain, rigidity.
S/S of shock: increased heart rate decrease BP
Diverticular disease
Diverticulosis
diverticulitis
Diverticulosis
Bulging pouches in the G.I. wall which push the mucosal lining through the surrounding muscle
Diverticulitis
Inflammed diverticula which may cause obstruction infection and hemorrhage
HESI HINT
Diverticulosis is the presence of patches in the wall of the intestine.
diverticulitis is an inflammation of the diverticula (pouches)
Signs and symptoms of diverticular diseases
Left lower quadrant pain
Increased flatus
rectal bleeding
Diagnostic study for diverticular diseases
Barium enema or colonoscopy positive for diverticular disease. Barium not used during active phase of illness. Obstruction, Ileus or perforation confirmed by abdominal radiograph.
Diet for diverticular diseases
Well-balanced, high fiber. Sometimes low residue, bland foods
Client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed as having diverticulosis. what are the nutritional needs of this client throughout recovery?
Acute phase: in NPO graduating to liquids.
Recovery phase: no fiber or foods that irritate the bowl
Maintenance phase: high fiber diet with bulk forming laxatives to prevent pooling of foods in the pouches where they can become inflamed. avoidance of small poorly digested food such as popcorn, nuts, seeds
Intestinal obstruction
Partial or complete blockage of intestinal flow that occurs mostly in the small intestines
Mechanical causes of intestinal obstruction
Adhesions
hernia (strangulates the gut)
Volvulus (twisting of the gut)
Intussusception (telescoping of the gut within itself)
Tumors
Neurogenic causes of intestinal obstruction
Paralytic ileus
spinal cord lesions
Bowel obstruction: mechanical
Due to disorders outside the bowl caused by disorders within the bowl or by blockage of the lumen in the intestine
Bowel obstruction: nonmechanical
Paralytic ileus which does not involve any actual physical obstruction but results from inability of bowel itself to function
A client admitted with complaints of constipation, thready stools and rectal bleeding over the past few months is diagnosed with a rectal mass. what are the nursing priorities for this client?
NPO
NG tube
IV fluids
surgical preparations of bowel
foods and fluids are restricted for 8 to 10 hours before surgery
If patient has bowel obstruction, bowel cleansing is contraindicated.
Oral erythromycin and neomycin are given.
All clients who require surgery for obstruction undergo NG intubation and suction before surgery.
Colorectal cancer
Tumors in the colon
Diet for colorectal cancer
High-fiber
low-fat foods
Cruciferous vegetables (broccoli, cauliflower, cabbage, kale)
American Cancer Society recommendations for early detection
Digital rectal exam every year after 40. stool blood test every year after 50.
colonoscopy examination every 10 years after the age of 50.
Diagnostic test for colorectal cancer
Digital examination,
flexible fiber optic sigmoidoscopy with biopsy
colonoscopy
Barium enema
Signs and symptoms of Colorectal cancer
Rectal bleeding
change in bowel habits
abdominal pain
weight-loss
abdominal distention
History of polyps
family history of cancer
Bowel preparation for surgery
Polyethylene glycol (GoLYTELY)
Stoma care
More distal the stoma is the greater the chance of continence.
The lower the stomas location is in the G.I. tract the more solid the stool.
Greatest chance for continence
Stoma created from the sigmoid colon on the left side of the abdomen
Cirrhosis
Degeneration of liver tissue causing enlargement, fibrosis and scarring
Causes of cirrhosis
Chronic alcohol ingestion
viral hepatitis exposure to heptotoxins
infections
congenital abnormalities
chronic severe right-sided heart failure
Physical findings of cirrhosis
Weakness
anorexia
palpable liver
jaundice
Fector hepaticus Asterix
mental and behavioral changes
bruising, erythema
Dry skin
spider angiomas
ascites, peripheral neuropathy
Palmer erythema
Clinical manifestations of Jaundice
Yellow skin, sclera or mucous membranes(bilirubin in skin). Dark colored urine (bilirubin in urine). Clay colored stools (absence of bilirubin in stools)
Ascites
Buildup of fluid in the abdomen. Paracentesis may be needed.
