A nurse is caring for a client with a spinal cord injury. What are possible causes of autonomic dysreflexia that the nurse should monitor for? distended bladder (most common), fecal impaction, cold stress or drafts on lower part of body, tight clothing, undiagnosed injury or illness. A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor. Which of the following postoperative prescriptions should the nurse clarify with the provider?
A. Dexamethasone (Decadron) 30 mg IV bolus BID
B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain
C. Ondansetron (Zofran) 4 mg IV bolus PRN every 4 to 6 hr for nausea D. Phenytoin (Dilantin) 100 mg IV bolus TID
A client has been admitted to the hospital with a diagnosis of tuberculosis. Provide three (3) measures the nurse can take to prevent disease transmission. Use N-95 respirator, place client negative airflow room (airborne precautions), use barrier protection when the risk of hand or clothing contamination occurs.
A nurse is caring for a client who has been admitted with renal calculi. List three (3) interventions the nurse will take in the management of renal calculi. Encourage increased oral intake to 3L/day unless contraindicated, encourage ambulation to promote passage of stone, Strain all urine to check for passafe of the stone and save the stone for lab analysis.
Define the following types of urinary incontinence: Stress, urge, overflow, reflex, functional, total. Stress – loss of small amounts of urine with sneezing, laughing, or lifting. Stress incontinence is related primarily to weak pelvic muscles, urethra, or surrounding tissues. Urge – the inability to stop urine flow long enough to reach the toilet. Urge incontinence is related to an overactive detrusor muscle with increased bladder pressure. Overflow – urinary retention associated with bladder overdistention and frequent loss of small amounts of urine.
Overflow incontinence is related to obstruction of the urinary outlet or an impaired detrusor muscle. Reflex – involuntary loss of a moderate amount of urine usually with warning. Reflex incontinence is related to hyperreflexia of the detrusor muscle, usually from altered spinal cord activity. Functional – inability to get to the toilet to urinate. Functional incontinence is related to physical, cognitive, or social impairment. Total incontinence – involuntary, unpredictable loss of urine that does not generally respond to treatment.
A nurse is providing education to a client with high blood pressure about the importance of maintaining antihypertensive therapy. What are three (3) complications that can occur with prolonged, untreated or poorly controlled hypertension? peripheral vascular disease that affects the heart, brain, eyes, and kidneys. Hypertrophy of the left ventricle can develop as the heart pumps against resistance caused by HTN.
A nurse is caring for a client experiencing metabolic acidosis. What are three (3) causes of metabolic acidosis? excess production of hydrogen ions (DKA, lactic acidosis, starvation, heavy exercise, seizure activity, fever, hypoxia, intoxication with ethanol or salicylates), inadequate production of bicarbonate (kidney failure, pancreatitis, liver failure, dehydration), excess elimination of bicarbonate (diarrhea, ileostomy)
A nurse is caring for a client with pneumonia. What are three (3) physical assessment findings that are noted with the development of pneumonia? dull chest percussion over areas of consolidation, decreased o2 sat, purulent blood tinged/rust colored sputum (not always), fever, chills, flushed face, diaphoresis, SOB, tachypnea, pleuritic chest pain (sharp), yellow tinged sputum, crackles and wheezes
A nurse is caring for a client scheduled for a liver biopsy. What nursing actions should be taken before, during and after this procedure? Before procedure explain procedure, witness informed constent, ensure client fasts for at least 2 hr., administer preprocedural meds as prescribed. During procedure assist the client into supine with URQ of abd exposed, assist client with relaxation techniques, instruct client to exhale breath and hold for at least 10 seconds while the needle is inserted and to resume breathing once the needle is withdrawn, apply pressure to puncture site. After procedure assist client to a right side-lying position and maintain for several hours, monitor vital signs, assess for pain and bleeding
A nurse is caring for a client with colorectal cancer who is scheduled for a colectomy. What preoperative and post-operative education should be provided to this client? educate client regarding preop diet (clear liquids several days prior to surgery), instruct the cliet to complete bowel prep with cathartics as prescribed, inform the client of the administration of antibiotics to eradicate intestinal flora. postop educate the client regarding the care of the incision, activity limits, and ostomy care if applicable.
A worker is taken the employee health nurse with an obvious open fracture to the right arm. What priority care measures should the nurse provide while awaiting emergency transport ABCs, stabilize injured area including joints above and below fracture, avoid unnecessary movement
A nurse is caring for a client with multiple risk factors for peripheral vascular disease. List four (4) risk factors associated with peripheral vascular disease. Hypertension, hyperlipidemia, diabetes mellitus, cigarette smoking, obesity, sedentary lifestyle, familial predisposition
A client is diagnosed with Addisonian Crisis. List the lab values that will be affected by this disease process. increased potassium, decreased sodium, and increased calcium, BUN and creatinine increased, serum glucose decreased, serum cortisol decreased
A nurse is caring for a client with a tension pneumothorax. What is a tension pneumothorax and what manifestations should the nurse expect? a tension pneumothorax occurs when air enters the pleural space during inspiration through a one-way valve and is not able to exit upon expiration. the trapped air causes pressure on the hear and lung. As a result the increase in pressure compresses the blood vessels and limits venous returen, leading to a decrease in cardiac output. Death can result if not treated immediately. manifestations- tracheal deviation to unaffected side, respiratory distress, asymmetric chest wall movement.