Lab data for cirrhosis
Elevated bilirubin, AST, AL T, alkaline phosphatase, PT and ammonium. Decreased Hgb, HCT, electrolytes and Albumin
Complications from cirrhosis
Ascites
edema
portal hypertension
Esophageal varices
encephalopathy
respiratory distress
coagulation defects
Vitamin supplements for cirrhosis
Vitamin A
B complex
C
K
Diet for cirrhosis
Low sodium
low potassium
low fat
high carb
Hepatitis
Widespread inflammation of liver cells usually caused by virus
Hepatitis A: source of infection
Contaminated food, water or shellfish
Hepatitis A: route of infection
Oral
Fecal
Hepatitis A: incubation period
15-50 days
Vaccine for hepatitis
Only hep A & B
Hepatitis B: source of infection
Contaminated blood products, mother to child at birth, contaminated needles
Hepatitis B: route of infection
Parenteral, oral, fecal, direct contact, sexual contact
Hepatitis B: incubation period
14-180 days
Hepatitis C: source of infection
Contaminated blood products, contaminated needles, IV drug use, dialysis
Hepatitis C: route of infection
Parenteral
Sexual contact
Hepatitis C: incubation period
Average 14-180 days
Pancreatitis
Nonbacterial inflammation of the pancreas
Acute pancreatitis
Digestion of the pancreas by it’s own enzymes, primarily trypsin
Cause of acute pancreatitis
Alcohol ingestion and biliary tract disease
Chronic pancreatitis
Progressive destructive disease that causes permanent dysfunction
Cause of chronic pancreatitis
Long term alcohol use
Signs and symptoms of acute pancreatitis
Severe mid epigastric pain radiating to back (LUQ)
abdominal guarding
nausea/vomiting
elevated temperature
tachycardia
decreased BP
elevated amylase, lipase and glucose levels
Signs and symptoms of chronic pancreatitis
Continuous burning or gnawing abdominal pain
recurrent attacks of severe upper abdominal and back pain
ascites
diarrhea, steatorrhea
weight loss
Jaundice
signs and symptoms of diabetes mellitus
Nursing plan for acute pancreatitis
Maintain NPO status
Maintain NG suction
Dilaudid/fentanyl as needed
Antacids, histamine H2 receptor blocking drugs, anticholingerics, PPI
Monitor for hypocalcemia
Nursing plan for chronic pancreatitis
Dilaudid/fentanyl/morphine as needed.
Bland, low fat diet.
Admin pancreatic enzymes: pancreatin or pancrelipase with meals.
Foods to avoid with pancreatitis
Alcohol
caffeine
rich foods
Fatty or spicy foods
Cholecystitis
Acute inflammation of the gallbladder
Cholelithiasis
Formation or presence of stones in the gallbladder
Treatment for cholelithiasis
Dissolution therapy
Endoscopic retrograde cholangiopancreatography
Lithotripsy
Acute renal failure
Abrupt deterioration of the renal system
Total urine output for adults
Approximately 1500 to 2000 ML
Three major types of acute renal failure
Prerenal-interference with renal perfusion.
Intrarenal-damage to renal parenchyma
Postrenal-obstruction in the urinary track anywhere from the tubules to the urethral meatus
Three phases of acute renal failure or
Oliguric
Diuretic
Recovery
HESI hint
Electrolytes are profoundly affected by kidney problems. Sodium and chloride extracellular ions.
potassium and phosphate intracellular ions.
Diagnostic findings in oliguric phase
Increased BUN and creatinine
increased potassium
decrease sodium
decreased pH
fluid overload
high urine specific gravity >1.020
Diagnostic findings in the diuretic phase
Decreased fluid volume
decrease potassium
further decrease in sodium
low urine specific gravity <1.020
HESI hint
Watch for signs of hyperkalemia:
dizziness
weakness
cardiac irregularities
muscle cramps
diarrhea
nausea
HESI hint
Potassium affects the heart. Limit high potassium foods and salt substitutes. Limit fluid and sodium intake in acute renal failure pts
Chronic renal failure: end stage renal disease
Progressive, irreversible damage to the nephrons and glomeruli, resulting in uremia
Diet for chronic renal failure
Low-protein
low sodium
low potassium
low phosphate
Urinary tract obstruction
Partial or complete blockage of the flow of urine at any point in the urinary system
Location of pain to determine location of stone
Flank pain means the stone is in the kidney or upper ureter. Pain radiating to the abdomen stone is likely to be in the ureter or bladder
Benign prostatic hyperplasia
Enlargement or hyper trophy of the prostate.
Most common treatment
Transurethral resection of the prostate gland
Signs and symptoms of BPH
Nocturia
hesitancy
terminal dribbling
decrease in size & force of stream
increased frequency of voiding with decrease amount
Respiratory acidosis: cause
Hypo ventilation
COPD
pulmonary disease
obesity
sleep apnea
Metabolic acidosis: cause
Addition of large amounts of fixed acids to body fluids
Lactic acidiosis
keto acidosis
phosphates and sulfates
acid indigestion
adrenal insufficiency
Respiratory alkalosis: cause
Hyperventilation
response to acidosis bacteremia
thyrotoxicosis
fever
Hepatic failure
hysteria
Metabolic alkalosis: cause
Retention of base or removal of acid from body fluids
vomiting
Burns
potassium depletion
pH
7.35-7.45
PCO2
35-45
HCO3
21-28
Respiratory acidosis
pH: low
PCO2: high
HCO3: normal
Respiratory alkalosis
pH: high
PCO2: low
HCO3: normal
Metabolic acidosis
pH: low
PCO2: normal
HCO3: low
Metabolic alkalosis
pH: high
PCO2: normal
HCO3: high
Isotonic IV solution
Normal saline
Lactated ringers
5% dextrose in water
Hypotonic IV solution
0.5% normal saline
2.5% dextrose in 0.45% NS
Hypertonic IV solution
5% dextrose in lactated ringer’s
5% dextrose in 0.45% saline
5% dextrose in 0.9% saline
10% dextrose in water
Hyponatremia: causes
Diuretics
GI fluid loss
diaphoresis
Hyponatremia: signs and symptoms
Anorexia
nausea / vomiting
weakness
Lethargy
confusion
seizures
Na < 135
Hypernatremia: causes
Diabetes insipidus
heatstroke
hyperventilation
renal failure
Cushing syndrome
Hypernatremia: signs and symptoms
Thirst
hyperpyrexia
dry mouth
hallucinations
irritability
lethargy
Na > 145
Hypokalemia: causes
Diarrhea
vomiting
gastric suction
hyperaldosteronism
bulimia
Cushing syndrome
Hypokalemia: signs and symptoms
Fatigue
anorexia
nausea
muscle weakness
dysrhythmias
K <3.5
Hyperkalemia: causes
Oliguria
acidosis
renal failure
Addison’s disease
Hyperkalemia: signs and symptoms
Muscle weakness
bradycardia
dysrhythmias
Flaccid paralysis
K > 5.0
Hypocalcemia: causes
Renal failure
hypoparathyroidism
malabsorption
pancreatitis
Hypocalcemia: signs and symptoms
Diarrhea
numbness
tingling of extremities
positive trousseau sign
Ca <8.5
Hypercalcemia: causes
Hyperparathyroidism
prolonged immobilization
excess calcium supplementation
Hypercalcemia: signs and symptoms
Muscle weakness
constipation
anorexia
polyuria
polydipsia
dysrhythmias
Ca >10.5
Hemoglobin
M: 14 – 18
F: 12 – 16
Hematocrit:
M: 42 – 52
F: 37 – 47
RBC’s
M: 4.7 – 6.1
F: 4.2 – 5.4
Platelets
5,000 – 10,000
Calcium
9 – 10.5
Potassium
3.5 – 4.7
Sodium
135 – 145
Isotonic IV solut